Biomedical subjects

R S Sawin

Publications and source records attributed to R S Sawin.

At least 19 recordsLinked to original sources

PubMed2001

Intussusception: hospital size and risk of surgery.

OBJECTIVE: To determine whether the risk of operative management of children with intussusception varies by hospital pediatric caseload. DESIGN: A cohort of all children with intussusception in Washington State from 1987 through 1996. SETTING: All hospitals in Washington State. METHODS: Five hundred seventy children with a hospital discharge diagnosis of intussusception were identified. Sixty-two were excluded because of missing data. Procedure codes for operative management and radiologic management were also identified. RESULTS: Fifty-three percent of the children had operative reduction and 20% had resection of bowel. Children with operative reduction did not differ from those with nonoperative care by median age or gender; however, children with operative care were significantly more likely to receive care in hospitals with smaller pediatric caseloads and to have a coexisting condition associated with intussusception. Sixty-four percent of children who received care in a large children's hospital had nonoperative reduction, compared with 36% of children who received care in hospitals with 0 to 3000 annual pediatric admissions and 24% of children who had care in hospitals with 3000 to 10 000 annual pediatric admissions. Median length of stay and charges were significantly less in the large children's hospital, compared with other centers. CONCLUSIONS: Children who received care for intussusception in a large children's hospital had decreased risk of operative care, shorter length of stay, and lower hospital charges compared with children who received care in hospitals with smaller pediatric caseloads.

Child, Preschool↗

PubMed2000

Comparison of telomerase levels before and after differentiation of two cell lines of human neuroblastoma.

BACKGROUND: Telomerase is the enzyme that is responsible for maintaining telomere length in human germ cells, tumor cells, and immortalized cells. Its specific role in the immortilization process is unknown. This study was performed to determined whether the level of telomerase activity in human neuroblastoma cell lines correlated with their level of differentiation. We proposed that as neuroblastoma cells differentiated into more mature or benign cells, the levels of telomerase expression would decrease. MATERIALS AND METHODS: Two human neuroblastoma cells lines, SK-N-AS and SK-N-DZ, were differentiated using retinoic acid. These cells were assayed for telomerase activity by the telomere repeat amplification protocol (TRAP) before, during, and after treatment with retinoic acid for 8 days. Untreated cells were used for control and were compared to the retinoic acid-treated cells. Differentiation of the cell lines was confirmed by assaying expression of ret mRNA using the reverse-transcriptase polymerase chain reaction (RT-PCR) and gel electrophoresis of the radiolabeled products. RESULTS: No statistical difference in telomerase activity was noted between control and treated groups. CONCLUSIONS: While telomerase activity has been shown by others to correlate with tumor aggressiveness in human neuroblastoma cells, the mechanism that is involved appears to be separate from cellular differentiation.

Cell Differentiation↗

PubMed2000

Minimally invasive surgery and clinical decision-making for pediatric malignancy.

BACKGROUND: Minimally invasive surgery (MIS) is an ideal way to obtain biopsy specimens in children with cancer. We examined the safety, reliability and outcome of decisions made based on tissue obtained using MIS. METHODS: Fifty-nine oncology patients underwent 62 MIS procedures between January 1994 and July 1998. Complications, biopsy results, and outcomes were reviewed. RESULTS: The study population comprised 32 boys and 27 girls, with an average age of 8.8 years. There were 47 thoracoscopic and 15 laparoscopic operations. Laparoscopic procedures included initial biopsy, determination of resectability, and second-look exam. Thoracoscopic procedures included 40 lung biopsies and seven biopsies/resections of mediastinal masses. Diagnostic accuracy was 100% in all cases. No patient was found retrospectively to have been inadequately treated based on decisions made from tissue obtained by MIS. CONCLUSION: MIS is a safe and accurate means of obtaining tissue in pediatric oncology patients. Treatment decisions can be made accurately and with confidence using these techniques.

Abdominal Neoplasms↗

PubMed2000

Adrenocortical insufficiency in infants with congenital diaphragmatic hernia: a pilot study.

BACKGROUND/PURPOSE: Prior reports have documented that premature infants do not have normal serum levels of cortisol. In contrast, full-term infants usually have adequate cortisol levels. The stress response in critically ill infants may be vital to their recovery. The purpose of this pilot study was to determine whether critically ill full-term infants with congenital diaphragmatic hernia (CDH) show a subnormal adrenal stress response. METHODS: Random serum cortisol levels in infants with CDH (n = 10) were measured using fluorescent polarization immunoassay. In addition, serum cortisol levels were measured after exogenous adrenocorticotropic hormone stimulation (Cosyntropin stimulation test). RESULTS: Six of the 10 infants studied died. Most (79%) of the cortisol levels were subnormal (<7 microgm/dL). Although no significant differences in mean cortisol levels from terminally ill infants compared with surviving infants were detected, survivors tended to have higher cortisol levels. Cosyntropin stimulation resulted in inappropriately low cortisol levels in 2 of the 4 fatally ill patients tested (<30 microgm/dL) and normal responses in the 2 survivors tested. CONCLUSIONS: Infants born with CDH may have an inadequate adrenal stress response despite a life-threatening anomaly. A large-scale prospective study may be warranted to confirm this apparent association. Corticosteroid therapy may be beneficial in this population of patients.

Adrenal Cortex Function Tests↗

PubMed1998

Delayed primary repair of esophageal atresia with tracheoesophageal fistula: is it worth the wait?

OBJECTIVE: To characterize a successful approach to the management of infants with long-gap esophageal atresia (EA) with tracheoesophageal fistula (TEF), significant prematurity with respiratory distress syndrome (RDS), or both, so as to preserve the native esophagus. DESIGN: A review of the medical records and office charts of a cohort of patients with EA and TEF. SETTING: A tertiary care children's hospital affiliated with a major university. PATIENTS: A total of 118 children with EA and TEF admitted from February 1986 through December 1996. All of the patients diagnosed as having EA and TEF during this period were included. INTERVENTION: Of the 118 infants, 88 received primary repair of EA and TEF within 48 hours of birth. An additional 23 children had the TEF divided and a gastrostomy placed secondary to (1) severe RDS and prematurity (n = 6), (2) long-gap EA (gap length > 4 cm or the upper pouch above the thoracic inlet (n = 10), or (3) associated cardiac defects (n = 7). Delayed primary EA repair was done when the RDS resolved or the gap length was 2 cm or less. MAIN OUTCOME MEASURES: Successful anastomosis of native esophagus. Comparison of incidence of gastroesophageal reflux, anastomotic complications, or survival between groups undergoing primary or delayed repair. RESULTS: Primary EA was accomplished in 88 patients. Delayed EA was successfully accomplished in 18 of the 19 surviving patients within 5 months, thereby preserving the native esophagus in all surviving infants. There was no difference in anastomotic complications, gastroesophageal reflux, or survival when the delayed group was compared with those who had a primary repair. CONCLUSIONS: Using delayed EA repair, all children with EA and TEF, regardless of gap length, can have their esophagus preserved. The primary cause of mortality was the association of a severe cardiac anomaly with EA and TEF.

Anastomosis, Surgical↗

PubMed1998

High morbidity of enterostomy and its closure in premature infants with necrotizing enterocolitis.

OBJECTIVE: To review the morbidity and mortality among 68 premature infants treated with enterostomy for necrotizing enterocolitis. DESIGN: Data were collected retrospectively from hospital medical records to include the period between January 1, 1987, and September 30, 1997. SETTING: Tertiary care children's hospital. PATIENTS: A group of 68 infants aged 2 to 35 days (mean age, 12.5 days), weighing 1500 g or less, with necrotizing enterocolitis necessitating surgical enterostomy for treatment. INTERVENTIONS: Creation of any enterostomy during exploratory laparotomy for necrotizing enterocolitis and subsequent closure. MAIN OUTCOME MEASURES: Morbidity and mortality associated with infant enterostomy and its closure. RESULTS: Thirty-nine infants underwent ileostomy with mucous fistula, 16 underwent ileostomy with a Hartmann pouch, 7 had jejunostomy with mucous fistula, 2 had colostomy with mucous fistula, and 4 had colostomy with a Hartmann pouch. Eighteen (26%) of the 68 infants died in the postoperative period of sepsis (n = 10), continuing necrotizing enterocolitis (n = 5), or respiratory distress (n = 3). Of the remaining 50 infants, complications developed in 34 (68%). These complications included strictures requiring further resection at the time of enterostomy closure in 20 infants; stricture of the enterostomy requiring surgical revision in 6; incisional hernia in 3; parastomal hernia in 4; enterostomal prolapse or intussusception in 6 and 1, respectively; wound dehiscence in 4; wound infection in 8; small-bowel obstruction requiring laparotomy in 2; and anastomotic complications in 2. Only 16 enterostomies were closed uneventfully, with 3 of these infants subsequently dying of sudden infant death syndrome between 6 and 8 months after the operation. Of the surviving infants, 3 (6%) continue to require home hyperalimentation. CONCLUSIONS: Although enterostomy in infants with low birth weight with necrotizing enterocolitis may be lifesaving, it is also a major cause of morbidity. These data suggest the feasibility of a prospective study comparing resection and primary anastomosis with resection and enterostomy.

Enterocolitis, Pseudomembranous↗

PubMed1998

Long-term outcome for infants and children with sacrococcygeal teratoma: a report from the Childrens Cancer Group.

BACKGROUND/PURPOSE: Sacrococcygeal teratomas (SCT) are a relatively uncommon tumor affecting neonates, infants, and children. This study was designed to determine the effect of therapy on the long-term outcome of neonates and children with sacrococcygeal teratomas (SCT). METHODS: The authors conducted a retrospective review of children with SCT treated at 15 Childrens Cancer Group institutions from 1972 to 1994. RESULTS: One hundred twenty-six children presented with SCT diagnosed prenatally (n = 32), at birth (n = 79), or later in infancy (n = 15). For neonates, complete resection was performed except in two babies with lethal associated defects. All others (n = 15) underwent resection at the age of diagnosis. Six had a sacral mass identified at birth but had delayed surgery (1.5 to 11 months) and of these, two were malignant. Resection was via sacral (n = 96) or abdominosacral (n = 28) approach. Histology showed mature teratoma (MT, 69%), immature teratoma (IT, 20%), or endodermal sinus tumor (EST, 11%) at presentation. Seven neonates (5.6%) died of perioperative complications, whereas the remaining 117 were available for long-term follow-up. Between 6 and 34 months postresection, recurrent disease developed in 9 of 80 MT patients (11%) followed-up for a mean of 5 years. Recurrent disease was MT (n = 2) and EST (n = 7). The recurrent EST patients were treated with adjuvant chemotherapy. Six are alive with mean follow-up of 114 months, whereas one with metastatic disease was lost to follow-up. Recurrence (MT) developed in only 1 of 24 IT patients, and all are alive and well at mean follow-up of 39 months. Patients presenting with EST (n = 13) underwent excision, with two dying from non-EST causes. Six EST patients received no chemotherapy, with two of the six (33%) experiencing recurrence within 11 months and both disease free after salvage chemotherapy. The remaining five EST patients received adjuvant chemotherapy; four are alive and one died of metastatic disease. Of the 18 EST patients followed-up after resection (presentation, 11, recurrent teratoma, 7), 16 (89%) are free of disease with a mean follow-up of 91 months. CONCLUSIONS: (1) Benign teratomas have a significant recurrence rate mandating close follow-up for more than 3 years. (2) Surgical resection alone is adequate therapy for nonmetastatic malignant tumors. (3) Survival for malignant lesions with metastases is excellent with modern chemotherapy.

Child, Preschool↗

PubMed1998

Pediatric chest lesions.

Pediatric chest lesions are usually either symptomatic or strikingly visible. The most common lesions, as well as the lesions that require prompt surgical treatment, are reviewed in this article. Careful imaging studies and diagnostic tests such as bronchoscopy can usually characterize these lesions and enable a safe, directed surgical approach. Although many chest lesions can be managed without surgery, primary care providers can expedite treatment of these problems by early referral to pediatric surgeons or pediatric thoracic surgeons.

Emphysema↗

PubMed1997

Pseudoaneursym of the external carotid artery after tonsillectomy. A rare complication.

Tonsillectomy is one of the most common major surgical procedures performed in children in the United States. Otolaryngologists should be cognizant of the potential complications associated with the procedure. We report a case of a pseudoaneurysm of the external carotid artery that developed in a boy after elective adenotonsillectomy for management of obstructive sleep symptoms.

Adenoidectomy↗

PubMed1997

Improved long-term outcome for patients with jejunoileal apple peel atresia.

BACKGROUND/PURPOSE: Although apple peel intestinal atresia is a rare lesion associated with significant morbidity and high mortality, the authors have seen no deaths since 1983. Similar success has rarely been reported, and there are no reports of long-term follow-up. This study examines the short-term and long-term complications and outcome for these children, critiques our evolution in care, and gives current recommendations for therapy. METHODS: A retrospective review of 12 patients over 11 years was conducted. Perinatal history and operative and perioperative management were examined and end results and complications using different management plans compared. Long-term outcome was determined through clinic follow-up. RESULTS: Mean follow-up was 5.1 years. Children had a mean 61.4 cm of total small bowel. Seven patients underwent a primary anastomosis and five had enterostomies. The proximal jejunum was tapered, plicated, resected or left intact. Eleven children required gastrostomy tubes. All children required total parenteral nutrition. Full enteral feeding was achieved in all children, but three required gastrostomy supplementation. Three patients who had enterostomies suffered bowel obstruction, two with dilated, dysmotile proximal jejunum required subsequent tapering. Eight children maintained a growth curve between the 5th and 50th percentile. None have short bowel physiology, and all have achieved acceptable bowel function. CONCLUSIONS: (1) Total parenteral nutrition is essential for initial nutritional management. (2) Use of an enterostomy leads to an increased incidence of complications. (3) The dilated proximal bowel should be resected, tapered, or plicated, and a primary anastomosis should be performed. (4) Gastrostomy tubes are necessary for initial management. (5) Early morbidity is common, though excellent long-term outcome and normal growth and development are expected.

Anastomosis, Surgical↗

PubMed1997

Aortic arch anomalies associated with long gap esophageal atresia and tracheoesophageal fistula.

PURPOSE: The purpose of this study was to determine whether aortic arch anomalies are associated with long gap esophageal atresia and tracheoesophageal fistula (EA-TEF). METHODS: The authors performed a retrospective review of all infants who had EA-TEF from 1980 to 1996 at two pediatric surgery centers. Two hundred three infants who had EA-TEF were identified. RESULTS: Twelve infants were noted to have both long gap EA-TEF defined as a gap length greater than 3 cm and aortic arch anomalies. Of these 12, 7 had aberrant right subclavian arteries originating from the descending aorta. Four of the seven infants who had aberrant right subclavian artery (SCA) had gap lengths greater than 4 cm. All four had their fistulae divided initially through a right thoracotomy with primary repair performed at a later date. The remaining five infants who had long gap EA-TEF had right-sided aortic arch with aberrant left subclavian arteries. All five initially underwent exploration through the right chest. On discovery of the long gap EA and concurrent vascular anomaly, the thoracotomies were closed, and the infants underwent definitive repair of both their EA-TEF and their vascular anomaly through a left thoracotomy. CONCLUSIONS: The authors find that aortic arch anomalies are associated with long gap EA-TEF. Patients who have these two anomalies tend to have a long gap. Preoperative diagnosis of these anomalies may alter the timing and technique of surgical intervention. The embryogenesis of these vascular lesions may account for this more severe form of esophageal atresia.

Aorta, Thoracic↗

PubMed1997

Needle localization for thoracoscopic resection of small pulmonary nodules in children.

BACKGROUND: Children who have malignant disease and pulmonary nodules frequently need a tissue diagnosis to direct therapy. Computed tomography (CT)-guided needle localization and methylene blue marking allow thoracoscopic resection of nonvisible nodules. METHODS: Malignant disease was diagnosed in three patients aged 2, 2.5, and 11 years. Pulmonary nodules seen on chest CT, representing either metastatic disease or infection developed in each patient. All lesions were 1 to 2 cm deep to the pleural surface, precluding thoracoscopic visualization. A Homer mammographic needle was placed near the lesion using CT guidance under general anesthesia. The pleura overlying the lesion was also marked with methylene blue. Under the same anesthetic, patients went to the operating room where the lesions were thoracoscopically resected. RESULTS: Needle localization and methylene blue staining accurately localized the lesion in all cases. Thoracoscopic resection provided a diagnosis of metastatic disease or infection in all cases. There were no complications. CONCLUSION: CT-guided needle localization of pulmonary lesions deep to the pleural surface, is a safe, accurate method for allowing thoracoscopic resection in these children who would otherwise need open thoracotomy for diagnosis.

Biopsy↗

PubMed1997

Functioning adrenal neoplasms.

Neoplasms of the adrenal gland may cause increased hormone activity, which has profound effects on the growing child. The adrenal gland should be viewed as two functionally separate glands: the adrenal medulla and adrenal cortex. Neoplasms of the adrenal cortex secrete excess glucocorticoids, mineralocorticoids, or androgens. Adrenal medulla neoplasms generally secrete excess catecholamines. Understanding the anatomy, embryology, and physiology of the adrenal cortex and medulla allows surgeons to diagnose these tumors, prepare the patients for surgery, and treat them effectively after resection. Because adjuvant therapy for adrenal cortical and medullary tumors is of limited effectiveness, the surgeon's role in the treatment of these neoplasms is extremely important.

Adrenal Cortex↗

PubMed1996

Preresection chemotherapy improves survival for children with Askin tumors.

OBJECTIVE: To test whether patients with Askin tumor treated with aggressive neoadjuvant chemotherapy have a better clinical outcome. DESIGN: Retrospective case series. SETTING: Pediatric referral center. PATIENTS: All children diagnosed with malignant small-cell tumors of the chest wall (Askin tumor) and treated from 1975 to September 1987 (phase 1, n = 6) and from September 1987 to the present (phase 2, n = 9). MAIN OUTCOME MEASURES: Survival as a function of extent of disease and response to therapy as measured by tumor volume, survival, and recurrence. RESULTS: All phase 2 patients had significant reduction of tumor volume and improved survival by Kaplan-Meier estimates compared with phase 1 patients. No phase 1 patients are still alive. CONCLUSION: Patients with Askin tumor treated with aggressive preresection chemotherapy have smaller tumors to resect and improved survival.

Adolescent↗

PubMed1996

Surgical implications of necrotizing fasciitis in children with chickenpox.

Varicella (chickenpox) affects approximately 90,000 children each year. Although most cases resolve, some develop necrotizing soft tissue infections secondary to group A streptococcus and staphylococcus. Delay in diagnosis is common. At the time of initial presentation, the need for surgical intervention is not always clear. The authors conducted a retrospective review of 30 patients with varicella (seen from December 1993 to June 1995) for whom there was clinical concern for necrotizing soft tissue infection. Various parameters were examined, including tachycardia, band count, temperature, and clinical symptoms, to differentiate the children who required surgery from those who did not. Of the 30, 22 underwent surgery. Eighteen had necrotizing fasciitis and required debridement, and four had abscesses that were incised and drained. Eight patients had simple cellulitis and did not require operation. Group A streptococcus was the most common organism cultured. All patients were treated with appropriate antibiotics. Twenty of the 22 surgical patients had elevated band count (> or = 5%), 21 had tachycardia, and 18 were febrile at the time of presentation (> 4 days after the onset of chickenpox). Although all patients with necrotizing fasciitis had tachycardia, this sign was a less specific indicator for surgery than was increased band count. Severe pain, erythemia, and induration was the most common signs/symptoms in the surgical patients. The survival rate for these 30 patients was 100%, and there was little long-term morbidity. The authors recommend immediate surgical intervention for children with chickenpox who present more than 2 or 3 days after the onset of the viral illness with symptoms that include fever, tachycardia, and an elevated band count in association with an erythematous, indurated, painful lesion. With this sign/symptom complex, the presumptive diagnosis must be necrotizing fasciitis until proven otherwise. If the patient has suspicious symptoms or if these symptoms are associated with tachycardia or an elevated band count, the patient warrants admission, institution of intravenous fluids, nafcillin, clindamycin, and close observation over several hours. If the symptoms progress over the next few hours or if the tachycardia persists despite rehydration and antibiotics, the patient should be taken to the operating room for exploration. The authors strongly endorse such exploration despite the risk of a negative operation, because the morbidity and mortality associated with delayed surgical treatment are potentially significant. With prompt aggressive surgical and medical treatment, a good outcome can be anticipated for these patients.

Anti-Bacterial Agents↗

PubMed1996

Does posterior sagittal anorectoplasty in patients with high imperforate anus provide superior fecal continence?

The posterior sagittal anorectoplasty (PSARP) has become the primary surgical procedure for patients with high imperforate anus. Very few careful long-term follow-up studies have established the superiority of the PSARP procedure over other surgical repair techniques. The authors' goal was to evaluate the operation and to identify the factors associated with improved continence. The medical records, operative reports, and radiographs of 53 patients (46 male, 7 female) who underwent PSARP for high imperforate anus at Children's Hospital and Medical Center (CHMC) between 1982 and 1990 were reviewed retrospectively. Subjective follow-up data were collected by telephone questionnaire, assessing habits indicative of stool continence, and a "fecal continence score" (FCS) was calculated for each patient. A prospective, 7-day diary assessing similar patterns of fecal continence was completed by each patient's family. The mean age of the patients studied was 8.0 years, and the mean follow-up period was 6.8 years. The telephone questionnaire was completed for 48 patients (94%). Toilet training for bowel continence was successful in 20 patients (42%) and occasionally successful in another 20 patients (42%), but 8 patients (16%) had no awareness of impending stool. Forty-five (94%) were physically active, but 16 (33%) reported social problems related to offending odor. The mean fecal continence score for all patients was 3.0 +/- 1.4 (5=excellent, completely continent), which was nearly identical to published scores for the other types of surgical repair. The FCS did not improve with age. The parents' responses to the telephone questionnaire matched the results obtained from the prospectively collected continence diary data. The authors' results for PSARP in patients with high imperforate anus do not differ substantially from those achieved by other repair techniques. Previously cited prognostic factors such as fistula anatomy and sacral anomalies did not appear to alter the functional results in the authors' series. Aggressive postoperative bowel management should be anticipated in all patients who have high imperforate anus and may benefit those who otherwise would achieve less satisfactory continence.

Adolescent↗

PubMed1996

Laparoscopic Ladd's procedure and assessment of malrotation.

Upper gastrointestinal series are frequently obtained on children with abdominal pain and vomiting. If the ligament of Treitz (LOT) is in an equivocal position and not to the left of the spine at L1 or L2 it is important to determine the position and fixation of the cecum to assess the breadth of the mesenteric pedicle. Radiographic studies may not accurately accomplish this because of the changing position of the cecum. Laparoscopy can he used to determine the position of LOT and whether the cecum is fixed in the right lower quadrant. If the patient is judged to be at risk for volvulus (i.e., a shortened mesenteric pedicle) a Ladd's procedure can be accomplished laparoscopically with good long-term results. The use of the laparoscope is not advocated when acute volvulus is suspected.

Cecum↗

PubMed1995

Secretion of gastrin-releasing peptide by retroperitoneal tumors.

PURPOSE: Gastrin-releasing peptide (GRP) is a neuropeptide with growth factor activity in vitro for a variety of tumors including neuroblastoma. If GRP is secreted by neuroblastomas, its detection in serum might be an excellent way to both diagnose and monitor this tumor in patients. METHODS: Small portions of resected tumor specimens were maintained in tissue culture as tumor explants for 24 hours. The tumors included: 3 ganglioneuromas, 1 neuroblastoma, 1 primitive neuroectodermal tumor, 1 Wilms' tumor, 1 rhabdoid tumor, and 1 benign brachial plexus tumor. Control flasks were maintained simultaneously under identical conditions. After 24 hours of incubation, the tumor-conditioned media and the control media were assayed in duplicate for [GRP] using a radioimmunoassay. RESULTS: All the conditioned media from the benign tumors contained < 25 pg/mL net GRP, whereas all the malignant tumor-conditioned media contained > or = 45 pg/mL (P = 0.003). CONCLUSIONS: These data suggest that GRP is secreted by pediatric retroperitoneal tumors and that the amount secreted varies directly with the degree of malignancy of the tumor. This study suggests that GRP may be a candidate tumor marker for pediatric retroperitoneal tumors.

Biomarkers, Tumor↗