Surgical diseases of the spleen.
Recognition of the spleen's important immune function has led to a more conservative surgical approach to the spleen. This has proved to be both safe and beneficial to the patient.
Anemia, Hemolytic↗
Biomedical subjects
R M Filler
Publications and source records attributed to R M Filler.
Blunt hepatic trauma in children: experience with operative and nonoperative management.
Between 1974 and 1982, 32 children were treated for blunt hepatic trauma. Twenty-three injuries were secondary to motor vehicle accidents. Twenty-three patients had associated injuries. The hepatic injury was treated surgically in 18 patients. Urgent surgery for massive bleeding was required in 7 patients; 8 underwent laparotomy for continued bleeding after initial stabilization; 2 underwent laparotomy for marked abdominal tenderness, and 1 for an expanding hepatic hematoma. Various excisional, debridement, suture, and drainage procedures were employed. Seven patients died, 5 from uncontrollable bleeding and 2 from associated severe head injury. The eleven survivors did well. The only postoperative complications were two wound infections. Fourteen patients were managed nonoperatively. Liver scan provided the diagnosis in all. Five of these patients required blood transfusion, and the mean volume of transfusion was 33cc/kg. The hospital courses in all cases were uneventful, and there were no late complications. A follow-up liver scan was obtained in 11 patients, showing resolution of the injury in all. We conclude that laparotomy is necessary for hepatic injury when it is associated with continuous massive bleeding. Hemodynamically stable patients can be managed nonoperatively, even when the blood-transfusion requirements are significant.
Adolescent↗
The effect of intrauterine esophageal ligation on growth of fetal rabbits.
Babies with pure esophageal or duodenal atresia weight less than normal babies at birth. Whether this is due to the obstruction to fetal swallowing or some other cause is not known. To determine how intrauterine interruption of swallowing affects fetal growth, we developed a model of esophageal atresia in the fetal rabbit. Twenty-five time-mated rabbits at 24 days gestation were anesthetized with halothane and ketamine. The uterus was exposed through a midline abdominal incision. The head and neck of the fetus in the distal end of one horn were isolated through a 2-cm hysterotomy. Biparietal diameter (BPD) was measured and the esophagus was isolated and ligated through a midline cervical incision. The fetus in the distal end of the opposite horn underwent sham operation. Four days later, cesarean section was done. The newborn rabbits were weighed, and crown/rump length and BPD were measured. Ligation of the esophagus was confirmed by re-exploration of the neck. Three does died under anesthesia and two aborted. From the remaining 20, 156 fetuses were recovered, of which 135 were alive. One set of operated fetuses was dead, leaving 19 pairs for analysis. There was a statistically significant reduction in weight gain (31.7 +/- 1.3 g to 29.1 +/- 0.9 g, P less than 0.05) following interruption of the esophagus but linear growth was unchanged. Obstruction to normal fetal swallowing may account for the low birth weight with normal head circumference reported in babies with esophageal and duodenal atresia.
Animal Nutritional Physiological Phenomena↗
The relationship between PaCO2 and ventilation parameters in predicting survival in congenital diaphragmatic hernia.
Fifty-eight infants with congenital diaphragmatic hernia presenting within the first 6 hours of life, who underwent surgical repair, were analysed prospectively in order to produce a reliable index of severity of disease that would reliably predict eventual outcome. All were treated with paralysis hyperventilation and intravenous (IV) isoproterenol for the first 48 hours. There were 30 survivors and 28 deaths in this series (mortality 48%). Using arterial PCO2 values measured 2 hours after surgical repair and correlating them with an index of mechanical ventilation (mean airway pressure and respiratory rate), we have been able to clearly define two groups of diaphragmatic hernia based on their response to IPPV. The first group, with CO2 retention and severe preductal shunting, was unresponsive to hyperventilation with high rates and pressures; the mortality was 90%. The second group responded well to hyperventilation and demonstrated reversable ductal shunting only. Survival in this group was 97%. Only four patients out of 58 exhibited the "honeymoon period," with a period of stability followed by severe ductal shunting. Arterial CO2 accurately reflects the degree of lung development in this disease and separates those patients with severe pulmonary hypoplasia, where the outcome is invariably fatal, from those with a well-developed contralateral lung where there is excellent potential for survival.
Carbon Dioxide↗
Neonatal intestinal pseudoobstruction.
In the past 10 years, the diagnosis of pseudoobstruction lasting more than two months was confirmed in 10 infants after sepsis, meconium ileus, and Hirschsprung's disease were excluded, and surgery or autopsy failed to demonstrate a site of mechanical intestinal obstruction. Four infants had undergone prior operation for another anomaly: gastroschisis (2) and ileal atresia (2). Five of the remaining infants also had megacystis. The lack of coordinated intestinal motility was best appreciated by radiocontrast small bowel studies, which showed degrees of aperistalsis or segmentation. Rectal manometric studies were not helpful. Histology of the intestine was normal in seven, while a gross deficiency of nerve fibres was noted in one patient and a myopathy of smooth muscle in another. A variety of drugs used to stimulate peristalsis were ineffective. Seven patients had 25 operations, often to exclude mechanical causes of obstruction. The mainstay of treatment was TPN and intestinal decompression. Six children survived; their ages ranged between 8 months and 9 years (median age, 16 months). There has been improvement in intestinal peristalsis in five children, three of whom now tolerate a regular diet and two of whom are on TPN and are currently increasing oral intake. Four infants died, two from sepsis, two from TPN-related hepatic failure. In contrast to previous reports, we conclude that intestinal pseudoobstruction may be self-limited in some neonates, including those with megacystis. Therapy should consist of long-term nutritional support and treatment of other anomalies that may be present.
Combined Modality Therapy↗
Surgical management of persistent neonatal hypoglycemia due to islet cell dysplasia.
We have reviewed ten children who underwent surgical therapy for persistent neonatal hypoglycemia over a 5-year period. All had inappropriately high insulin levels in the face of hypoglycemia, and all failed medical management with intravenous glucose, frequent feeds, diazoxide and glucagon. Two groups of five patients each were analysed retrospectively. Group 1 underwent 95% pancreatectomy, leaving a small amount of pancreatic tissue on the duodenum and common bile duct. The only major complication in this group was in one patient with common duct obstruction requiring choledochoduodenostomy. All these children are developing normally, without diabetes, steatorrhea, or recurrent hypoglycemia. Group 2 underwent 85% pancreatectomy, leaving the uncinate process in situ. Two of these children are well. Two required conversion to 95% resection because of recurrent hypoglycemia; one of these required a subsequent total pancreatectomy, at which time the pancreatic remnant had significantly regenerated. The other Group II patient was normoglycemic but died at age 3 from pneumonia. Pathology in nine cases showed islet cell dysplasia; 5 of these also had microadenomatosis. One case had a histologically normal pancreas. We conclude that 95% pancreatectomy is a safe operation with a lower failure rate than less radical resections, and should be used early in the management of this condition.
Female↗
Experience with the management of splenic injuries.
This paper reviews the experience of treating 128 patients with splenic trauma over a 10 year period. All patients were aged under 16 years and all except one had sustained non-penetrating abdominal injuries. The diagnosis was established at operation or by spleen scan or by angiography but the decision to operate was made on clinical grounds. Patients who were stable on admission or after initial resuscitation were managed expectantly. In patients requiring surgery for massive bleeding or for other injuries the spleen was repaired whenever possible. Only 29% of patients required operation and in three quarters of these patients the spleen was able to be preserved. Delayed rupture of the spleen did not occur in the non-operative group and septic complications have not been observed in any survivors. There were 14 deaths in the series, 11 from severe head injury and three from massive haemorrhage.
Adolescent↗
Sustained normoglycemia in newly diagnosed type I diabetic subjects. Short-term effects and one-year follow-up.
The impact on remission of normalizing blood glucose levels immediately after diagnosis of type I diabetes was studied in 14 adolescents. Accordingly, in this randomized prospective primary intervention study, 7 of the subjects (i.v. group) received insulin by continuous intravenous (i.v.) infusion via a portable preprogrammed system for 28-62 days and 7 (s.c. group) received conventional subcutaneous (s.c.) therapy. Before therapy, the two groups did not differ significantly with respect to glycosylated hemoglobin, fasting plasma C-peptide, or 24-h urinary C-peptide excretion. During the infusion period, the overall mean fasting plasma glucose (FPG) concentration for the i.v. group was 84 mg/dl with a mean coefficient of variation of 18 +/- 4% (mean +/- SD). During the comparable period for the s.c. group, the mean FPG was 253 mg/dl with a coefficient of variation of 30 +/- 20%. Twenty-four-hour urinary glucose excretions for the two groups were 0.29 +/- 0.06 (mean +/- SEM) and 59 +/- 11 g/day, respectively. Daily insulin requirements in the i.v. group decreased from 1.47 +/- 0.19 U/kg body wt/day at the start to 0.47 +/- 0.10 U/kg/day at the end of the infusion period. Notably, 10-25 days after the infusion period, 5 of 7 subjects experienced a further decrease to a low of 0.27 +/- 0.01 U/kg/day. The mean peak and low requirements in the s.c. group were 0.71 +/- 0.15 and 0.33 +/- 0.13 U/kg/day, respectively, with the only peak requirements being significantly different (P less than 0.01). No patient was able to discontinue insulin therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Continuous muscle and subcutaneous tissue pH monitoring with polymer sensor].
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Acidosis, Respiratory↗
Effect of prosthetic airway splint on the growing trachea.
Airway splints are now used clinically to treat tracheomalacia and may also have a place in the management of tracheal stenosis. These studies in 5 to 7 Kg piglets were designed to assess the effects of prosthetic airway splints on airway growth and to establish their usefulness in the reconstruction of tracheal defects. Three experimental groups were studied: group I (n = 8). Silastic reinforced Marlex mesh or Vicryl mesh prostheses were placed around 75% of the circumference of a 3 cm segment of trachea. Pigs were sacrificed at 4 months (average weight = 78.9 +/- 9.0 Kg) and the cross-sectional area of trachea was measured. Group II (n = 5). The same prostheses were used to replace the tracheal defect created by excising three rings (50% of tracheal circumference). Tracheas were examined grossly and histologically at sacrifice. Group III (n = 5). Same as Group II except tracheal defect covered by strap muscles. Prostheses placed external to them to prevent airway collapse. Group I had 4% to 14% (mean 8%) decrease from normal cross-sectional area of trachea at site of splint. No airway obstruction and no infection was encountered. Group II, severe airway obstruction, granulation tissue, and infection at site of defect was noted. Group III showed no signs of airway obstruction, no infection, and minimal airway narrowing. Re-epithelialization of the muscle surface in contact with airway occurred in all these animals. Silastic reinforced Marlex or Vicryl splints placed around the intact rapidly growing trachea do not significantly limit its growth. In addition, these synthetic materials appear to be well-tolerated when used to reconstruct tracheal defects if placed over well-vascularized tissue such as muscle.
Animals↗
Surgery for anomalies of the urachus.
Thirty-five children with anomalies of the urachus which have required surgical management have been encountered in this institution over a 20-year period. Of these 35, 19 were classified as patent urachus, 12 as urachal cyst, and 4 as urachal sinus. All cases were treated by excision or drainage. There was one death. Gastrointestinal and other genitourinary anomalies were commonly seen in these patients. Intravenous pyelography was helpful in identifying unsuspected associated genitourinary anomalies while cystography was not. Investigation of the gastrointestinal tract does not appear to be warranted in the absence of symptoms.
Abnormalities, Multiple↗
Recurrent tracheoesophageal fistulas seventeen-year review.
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Esophageal Atresia↗
Segmental infarction of the greater omentum: a cause of acute abdomen in childhood.
Segmental infarction of the greater omentum is an unusual cause of acute abdominal pain in children. Over 30 years at the Hospital for Sick Children in Toronto, this entity was encountered nine times. All children complained of right lower quadrant pain. They were tender in that area and were thought to have acute appendicitis. At operation, the appendix was found to be normal in all and an area of infarcted omentum was identified as the cause of the acute illness. Torsion of the infarcted omentum was noted in four cases. Excision of the omentum was curative.
Abdomen, Acute↗
Rational use of antibiotics for perforated appendicitis in childhood.
Gangrenous and perforated appendicitis was reviewed in 300 pediatric patients. Those with only gangrene generally had a benign course regardless of whether antibiotic therapy was used. However, patients with local perforation or generalized peritonitis had a high incidence of infective complications if they were not treated with antibiotics. Children treated with ampicillin, gentamicin, and clindamycin had markedly fewer wound infections and abscesses and were able to tolerate a diet and go home sooner than those receiving ampicillin and/or gentamicin.
Abscess↗
Treatment of segmental tracheomalacia and bronchomalacia by implantation of an airway splint.
A silastic reinforced marlex mesh splint was inserted surgically to support a collapsing airway in 3 children with tracheomalacia and 1 with bronchomalacia. The operation was well tolerated and no complications occurred. The splint successfully eliminated symptoms of airway collapse in all children. Its effect on airway growth is not yet certain. This method is applicable to patients with tracheomalacia in whom vascular suspension does not eliminate collapse and for those with bronchomalacia in whom pulmonary resection might otherwise be necessary.
Bronchi↗
THe significance of fever following operations in children.
To determine the incidence and clinical significance of early postoperative fever, all children (n = 256) undergoing surgery in the main operating theatres during a 4 wk period were studied. Admission and operating room data were reviewed and the clinical record was monitored at 12 hourly intervals for the first 3 postoperative days. The patients were followed for 1 mo for the development of recognizable complications. Seventy-three children (28.5%) developed fever greater than 38 degrees C but in only four (1.6%) did this represent a septic process. Physical examination led to the proper diagnosis in all. Risk factors that correlated statistically with postoperative fever were operation of greater than 2 hr (p less than .001), intraoperative transfusion (p less than .001), preexisting infection (p less than .01) and the use of preoperative antibiotics (p less than .001). Anatomic site of operation, age and sex were not significant factors. We conclude that many factors other than infection are responsible for post-operative fever. Further, only a very small proportion of children with early postoperative fever develop significant septic complications. In the assessment of postoperative fever a protocol which indiscriminately includes lab investigations and X-rays is costly and usually not diagnostic. Laboratory tests are indicated mainly to confirm diagnoses suspected by clinical evaluation.
Adolescent↗
Fictitious pancreatitis in choledochal cyst.
The classical presentation of choledocal cyst has been regarded as a triad of abdominal pain, jaundice and a palpable abdominal mass; unusual presentations include rupture of the choledocal cyst with bile peritonitis, pancreatitis and bleeding esophageal varices. We are reporting 3 children presenting clinically as recurrent acute pancreatitis with elevated serum amylase and found to have type I choledocal cyst. Despite elevated serum amylase there was no evidence of pancreatic inflammation at laparotomy. High amylase concentration was found in fluid contained within the cyst. This was probably responsible for the elevated serum amylase and also the inflammatory reaction seen in the wall of the choledocal cyst. These cases support the hypothesis that pancreatic reflux into the bile ducts is the etiological factor in the development of choledocal cyst. Our 3 cases were treated by cyst excision and have remained asymptomatic. The presence of hyperamylasemia should not delay appropriate surgical management. The treatment of choice is cyst excision, since it will eliminate factors contributing to the development of cholangitis and hyperamylasemia.
Adolescent↗
Motilin, human pancreatic polypeptide, gastrin, and insulin plasma concentrations in fasted children.
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Adolescent↗