Biomedical subjects

S H Ein

Publications and source records attributed to S H Ein.

At least 19 recordsLinked to original sources

PubMed1998

Patterns of recurrence of intussusception in children: a 17-year review.

PURPOSE: Patterns of recurrence of intussusception (INT) were reviewed to determine whether changes in management have affected the rate and patterns of recurrence as well as long-term outcome in children with multiple (i. e., 2 or more) recurrences. MATERIALS AND METHODS: Review was done of 763 children with 876 intussusceptions, including (1) recurrence rate, (2) patterns of recurrence (number of and interval between recurrences), (3) reducibility, (4) pathologic lead points (PLP), (5) operative findings and (6) long-term follow-up in those with multiple recurrences. RESULTS: Above features (1)-(6) were the same in those managed with barium enema (1979-1985) and those managed with air enema (1985-1996). Overall recurrence rate was 9 %; 11 % with barium enema and 8 % with air enema. Sixty-nine patients had 113 recurrences: 47/69 (68 %) and 1 recurrence and 22/69 (32 %) had multiple recurrences. Multiple recurrences presented as isolated episodes or in clusters up to 8 years. Reducibility was 100 % for initial INT and 95 % for recurrent episodes; there were no perforations. Surgery, in 4 with irreducible recurrence, revealed no PLP. PLP were present in 5 (8 %): 2 (4 %) with 1 recurrence and 3 (14 %) with multiple recurrences. No pattern of recurrence was predictive for PLP. Long-term follow-up (up to 15 years) available in 11 with multiple recurrences revealed a favourable outcome. CONCLUSIONS: Rates and patterns of recurrence did not change with altered management. Because of the high reduction rate of recurrences, lack of perforation and favourable long-term follow-up, we recommend radiological reduction for recurrent INT. Multiple recurrences are not a contraindication. A careful search for PLP is mandatory. Surgery should be reserved for irreducible recurrences or for demonstrated PLP.

Adolescent↗

PubMed1998

To tube or not to tube: do infants and children need post-laparotomy gastric decompression?

The purpose of this study was to evaluate the role of nasogastric (NG) decompression after laparotomy in pediatric surgical practice: 94 children who underwent abdominal surgery by a single surgeon were consecutively prospectively managed without postoperative NG tubes. Patients with either bowel obstruction or intra-abdominal infection were excluded from the study. These children were compared with 94 retrospective, matched controls who were routinely managed with postoperative NG decompression by the same surgeon. Data were analyzed with regard to patient, operative, and outcome variables. There was no difference in gender, age (3.8 +/- 0.5 vs 3.5 +/- 0.4 years, P > 0.7), or postoperative complications (P > 0.8) between the two groups. However, there was a higher incidence of postoperative vomiting (22% vs 11%, P > 0.05) in the children who did not have postoperative NG decompression. Nevertheless, a significant decrease in time to first feed, first stool, and discharge was noted in the group of patients managed without NG tubes (P < 0.05). NG decompression thus need not be routinely used in the pediatric patient undergoing abdominal surgery, as there is no difference in postoperative complications and the hospital stay is shortened.

Child, Preschool↗

PubMed1998

Gastric tubes in children with caustic esophageal injury: a 32-year review.

PURPOSE: Caustic injury to the upper aerodigestive system with scarring of the pharynx, hypopharynx, and esophagus is a challenging reconstructive problem. The author has used the gastric tube for this purpose for three decades. METHODS: During the last 32 years (1965 to 1996 inclusive) the author treated 11 patients who required esophageal replacement with a gastric tube conduit, which was anastomosed to the cervical esophagus. At the time of injury, ages ranged from 2 months to 13 years (mean, 3 years) in seven boys and four girls. Time from injury to esophageal replacement was 12 months to 14 years (mean, 5 years). All 11 had multiple dilations before the replacement. Two had injury and scarring of the epiglottis and larynx that required pharyngeal reconstruction and tracheostomy before replacement. Nine patients underwent reconstruction with a gastric tube anastomosed to the cervical esophagus, and the other two had an interposition with an intrathoracic anastomosis. Eight tubes were antiperistaltic and three isoperistaltic. Seven tubes were placed in the retrosternal space, three were transthoracic, and one was subcutaneous. Six tubes were completed in two stages and five in a single stage. RESULTS: Nontube complications were wound infection (n = 2), perforation (n = 2), paralyzed hemidiaphragm (n = 1), and recurrent laryngeal nerve injury requiring tracheostomy (n = 1). Tube complications were anastomotic leak (n = 9), stricture (n = 8), anastomotic resection (n = 3), ulcer (n = 1), and perforation (n = 1). Six required posttube multiple dilations for several years including self-bouginage (n = 2). All learned to swallow and eat initially with minimal aspiration; only one remains on tube feed supplements. Long-term follow-up (3 to 30 years) includes nine eating normally and not requiring dilations (the tracheostomy boy has chronic lung disease), one lost to follow-up after 1 year, and one death from tube hemorrhage 2 months after operation. CONCLUSION: Children with caustic injury to the upper aerodigestive system can undergo gastric tube replacement with good results. The majority of the problems relate to the esophagogastric tube anastomosis.

Adolescent↗

PubMed1998

Long-term morbidity in total colonic aganglionosis.

BACKGROUND/PURPOSE: No surgical treatment for total colonic aganglionosis (TCA) clearly has been proven superior. To identify clinical criteria associated with long-term functional outcome, a 28-year retrospective institutional review of this entity from 1969 through 1996 inclusive was undertaken. METHODS: Total colonic aganglionosis (TCA), defined here as aganglionosis extending from the anus to at least the ileocecal valve but no further than 50 cm proximal to the ileocecal valve, was identified in 29 infants and children. Appropriate leveling ileostomy was performed in 28 of 29 patients, and definitive surgical reconstruction was performed in 26 of 29. Three groups were identified based on the definitive surgical repair performed: group 1, construction lacking or incorporating a short ganglionic-aganglionic common channel (modified Soave or modified Duhamel, n = 8); group II, construction of an extended common channel (Martin-Duhamel, Martin-Soave; n = 6); and group III, all others including an intermediate-length common channel (n = 13). RESULTS: Functional outcome at extended follow-up (mean, 6.6 +/- 5.6 years; range, 0.7 to 23) was determined based on survival, long-term ostomy requirements, growth, major complications, continence, and enterocolitis and bowel movement frequency. Although long-term functional outcome was deemed satisfactory in six of seven patients in group I, function was satisfactory in none of six group II patients. Group III results were intermediate (satisfactory in 6 of 13). CONCLUSIONS: Acceptable long-term outcome was most frequent in TCA patients whose definitive repair did not incorporate an extended ganglionic-aganglionic common channel. The use of extensive lengths of aganglionic bowel to maximize fluid absorption is frequently met with substantial morbidity.

Analysis of Variance↗

PubMed1998

Management of gastroschisis with concomitant jejuno-ileal atresia.

BACKGROUND: The incidence of jejuno-ileal atresia in neonates concomitantly found to possess gastroschisis has been reported to be 5% to 25%. Initial treatment for this condition has not been well established. METHODS: Thirteen newborns with gastroschisis and coexisting jejuno-ileal atresia, were identified and treated at our institution over the past 16 years (1978 through 1996). Patient characteristics at presentation, surgical therapy, and complications at extended follow-up were reviewed. RESULTS: All neonates were preterm (mean gestational age, 35.2 +/- 2.0 weeks) and of low birth weight (2.1 +/- 0.4 kg). Atresia types II, IIIa, IIIb, and IV were identified at the initial surgical procedure in one, eight, one, and three patients respectively; however, one synchronous small bowel atresia went unrecognized. A primary anastomosis was fashioned in 8 of 13 newborns, the creation of which did not influence length of hospitalization, length of total parenteral nutrition (TPN) requirement, complication rate, or survival; however, reoperation was required in two of eight patients to mediate anastomotic complications. Atresia associated with intestinal gangrene or perforation was treated by primary anastomosis in three of six patients and the remaining three by enterostomy. Primary abdominal wall closure was possible in 10 of 13 patients; a Silon pouch was required in three. All nine survivors (69%) displayed protracted small bowel dysfunction requiring TPN (mean TPN duration of 3.6 +/- 3.0 months; range, 1 to 11). Mortality in four patients was a consequence of severe prematurity, Silon pouch wound sepsis, or TPN-induced cirrhosis. CONCLUSIONS: When technically feasible, restoration of intestinal continuity by primary anastomosis is a reasonable treatment option in patients with coexisting gastroschisis and jejuno-ileal atresia. Favorable outcome is as much a function of supportive care and parenteral nutrition as the type of surgical repair performed for either the intestinal or the abdominal wall defect.

Abdominal Muscles↗

PubMed1997

Intussusception in the 1990s: has 25 years made a difference?

To evaluate the current management of the infant and child with intussusception, the medical records of 188 consecutive intussusception patients over 5 years (1985-1990) were reviewed and compared to our series from 25 years ago (1959-1968). The peak months changed from May and June to January and July. Duration of symptoms and signs prior to diagnosis increased by one-third to 35 h with, however, a decrease in the incidence of pain, vomiting, abdominal mass, and rectal blood. Air was the only contrast used for the hydrostatic enema in the present series and was tried in every case with 81% success; this is a major improvement from 45% in the old series. There were three perforations (1.4%) with air-enema attempts compared with 1 (0.2%) 25 years ago. Recently only 19% of patients required operation but 30% needed resection; 55% of the patients in the older series required operation and 20% needed resection. Ten percent of intussusceptions continue to be found spontaneously reduced at operation. There were many less pathologic lead points in the newer series. The recurrences increased from 4% to 7%, but their reduction rate also increased from 31% with barium to 100% with air. There were no deaths in the last 25 years.

Barium Sulfate↗

PubMed1997

Imperforate anus (anal agenesis) with rectal and sigmoid atresias in a newborn.

A male baby was born to a healthy mother after an uncomplicated 39-week pregnancy. He had finger and toe syndactyly, right hemidiaphragm eventration, and a high imperforate anus (anal agenesis). The kidneys and chromosomes were normal. A right transverse colostomy was done and 5 months later he underwent a posterior sagittal anorectoplasty (Pena procedure). An intermediate imperforate anus with no urethral fistula and a rectal atresia 2 cm proximal to the distal rectal pouch were found; the distal rectal pouch was resected and the standard Pena procedure completed. Dilatations were initiated 2 weeks postoperatively and continued until the colostomy was closed. Prior to closure of the colostomy, a distal colon loopogram demonstrated an obstruction in the sigmoid; constrast introduced via the rectum outlined the same obstruction separated by 2 cm. A low sigmoid atresia was then repaired. Three weeks later, a contrast loopogram showed a narrow but intact rectosigmoid anastomois, and the colostomy was closed. The anorectal dilatations were discontinued and he remains well at 7 years of age.

Abnormalities, Multiple↗

PubMed1997

Pediatric pheochromocytoma. A 36-year review.

Fourteen children (10 boys and 4 girls, aged 8 to 17 years) had 20 pheochromocytomas treated over a 36-year period from 1959 to 1995 inclusive. Nine patients had 11 tumors before 1980; 5 children had 9 tumors up to 1987. There were no new children with pheochromocytomas at our hospital from 1988 to 1995. Hypertension, sweating, headache, and visual blurring were the most common symptoms and signs (average 5 months). The most reliable biochemical investigations were the urinary catecholamines and norepinephrine. Before 1980, intravenous pyelography and angiography were most successful in localizing the tumor, but since then ultrasonography and computerized tomography have been the radiological investigations of choice. Early involvement of the anesthesiologist in the preoperative control of the hypertension is essential; blood pressure (BP) control was achieved with phenoxybenzamine. The main anesthetic drugs used were: sodium thiopental, fentanyl, methoxyflurane, isoflurane, nitrous oxide, and metocurine. Sixteen tumors were adrenal and 4 were extra-adrenal (1 intrathoracic and 1 extradural). All except 2 tumors were completely resected; they ranged in size from 1.3 to 14 cm. Ligation of the tumor's venous drainage was usually associated with a sudden, temporary fall in systemic BP. There were 2 children with malignant tumors. Four patients had five recurrences (second pheochromocytoma) within 6 years, and all were heralded by a return of their original symptoms and signs. One girl was left with no adrenal tissue. The only complication was in a boy with a large, partly-resected malignant right adrenal tumor who had a subphrenic abscess drained and was left with a temporary bile fistula, cirrhosis, and chronic pain. All children were normotensive when discharged from hospital and remain alive and well with a follow-up of 7 to 36 years. There were no deaths. Long-term follow-up is essential. Key word Pheochromocytoma

Adolescent↗

PubMed1997

Laparotomy or drain for perforated necrotizing enterocolitis: who gets what and why?

Between 1974 and 1988, 86 newborns with perforated necrotizing enterocolitis (NEC) were treated by either laparotomy (usually involving a bowel resection and a temporary stoma) or a peritoneal drain under local anesthesia. The survival of babies in the laparotomy group was 57% versus 59% in the drained group. However, for neonates less than 1,000 g survival in the drained group was 69% compared to 22% for the laparotomy group (P <.01). As the weight of the babies increased over 1,000 g, the survival in the laparotomy group increased to 67%. There was no significant increase in survival in infants over 1,500 g. The highest neonatal mortality risk is generally found among babies weighing less than 1,000 g at birth with a gestational age of less than 30 weeks. This risk increases even more when perforated NEC is added to the prematurity. With the use of peritoneal drainage, survival in this group can approach that of larger neonates.

Drainage↗

PubMed1996

Is interval appendectomy necessary after rupture of an appendiceal mass?

Since 1980, the authors have not routinely removed an appendix on an interval basis after treatment of a ruptured appendiceal mass (phlegmon and/or abscess). In the present group of patients, there were eight boys and two girls, two to 15 years of age (mean, 8.5 years). All presented with symptoms and signs typical of ruptured appendix, with a mass suspected by history and examination, and proven by radiological means (usually ultrasonography). The patients were treated for at least 1 week with intravenous triple antibiotics; three required drainage of their abscess (2 radiological, 1 surgical). The follow-up has been both clinical and sonographic. In all cases the inflammation disappeared with 1 month. One child (2 years old) returned in 2 months with symptoms and signs of a ruptured appendix, and appendectomy was performed. The other nine have remained well, for 6 months to 13 years. From this experience and a review of the literature, only a relatively small number of patients with a properly treated ruptured appendiceal mass (phlegmon and/or abscess) will return with a flareup (recurrence) of appendicitis (requiring appendectomy); the rest live a normal life, with their asymptomatic appendix intact.

Abscess↗

PubMed1995

Partially reduced intussusception: when are repeated delayed reduction attempts appropriate?

The imaging techniques for diagnosis and monitoring of reduction of intussusception by fluoroscopy and ultrasound continue to evolve. The common goal of all protocols is to reduce the intussusception by enema in as many patients as possible and avoid laparotomy with its potential morbidity. We report two infants in whom the initial attempt at reduction by air enema only achieved partial reduction, from the descending colon to the transverse colon in one, and from the splenic flexure to the caecum in the other. Both patients became asymptomatic and clinically stable. In light of the clinical stability, and in consultation with the surgeons, laparotomy was deferred. Sonography was used to confirm the persistence of the intussusception before repeat air enema several hours later. Following three further air enemas in each child, the intussusceptions were successfully reduced after 20 h and 24 h respectively. Both patients remained asymptomatic and did not require surgery. In infants with partially reduced intussusception we suggest that if the patient becomes asymptomatic and stable, surgery can be safely delayed to permit further attempts at enema reduction. Sonography has a valuable role in determining the persistence of the intussusception prior to repeat enema. Close cooperation with the surgeon and careful clinical monitoring of the patient are essential requirements for this proposal.

Air↗

PubMed1995

Residual problems in chest donor sites after microtia reconstruction: a long-term study.

The rib cartilage has been the most popular autogenous tissue for microtia reconstruction. In this study, 88 chest donor sites were evaluated in 80 patients examined in the outpatient clinic at least 1 year after tissue removal. Microtia reconstruction usually was initiated between the ages of 2 and 3 years (42 percent), at which time an axial half of the sixth rib was harvested along with all of the seventh and eighth rib cartilages with their attached perichondrium. During this procedure, there were 19 uneventful pleural perforations (22 percent), and early in the series, 2 patients (2 percent) required a chest tube. Postoperative atelectasis without evidence of pneumothorax occurred in 7 patients (8 percent). Chest scars were classified by impartial observers as excellent (25 percent), good (33 percent), acceptable (28 percent), and poor (14 percent). Better scars were experienced in the cold-knife group than in incision by electrocutting. The younger group and the longer postoperative interval group showed better chest scars. Chest topography deformities were rated as normal (75 percent), mild retrusion (19 percent), and severe retrusion (6 percent). Costal margin contours improved as the postoperative interval lengthened.

Adolescent↗

PubMed1994

Intussusception: toward less surgery?

Since the 1950s, several large pediatric centers have used hydrostatic reduction with barium under fluoroscopic control as the treatment method of choice for ileocolic intussusception and have adopted rigid criteria for its management. One such rule has been that in order for an intussusception to be completely reduced, there must be adequate reflux of barium into the distal ileum. If this did not occur, it was assumed that the ileocolic intussusception had not been reduced, and the infant or child was taken straight to the operating room for laparotomy and surgical treatment. However, 10% of such intussusceptions were found to have reduced spontaneously. Needless to say, nonoperative management reduces morbidity and shortens hospitalization. From October 1985 through March 1991, 503 air contrast colon studies for suspected intussusception were performed on infants and children aged 2 days to 13 years (average, 16.8 months); 262 (52%) were normal, and 241 had an intussusception, 196 (81%) of which were reduced. The remaining 45 were operated on. In three patients (4 months to 2 years of age) the air enema reduced the intussusception from the colon without terminal ileum filling, but they all became asymptomatic immediately. For this reason they were not operated on; they were admitted and observed for 24 to 48 hours. Two of the three had recurrence of abdominal pain the next morning, but results of repeat air enemas were all normal (no intussusception observed, and normal terminal ileum filling).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1994

Pediatric malignant pheochromocytoma.

Pediatric malignant pheochromocytomas are very rare tumors, and no institution has more than one or two of these problem cases. The authors report on two children with such tumors, over a 9-year period, from two hospitals. In 1984, D.B. (14 years of age) presented with symptoms and signs of extradural metastasis from a right adrenal primary; he also had lung and bone metastases. After spinal decompression almost 4 years. He has remained well and is in remission 6 years later. In 1987, G.R. (13 years of age) presented with a larger right adrenal malignant pheochromocytoma invading surrounding structures; he also had liver metastasis. Preoperative chemotherapy did not shrink the tumor much; it was grossly resected, and there were many postoperative problems. In 1990, bone metastases developed, for which radiotherapy and chemotherapy were used. Three years later, the metastases have not disappeared; he remains on chemotherapy, and his liver function is borderline. From our small experience as well as a literature review, it appears that surgical excision remains the treatment of choice for the pediatric malignant phoechromocytoma. Unresectable tumors may be rendered resectable by intensive chemotherapy (similar to that used for neuroblastoma); adjuvant chemotherapy should be used for residual disease after surgery and for metastatic disease.

Adolescent↗

PubMed1994

Pure esophageal atresia: a 50-year review.

This review encompasses 50 years (1942 through 1991) and 69 newborns (43 boys, 26 girls). Half the babies were premature (weighing less than 2.5 kg), and about one third had other anomalies. The procedures used in this series were late primary anastomosis (17), gastric tube reconstruction (16), staging esophagostomy and gastrostomy (13), gastric pull-up (13), early primary anastomosis (4), and colon replacement (3). Four neonates received no treatment. The most common repair in the 1940s and 1950s was the gastric pull-up; the gastric tube was the most popular in the 1960s and 1970s. Delayed primary anastomosis has been the operation of choice since the 1980s. Over the last decade, it has become apparent that primary repair is successful in three quarters of such infants if the wait is 3 months and/or the newborn weight has at least doubled. This repair appears to provide the best functional result, unless there is an anastomotic stricture. Before the 1970s, the survival rate was below 40%, but since the 1980s the rate has more than doubled, to 90% in our series, regardless of the type of repair used.

Abnormalities, Multiple↗

PubMed1994

A new look at an old operation for aganglionosis.

Since 1980, the authors have operated on seven infants with total colon Hirschsprung's disease using the long Duhamel procedure. All infants were given an ileostomy when the diagnosis was made, and the long Duhamel procedure was performed between 6 and 24 months of age. This operation in the standard Duhamel procedure except that the sigmoid and descending colon form the fecal reservoir (as in the Martin variation of the Duhamel operation). A covering loop ileostomy was made in all the patients, and it was closed within 5 months; two infants had one episode of enterocolitis, 1 to 9 months after closure. The seven infants have had follow-up for 1 to 13 years; all are alive and well. The children are continent and toilet trained (age not withstanding); they have up to 10 formed stools per day. Two had some soiling at night. Whereas in the past the Duhamel procedure (in which a too-long anterior rectal pouch was left) often resulted in the formation of a fecal impaction, this does not occur when the material passing through the anus is at best semiliquid. With no long side-to-side anastomosis, the procedure is simple and complications are few.

Adolescent↗

PubMed1993

Pure esophageal atresia: outlook in the 1990s.

Eleven newborns with pure esophageal atresia were treated between 1980 and 1989 inclusive; there were six girls and five boys. Their gestational age ranged from 31 to 40 weeks (average, 37 weeks) and weight from 1.1 to 3.0 kg (average, 2.2). The only associated anomalies were Down's syndrome, respiratory distress syndrome, and patent ductus arteriosus. All babies received an immediate gastrostomy. Several radiologic studies were done to see if the distance between the two esophageal pouches was decreasing. Dilatations of the upper pouch were carried out in two patients. After a wait of 1 to 7 months (average, 3 1/2) a primary anastomosis was attempted; the weight of six babies doubled during this time. Eight neonates had a primary repair (two were aided by a circular myotomy). Two had a staged gastric tube constructed, and one baby had a gastric pull-up procedure. Three of the infants with a primary anastomosis required a subsequent antireflux operation, and one needed her anastomosis resected 16 months later. Ten of these 11 newborns are alive and well; one of the gastric tube children died from an adhesive small bowel obstruction at age four years.(ABSTRACT TRUNCATED AT 250 WORDS)

Anastomosis, Surgical↗

PubMed1993

Malignant benign neonatal sacrococcygeal teratoma.

Thirty-six patients with benign neonatal sacrococcygeal teratoma (SCT) were treated in our medical center from 1972 to 1990. Mean gestational age was 38.6 +/- 3.3 weeks with a mean birth weight of 3,484.0 +/- 938.5 g. Twenty-nine patients (89%) were females. The majority of the tumors (75%) contained cystic components and 96% were Altman classification I and II. The initial surgical removal of the SCT (including the coccyx) was carried out during the first 7 days of life. Six patients (22%) developed recurrence of the tumor. Three were benign and reappeared locally after 12 +/- 3 months and were reexcised. The mean serum alpha-fetoprotein level in this group was 13 +/- 1 g/L. The malignant recurrence (all originally reported as being mature benign SCT) appeared at 20.3 +/- 1.5 months and had markedly elevated serum alpha-fetoprotein levels (7,320 +/- 4,630 micrograms/L). All the patients in this group had multimodal therapy including complete excision of the recurrent tumor. We conclude that SCT, although histologically benign, has an alarming potential to recur either as a benign or malignant tumor during the first 2 years of life. Close follow-up for at least 3 years (frequent examination, serum alpha-fetoprotein, and diagnostic imaging) is recommended for all patients who had undergone excision of SCT in the newborn period.

Combined Modality Therapy↗