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Biomedical subjects

R M Filler

Publications and source records attributed to R M Filler.

At least 127 records · Page 7Linked to original sources
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

Circular myotomy and esophageal length and safe esophageal anastomosis: an experimental study.

The indication for circular myotomy is often unclear at the time of esophageal atresia repair because the maximal permissible tension at the anastomosis and the precise effect of myotomy on esophageal length and anastomotic tension are not known. This study was undertaken to answer these questions. In piglets, 0 to 6.5-cm segments of thoracic esophagus were excised and approximation force was measured by dynamometers attached to traction sutures in each cut end of the esophagus prior to anastomosis. When approximation force was greater than 75 g. esophageal leaks occurred and increased fibrosis was noted at the anastomosis. Circular myotomy of the upper segment reduced the force necessary to approximate the ends of the esophagus after a 5- to 6-cm resection by about 50%, and double circular myotomy by as much as 75%. When the upper third of the esophagus of piglets and neonatal cadavers was stretched by the application of traction forces of 0 to 75 g. esophageal length increased by about 40%. Thereafter, length increase ws minimal. For any given traction force, each circular myotomy increased esophageal length by about 5 mm. These studies suggest that accurate measurement of approximation force would be useful at the time of esophageal atresia repair. On the basis of these data, circular myotomy(s) is indicated to elongate the esophagus and reduce anastomotic tension when a force greater than 75 g is needed to approximate the esophageal ends.

Animals↗
PubMed1981

Liver tumors.

Several different malignant and benign tumors of the liver are seen in children. They pose a significant challenge for the pediatric surgeon because they reach a very large size before discovery and hepatic resection is usually necessary for cure. Surgical mortality and morbidity are still significant.

Hemangioendothelioma↗
PubMed1981

Testicular tumours in maldescended testes.

Maldescent is known to increase the risk of cancer of the testis. However, the effect of orchiopexy on reducing tumour risk and altering tumour type or stage at diagnosis is not established. The authors review the records of patients with testicular tumours seen for seminoma (1958 to 1975) and nonseminoma (1958 to 1970). Of 646 patients, 53 (8.2%) had a history of testicular maldescent; in 42 (79%) the maldescent was unilateral and in 6 of these, the tumour developed in the normally descended testis. Twenty patients had successful orchiopexy at a median age of 14 years (range from 6 to 35 years). Tumours found in the 53 patients were seminoma (38 patients), teratoma (7 patients), embryonal carcinoma (6 patients), teratocarcinoma (1 patient) and choriocarcinoma (1 patient). Average age at the time of diagnosis of seminoma was 38 years and of nonseminoma 31 years. Average age was lower at the time of diagnosis of the tumour for those who had successful orchiopexy than for those who did not. Earlier stage nonseminomas were found in patients who had an orchiopexy. Twenty-five (66%) of the 38 seminomas occurred in testes located outside the scrotum, whereas only 6 (40%) of 15 nonseminomas occurred in a nonscotal position, suggesting that persistent maldescent favours seminoma over nonseminoma. In this retrospective review, no statement can be made about the effect of orchiopexy on tumour risk. However, this procedure appears to lead to an earlier diagnosis and may influence the type of tumour that subsequently develops.

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↗
PubMed1981

Wide gap esophageal atresia with inaccessible upper pouch.

Circular myotomy of the proximal esophageal pouch has allowed end-to-end esophagoesophagostomy in infants with wide gap esophageal atresia. Occasionally, the proximal pouch ends so high in the thorax that the circular myotomy is technically impossible under conventional means. Exteriorization, mobilization, and myotomy of the proximal esophageal pouch via a separate cervical incision has allowed us to overcome this limitation of an inaccessible upper pouch and has permitted esophagoesophagostomy. This technique has been performed successfully in two infants with good results and no morbidity over a follow-up period of 1 1/2 to 3 1/2 years.

Esophageal Atresia↗
PubMed1980

Long-term follow-up circular myotomy for esophageal atresia.

Between January 1976 and March 1979, esophageal atresia was successfully repaired in six infants with circular myotomy (Livaditis technique) and end-to-end anastomosis. Children were 1 day-6 mo in age and weighed 2.4 to 8.0 kg at the time of repair. Four children required one and two children required two circular myotomies in the proximal esophagus to bridge gaps between esophageal ends, which varied from 1.2-3.0 cm. Follow-up has been 1-4 yr (mean-3 yr). Operative complications included: opening of the mucosa at myotomy (2) and anastomotic leak (2). Subsequently, three children developed anastomotic stricture which required dilatation. Current x-rays show ballooning of the esophagus at the myotomy site during swallowing in all. However, the esophageal diameter at the myotomy site was never more than 2 cm greater than that of the distal esophagus. In the three children with anastomotic stricture, mucosal ballooning was not greater than in the others. During follow-up, weights have ranged from the 3rd to the 50th percentile for age. Swallowing has been good in 4, fair in 1 (dilatation still required), and poor in 1 (oropalatal deformities necessitate gastrostomy feedings). Circular myotomy offers a safe means of esophageal lengthening. Complications directly related to the myotomy are minimal (mucosal tear) and should be recognized at operation. Ballooning of the mucosa at the myotomy site is a common late finding but diverticulum formation has not occurred. Swallowing and esophageal motility are similar to other children who have had esophageal atresia repair.

Esophageal Atresia↗
PubMed1980

Tracheal compression as a cause of apnea following repair of tracheoesophageal fistula: treatment by aortopexy.

Tracheal compression is one of the many causes of apnea following repair of esophageal atresia with tracheoesophageal fistula. Since May, 1977 we have treated eight patients with "dying spells" usually occurring during and following a feeding. These episodes were characterized by cyanosis and bradycardia, which progressed to apnea. Tracheal compression was documented to be the etiology of the apnea spells. Other possible causes such as aspiration from gastroesophageal reflux, recurrent tracheoesophageal fistula and esophageal stricture were eliminated. Eight infants underwent aortopexy that was successful in terminating the apneic episodes in seven patients with an average follow-up of 20 mo. One patient continued to have symptoms from a previously undiagnosed vascular ring which was successfully divided one month following aortopexy. After being asymptomatic for 1 mo this infant died from a cardiorespiratory arrest at home. An autopsy did not reveal the cause. Intermittant tracheal obstruction leading to apneic spells is a life-threatening entity following tracheosophageal fistula repair, which can be corrected by aortopexy.

Aorta↗
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

Serum intralipid levels in neonates during parenteral nutrition: the relation to gestational age.

To detect hyperlipidemia, serum Intralipid levels have been monitored by nephelometry (light scanning index) in children on total parenteral nutrition with glucose, amino acids, and Intralipid during the past 2 yr. Sufficient data were available in 93 neonates to analyze the effect of an Intralipid dose on serum levels in infants of different gestational ages. Guided by monitoring, Intralipid was given by constant infusion at a dose varying between 0.5 to 6.0 g/kg/day. Median post natal age at the start of therapy was 7 days. Gestational age varied from 27 to 32 wk in 36 infants (Group I), 33 to 36 wk in 18 (Group II), and was more than 37 wk in 39 (Group III). Of Group I infants, 28% developed hyperlipidemia (Intralipid level greater than 100 mg/100 ml) as compared to an incidence of 7% in Groups II and III. Peak Intralipid levels were highest in Group I and regression analysis also indicated that Intralipid was least well tolerated by this group. The dose response during the first 48 hr of Intralipid therapy was not significantly different from dose response later. Similarly, diagnosis did not seem to affect the dose-response. Dose recommendations were based on analysis of dose response lines. Even using these guidelines monitoring of serum Intralipid is advisable to avoid hyperlipidemia during Intralipid therapy. It is recommended that measurements of serum Intralipid be made several times per week in very low birth weight infants (Group I), and weekly in more mature neonates after a safe maximum Intralipid dose is established.

Age Factors↗
PubMed1980

Treatment of choledochal cyst by excision.

Since 1969 excision of choledochal cyst and establishment of bile drainage by Roux-en-Y hepaticojejunostomy has been performed in 7 children whose ages ranged from 10 mo to 11 yr. In 3 children, the cyst had been treated 5 yr, 4 wk, and 3 wk previously by cystduodenostomy, cystjejunostomy, and cholecystduodenostomy, respectively; further surgery was indicated for biliary obstruction and severe cholangitis. The other four children were not acutely ill. All cysts were located distal to the confluence of the right and left hepatic ducts. The volume of the smallest cyst was 25 ml and the largest 500 ml. In all children a small remnant of distal cyst was not excised to avoid injury to the duodenum and pancreas. In four children a remnant of proximal cyst was left attached to the hepatic duct to allow a large biliary intestinal anastomosis and minimize the possibility of stricture. No serious intraoperative problems were encountered. Prolonged drainage (2-3 wk) from Penrose drain sites in two children were the only postoperative complications. Liver function tests have remained normal in all and no episodes of cholangitis or jaundice have been noted during follow-up (median: 4.5 yr). This experience supports recent reports that indicate that cyst excision is associated with low mortality and morbidity. Cyst excision is preferred over traditional internal drainage procedures because it (A) eliminates a reservoir for bile stasis, (B) removes a mechanism which allows continuous reflux of pancreatic juice into the cyst, and (C) probably prevents the occurrence of bile duct carcinoma which has been noted in 3.0% of patients with choledochal cyst.

Adolescent↗
PubMed1980

Pheochromocytoma in children--an update.

Eight cases of pheochromocytoma in children were managed between 1958 and 1978. Headache, visual blurring, sweating, and hypertension were the most common findings. One patient presented with a hypertensive crisis during appendectomy. Three other children had a family history of pheochromocytoma and Hippel-Landau disease, thyroid carcinoma, and renal stones. The diagnostic approach was based on a high suspicion of the disease from the clinical picture. The most reliable laboratory investigations were urinary VMA, metanephrine, and catecholamines. I.V.P. and angiography were successful in localizing the tumor. In 4 cases, CT scan localized the tumor, although a second tumor was not seen in 1 case. Preoperative control of hypertension was achieved with phenoxybenzamine, propanolol, apresoline and reserpine in seven cases. The main anesthetic drugs used were pentothal, methoxyflurane, nitrous oxide, Innovar, and pancuronium. Tumors were located in the right adrenal in four, the left adrenal in two, both adrenals in one, and bilateral para-aortic sites in one. In two cases, hypertensive episodes during manipulation of the tumor were controlled with phentolamine. Ligation of the venous drainage from a tumor was associated with a sudden sustained fall in systemic blood pressure in six cases. In two, blood pressure remained elevated until a second tumor was found and removed. Hypotension was then corrected by the rapid infusion of fluid and blood, and vasopressors were not used. There were no postoperative complications and all children remained normotensive during the follow-up. The tumors of seven of the patients were benign. One tumor showed a low grade malignancy.

Adolescent↗
PubMed1980

Hormonal bioassay of gonadotropin-producing hepatoblastoma.

Hepatoblastoma was associated with signs of isosexual precocity in an 11-month-old boy. Circulating gonadotropic hormone levels were elevated. Gonadotropic activity was demonstrated by bioassay in extracts of primary and metastatic tumor, and in media surrounding long-term tissue culture of the primary tumor. Morphology of the endocrine glands and bioassay of the pituitary gland obtained at autopsy indicated the presence of gonadotropins and other tropic hormones despite the physiologically abnormal hormone status. These ae the first direct studies of pituitary hormone content in this syndrome.

Biological Assay↗
PubMed1979

Parenteral feeding in the management of children with cancer.

Total parenteral nutrition TPN has been used to treat or prevent malnutrition in 65 children with a variety of solid tumors and leukemia in the past 7 years. TPN was used in 58 patients with gastrointestinal complications of surgery, chemotherapy, or radiation; in 2 patients for preoperative correction of malnutrition; and in 8 who were entered into a prospective study. During TPN, general nutrition and appearance improved in all patients. Weight gain was noted in most. Despite gastrointestinal complications, which usually require the interruption of chemotherapy and radiation, treatment could be continued at full dose in 31 children with nutritional support by TPN. TPN was discontinued in 6 patients when blood cultures became positive. Sepsis was treated successfully by removal of the central venous catheter in all 6 and administration of antibiotics in 3. TPN appears to be safe and effective means of combating malnutrition which may occur with cancer and its therapy.

Adolescent↗
PubMed1979

Prognostic factors in omphalocele and gastroschisis.

Size of the abdominal wall defect, viscera exposed or herniated, birth weight, associated medical conditions and congenital anomalies, mode and complications of treatment, and the use of total parenteral alimentation was reviewed in 79 cases of omphalocele and 44 cases of gastroschisis treated in the past 10 yr. Sixty-seven percent of infants with omphalocele and 73% of those with gastroschisis survived. In omphalocele, the most important factors affecting mortality were the presence of other associated abnormalities and low birth weight. The size of the abdominal wall defect, the viscera herniated, and the mode of treatment did not appear to affect mortality. In gastroschisis, the size of the abdominal defect, birth weight, viscera exposed or herniated, and associated anomalies were not significant factors affecting mortality. Mortality was usually secondary to intestinal or wound complications. Statistical analysis could not prove that primary repair resulted in greater survival than the use of a silon pouch, but analysis of complications clearly indicates that the former method is preferable and that silon pouch should be reserved for cases in which primary repair is not possible.

Abdominal Muscles↗