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Biomedical subjects

R M Filler

Publications and source records attributed to R M Filler.

At least 55 records · Page 3Linked to original sources
PubMed1992

APSA: a forum for progress in pediatric surgery.

The APSA scientific program has indeed been a forum for progress for a broad spectrum of medical and surgical problems affecting infants and children. Significant contributions from studies at the bedside and in the laboratory have been made by an extraordinarily large percent of APSA members from both children's and general hospitals. In addition to the many advances that apply to our own specialty, fundamental advances have been recognized and accepted by others. Developments for the future have been identified and our entire membership can be proud of the wonderful achievements of the last 20 years of APSA scientific programs. Finally, I thank you all for giving me the honor to serve as the President of this outstanding organization, which has accomplished so much already, but whose best days are yet to come.

General Surgery↗
PubMed1992

Repair of long tracheal defects with cryopreserved cartilaginous allografts.

Tracheoplasties with various autografts (cartilage, periosteum, pericardium) have been used in the treatment of long-segment tracheal stenosis. Previous studies have shown that cartilage allografts survive transplantation on a long-term basis in various sites of the body. In this study we set out to determine if cryopreserved cartilage and cryopreserved tracheal allografts would survive when used to cover tracheal defects in animals. A rectangular defect (2.8 +/- 0.3 cm long and incorporating 50% of tracheal circumference) was created in the thoracic trachea of 18 piglets. The defect was covered with the excised tracheal segment in 6 (group A, control group), with a cryopreserved tracheal allograft in 6 (group B), and with a cryopreserved cartilage allograft harvested from the scapula in 6 (group C). The allografts were cryopreserved, by a standard slow-freezing technique, at -80 degrees C for more than 21 days. All animals survived the grafting procedure and were killed after 2 months. None had signs of airway obstruction. Using the trachea above the defect as the standard, the mean sagittal narrowing of the airway in the repaired trachea was 0.4 mm in group A, 0.7 mm in group B, and 0.6 mm in group C; the coronal diameter in normal and grafted trachea was similar. The lumen of all grafts was lined by regenerating respiratory epithelium, and cilia were seen in many. Some cartilage was reabsorbed in group A and B but cartilage islands were present in all. In group A, reabsorption of cartilage was minimal. These findings suggest that segments of trachea or cartilage allografts can be cryopreserved, stored, and, subsequently, used when necessary for tracheoplasty.

Animals↗
PubMed1992

Severe tracheomalacia associated with esophageal atresia: results of surgical treatment.

This study reviews our experience from 1977 to 1991 with 32 children born with esophageal atresia and tracheoesophageal fistula (EA-TEF) who later underwent surgery for severe tracheomalacia. Indications for surgery included dying spells (21), inability to extubate the airway (nasotracheal tube 5, tracheotomy 3), and recurrent pneumonia (3). Diagnosis was confirmed by chest x-ray, esophagogram, and bronchoscopy. Aortopexy was performed in 31 of 32 children; a splint without aortopexy was used in one older girl. Splinting was also necessary in two of the 31 at the initial operation, when aortopexy failed to prevent tracheal collapse. There were four initial failures. Currently, 29 children are well (median follow-up, 6.6 years). Two have a tracheostomy in place, and one, who had a vascular ring divided after aortopexy, died at home of unknown cause 1 month later. These findings indicate that aortopexy provides long-term relief of severe symptoms of tracheomalacia associated with EA-TEF in almost all affected children. When aortopexy fails, the insertion of an airway splint may succeed; otherwise, tracheostomy is necessary.

Aorta↗
PubMed1992

The balloon posterior tracheal split: a technique for managing tracheal stenosis in the premature infant.

Congenital tracheal stenosis (CTS) in the premature infant almost invariably leads to death for lack of effective reconstructive techniques. We hypothesized that the complete or near complete cartilaginous rings of CTS have a weak point in the posterior portion. Aggressive balloon dilation would result in a posterior longitudinal disruption of the trachea, and an expanded tracheal wall would be created after an appropriate period of endotracheal stenting. Three premature infants with multiple anomalies and CTS were treated with endoscopic posterior tracheal splitting, dividing the trachea as predicted. Although two died of complications of congenital heart disease 2 weeks after the procedure, the third child is alive and well at 9 months of age without airway symptoms. The posterior tracheal wall also split when we performed the procedure in a fresh cadaveric CTS patient. We believe that balloon dilation may prove to be a valuable technique in the treatment of premature infants with congenital or acquired tracheal stenosis and/or in children with such complex diseases that major surgery is precluded.

Cadaver↗
PubMed1991

Current status of pancreatectomy for persistent idiopathic neonatal hypoglycemia due to islet cell dysplasia.

A series of 18 children suffering from persistent idiopathic neonatal hypoglycemia (PINH) is reported. Medical and surgical managements are described in detail. All patients subjected to surgery had failed medical treatment. These patients were divided into two groups: 1) 85% pancreatectomy leaving the uncinate process in situ, and 2) 95% pancreatectomy leaving a small rim of pancreatic tissue along the duodenum and the common bile duct. The spleen was preserved in all cases. Two out of 5 children of group 1 required further resection of the pancreas for persistent hypoglycemia and were converted to 95% pancreatectomy. Since 1981 95% pancreatectomy was exclusively employed. Only one patient required insulin for 3 weeks postoperatively. Histopathology and immunohistochemistry revealed islet cell dysplasia and islet cell nuclear hypertrophy in the majority of cases, 35% of the patients had focal adenomatosis. Better control of hypoglycemia is achieved by primary 95% pancreatectomy and, thus, 95% pancreatectomy is recommended as the initial procedure in the treatment of PINH.

Female↗
PubMed1991

Successful tracheal autotransplantation with a vascularized omental flap.

A major problem in tracheal transplantation is the restoration of an adequate vascular supply to the transplanted trachea. In 12 piglets, a segment (6 rings) of thoracic trachea was removed and the excised segment was then sutured back in place. In 9 animals (group A), a vascularized omental flap was wrapped around the autotransplanted trachea. In the other 3 pigs (group B), the omentum was not used. Eight of 9 group A pigs were killed, 1 or 2 months later, having had no signs of airway obstruction; the 9th pig was killed after 14 days because of airway obstruction. The 3 pigs in group B were killed after 11 to 13 days because of progressive respiratory obstruction. In the 8 asymptomatic pigs in group A, the omental flap was viable and tracheal growth was normal with no differences in diameter between normal and autotransplanted trachea. Histologically intact cartilage was lined with respiratory epithelium. In the one group A pig who was killed early, the omental flap was necrotic. In this pig and in the 3 group B animals, extensive tracheal necrosis and nonviable cartilage were observed. These findings indicate that in the pig, a 6-ring segment of trachea can be transplanted with vascularization provided by an omental flap.

Animals↗
PubMed1991

Partition of energy metabolism in the surgical newborn.

Variations in energy expenditure (EE) and substrate utilization were investigated in 12 surgical neonates (body weight, 2.81 +/- 0.15 kg) receiving total parenteral nutrition (TPN) at an energy intake of 66.34 +/- 2.16 kcal/kg/d in a thermoneutral environment of 32 degrees C to 34 degrees C. Respiratory gas exchange was continuously recorded for 12 hours by a computerized, open-circuit indirect calorimeter. Physical activity was monitored on a modified Freymond scale. Urine was collected over 3 days, including the time of the calorimetry study to determine the urinary nitrogen excretion rate. Oxygen consumption, carbon dioxide production, nonprotein respiratory quotient, and EE were calculated according to the principles of indirect calorimetry for each 30-minute period and for the entire 12 hours. During the indirect calorimetry study the patients were receiving a fat-free TPN mixture consisting of 10% glucose and 2% amino acids (GL/AA) for 8 hours. The fat-free TPN was interrupted by an isocaloric and isovolemic infusion of intralipid 10% (IL) for 4 hours. The effect of physical activity on EE was evaluated separately according to the macronutrient intake (GL/AA for 8 hours v IL for 4 hours) and then combined throughout the 12 hours of intravenous alimentation. The neonates were resting during 80% of the 12-hour study time (range, 38% to 90%). The partition of EE expressed as mean +/- SEM in kcal/kg/d was: total EE 48.5 +/- 2.1; resting EE 43.9 +/- 1.6; energy cost of activity 4.6 +/- 1.3.(ABSTRACT TRUNCATED AT 250 WORDS)

Calorimetry, Indirect↗
PubMed1991

Preoperative chemotherapy in hepatoblastoma.

Since January 1986, 15 children with hepatoblastoma received three to six cycles of chemotherapy with cisplatin (20 mg/m2/day x 5 days) and doxorubicin hydrochloride (25 mg2/m2/day x 3 days) every 3 weeks before surgery. The extent of the tumor was defined by computerized tomography scan of abdomen and chest and diagnosis confirmed by percutaneous liver biopsy before therapy was started. Tumors in 10 children were considered unresectable at diagnosis because of pulmonary metastases, extensive bilobar involvement, or venous involvement. Volume of tumor reduction ranged from 35% to 95% and was independent of tumor histologic findings. After a minimum of three chemotherapy cycles, excision was undertaken when tumor volume decreased to a size at which hepatic resection was feasible and safe. Chemotherapy complications that were not serious did not delay surgery or result in tumor growth during treatment. Complete surgical excision was possible in 13 children, including 10 who had had unresectable tumors and five with pulmonary metastases. Only three resections of more than one liver lobe were required, and partial lobectomy was possible in four children. One operative death and three postoperative complications, one severe, occurred. Cyclic chemotherapy was restarted 4 to 6 weeks after surgery until a total of six courses were given. Twelve children (eight whose tumors were originally unresectable) completed treatment 3 to 56 (median, 21) months ago and have no evidence of disease. Two other children currently undergoing therapy may have residual disease. The results to date far surpass historic survival rates, which ranged about 25%.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1990

Adriamycin and cis-platinum administered by continuous infusion preoperatively in hepatoblastoma unresectable at presentation.

Hepatoblastoma deemed surgically unresectable at presentation is fatal unless conversion to resectability is attained. We report a series of six consecutive patients, ranging in age from newborn to 5.75 years with hepatoblastoma unresectable at presentation, either because of size of tumor or its anatomical boundaries, or because of metastatic disease. All were treated with preoperative continuous infusions of cis-platinum and Adriamycin. All achieved resectability, and there was only one operative death. The five surviving patients are alive and free of disease off therapy. Potential benefit may accrue from preoperative chemotherapy in most cases of hepatoblastoma.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1990

Cyclic neutropenia with colonic perforation and nonhealing colocutaneous fistula.

Cyclic neutropenia is an hereditary disorder of white blood cells, characterized by profound neutropenic episodes approximately every three weeks. Septic complications are usually limited to cutaneous and oropharyngeal infections. A 4-year-old boy with known cyclic neutropenia was in shock with neutropenia, clostridial septicemia, and right lower quadrant peritonitis when he was admitted. At the time of laparotomy, inflammation of the cecum, with no gross perforation, was found; no resection or appendectomy was done. He subsequently developed a right lower quadrant abscess that was drained, resulting in a colocutaneous fistula. For the next 8 months his fistula persisted, with intermittent episodes of fever, increased fistula output, and abdominal pain during his neutropenic periods. Standard nonoperative approaches to healing the fistula failed (ie, elemental feeds, total parenteral nutrition, irrigations, antibiotics, and drains). Attempts to medically abolish his neutropenic episodes using lithium, gammaglobulin, and steroids also failed. Ultimately, he underwent an ileocecal resection with primary anastamosis; the operation was done immediately following a neutropenic episode, in order to allow adequate healing of his anastamosis before his next period of neutropenia. Postoperative course was satisfactory, and he remains well after 8 months follow-up. This case, and several similar previously reported cases, illustrate that cyclic neutropenia may present with serious surgical complications. They also underlines the important role that neutrophils play in the healing of enteric fistulae.

Agranulocytosis↗
PubMed1990

A 13-year experience with peritoneal drainage under local anesthesia for necrotizing enterocolitis perforation.

Between 1974 and 1986, inclusive, over 400 newborns with clinical, radiological, and/or pathological evidence of necrotizing enterocolitis (NEC) were treated at the Hospital for Sick Children, Toronto, Ontario. Within this group were 37 babies who had a bowel perforation that was treated with peritoneal drainage under local anesthesia. Eighty-eight percent of the 41 weighed less than 1,500 g and 65% weighed less than 1,000 g; during the same time 40 other neonates (9% of the total) with perforated NEC had laparotomies. Twelve neonates (32%) required only drainage with complete recovery of their intestinal tracts. The remaining 25 (68%) fell into one of three groups: (1) nine (24%) had rapid downhill course, sepsis, and death without laparotomy; (2) nine (24%) had rapid downhill course, sepsis, and laparotomy (five deaths); (3) seven (20%) had slow development of bowel obstruction requiring operation (two deaths). The overall survival rate was 56%. These results continue to indicate that this method is effective in temporizing 88% of the small and/or very ill babies with a NEC perforation. However, an added bonus is that 32% of these newborns treated in this fashion had complete resolution of their disease.

Anesthesia, Local↗
PubMed1990

Complications of gastroesophageal antireflux surgery in neurologically impaired versus neurologically normal children.

Antireflux surgery was performed in 234 children over a 5-year period; 153 were neurologically impaired (NI) and 81 were neurologically normal (NN). Initial presentation, demographic data, and type of antireflux operation were similar in the two groups. Eighty-six percent of the NI group versus 30% of the NN group had gastrostomy tubes placed. The incidence of late postoperative complications was 26% in the NI group and 12% in the NN group (P less than .01). During the late postoperative period, NI children underwent reoperation four times as frequently as NN children (19% v 5%, respectively; P less than .01). Wrap herniation accounted for 38% of complications and 59% of reoperations in the late postoperative period. Mortality due to aspiration occurred in 9% of the NI group versus 1% of the NN group. Combined failure rate (reoperation plus aspiration-induced deaths) was 28% in NI and 6% in NN (P less than .01). We conclude that neurological status is the major predictor of operative success and that wrap herniation due to crural disruption is the most common cause of operative failure.

Adolescent↗
PubMed1990

Reduced tracheal growth after reconstruction with pericardium.

Four groups of piglets were used to test the use of pericardium and periosteum as free grafts in the repair of full thickness cervical tracheal defects. Pericardium provided an airtight, rapidly healing graft, but did not give sufficient structural rigidity to prevent narrowing and growth failure at the graft site. Composite grafts of pericardium and periosteum were also unsatisfactory, in that the periosteum failed to produce enough bone to prevent collapse of the graft. Since previous studies have shown that periosteal grafts result in good bone formation when applied alone or as an extramucosal support, it is concluded that the osteogenic potential is dependent on the available blood supply and speed of revascularization. It appears that the presence of pericardium in the composite grafts may have inhibited this property.

Animals↗
PubMed1990

Xanthogranulomatous cholecystitis and cholecystoduodenal fistula formation associated with total parenteral nutrition in a six year old child.

A unique complication of florid xanthogranulomatous cholecystitis with cholecystoduodenal fistula formation is described in a 6 yr old male. The patient, who had a short gut syndrome, had been maintained on lifelong total parenteral nutrition (TPN) following extensive neonatal ischemic bowel necrosis secondary to gastroschisis. Endoscopic duodenal mucosal biopsy demonstrated a granulomatous inflammatory infiltrate surrounding bile casts suggesting the possibility of a fistula between the biliary tract and duodenum. Additional clinical and radiological evidence of a cholecystoduodenal fistula prompted surgical intervention. At laparotomy the gallbladder was firmly bound to the duodenum by dense fibrous adhesions. Histologic examination showed xanthogranulomatous inflammation in association with fragments of bile that were present both within the gallbladder wall and within a fistulous tract in the adjacent connective tissue.

Biliary Fistula↗
PubMed1990

Lymphoscintigraphy for cystic hygroma.

We present the case of an infant with a cystic hygroma investigated by lymphoscintigraphy. The source of lymph flowing into the hygroma was identified as were some ectatic lymphatics feeding it. Lymph flow was very rapid. The implications for therapy are discussed. Lymphoscintigraphy can assess many aspects of lymph flow not accessible by other means.

Antimony↗
PubMed1989

Esophageal atresia with distal tracheoesophageal fistula: associated anomalies and prognosis in the 1980s.

Ninety-seven newborns with esophageal atresia and distal tracheoesophageal fistula (EA-TEF) were treated between 1979 and 1985 inclusive; there were 54 boys and 43 girls. Their weights ranged from 800 to 4,000 g (average, 2.5 kg). They included: 28 neonates with cardiac defects (most common: patent ductus arteriosus [PDA], ventricular septal defect and atrial septal defect [VSD-ASD]), of whom 18 survived (64%); 17 babies with other gastrointestinal anomalies (imperforate anus, duodenal atresia), of whom 12 survived (70%); 12 patients with skeletal malformations (digital, vertebral), of whom 11 survived (91%); 8 newborns with genitourinary abnormalities (hypospadias, undescended testis), of whom 6 survived (75%); and 16 infants with other congenital lesions (trisomy 18, lung agenesis-hypoplasia), of whom 3 survived (18%). Forty-six infants (average, 2.7 kg) had no other anomalies and all survived. As the number of systems with defects increased, both the weight of the baby and survival rate decreased. From this entire series of 97 newborns with EA-TEF, 81 (83%) survived (average, 2.3 kg). Sixteen babies died (average, 1.9 kg); 11 had defects incompatible with life. Eleven of the 16 were never operated on (seven patients with trisomy died within 5 days, and four patients with complex cardiac defects died within 3 weeks). Four of the 16 who were operated on died between 3 months and 2 years from chest problems and one newborn died in the operating room. We concluded that (1) newborns who have the common type of EA-TEF will almost certainly survive if there are no other anomalies; (2) the most frequently associated congenital defects are cardiovascular (28%), gastrointestinal (17%), skeletal (12%), and genitourinary (8%); (3) as the number of systems with defects increases, the weight of the baby and its survival rate fall; and (4) 11% will have trisomy and/or complex cardiac defects with no survival.

Abnormalities, Multiple↗
PubMed1989

Preoperative chemotherapy in 'unresectable' hepatoblastoma.

Chemotherapy was used to treat 11 children with hepatoblastoma that was judged to be unresectable because of tumor tissue in both lobes of the liver (eight patients) or because of size of the primary tumor (three patients). Three with bilobar involvement also had metastatic disease. Adriamycin was used in all patients. In nine, it was used in combination with cisplatin. A combination of other agents was used in four of these children. After two to six cycles (mean, 4 cycles), eight primary tumors exhibited marked response with greater than 50% reduction in size. Metastases disappeared in two patients. Complete resection of residual tumor was attempted in eight cases, and was successful in seven. One patient died at the time of surgery during an extended right hepatectomy. Two children had anaplastic hepatoblastomas that did not respond to chemotherapy, and the children died. One responder with giant cell hepatitis died from a severe coagulopathy and bleeding during chemotherapy before surgery. With preoperative chemotherapy, seven of 11 children with "unresectable" hepatoblastoma are now alive without disease 4 to 42 months following successful resection.

Antineoplastic Combined Chemotherapy Protocols↗