Biomedical subjects
Publications and source records attributed to S Yazbeck.
A 3-year-old boy with relapsing nephrosis presented with a left sided varicocele. Echographic studies demonstrated enlargement of the left kidney, and there was delayed excretion on renal scintigraphy suggesting the presence of renal vein thrombosis. The varicocele resolved with remission of his nephrosis.
A four-year-old boy presented with a history of intermittent obstructive jaundice. Investigation and surgical exploration revealed an abnormal configuration of the biliary tree which, to our knowledge, has never been otherwise reported.
Forty-seven children with recurrent urinary tract infection were noted to have large fecal reservoirs by rectal examination and rectal manometry. Constipation was accompanied in the majority by enuresis and/or encopresis. Urodynamic studies indicated uninhibited bladder contractions. Aggressive treatment of the constipation resulted in cessation of infection in 44 patients, enuresis in 22 of 32 patients and encopresis in 20 of 21 patients and an improvement in bladder function with cessation of all other forms of treatment.
Many previous series reporting the construction of Brescia-Cimino fistulae in children describe a high rate of immediate and late patency failure. Using microsurgery, we have constructed 23 Brescia-Cimino fistulae in 23 children, 10 weighing less than 20 kg and 13 weighing more than 20 kg. An immediate patency rate of 100% was achieved in both weight groups with a late patency rate of 90%-100%, in those under and over 20 kg, respectively. We recommend using microsurgery for all such angioaccess procedures.
Recent widespread interest in a new approach to imperforate anus is ample testimony to the difficulty of the classical operations and to the unsatisfactory results. In the early seventies, Mollard began to use an anterior perineal approach to high imperforate anus as an alternative to the sacrococcygeal pull-through. It entails a semicircular retroscrotal incision allowing direct access and visualization of the urethra and puborectalis sling. Since 1976 we have switched to the anterior perineal approach. We now have experience with 30 patients, 27 males and 3 females. Two of the females had complicated cloacal anomalies, and three teenage patients were reoperated for incontinence following previous unsuccessful pull-throughs. Of the 27 primary operations, there were 17 with an uneventful early postoperative course. There were two major and eight moderate or minor complications. There was no mortality. A 3-year follow-up is available in 14 patients. The results are good in 8, fair in 4 and poor in 2. The advantages of this technique are threefold: it allows clear visualization and precise identification of the puborectalis sling; the dissection proceeds parallel to and with constant vision of the urethra, avoiding injury to it; and it obviates the need to change the position of the patient during the procedure. This operation is easier and safer than the sacral approach, it avoids cutting through the puborectalis sling as recently described, and, finally, it respects the criteria established by Stephens.
Between Jan. 1, 1961 and Dec. 31, 1981, 16 infants (9 boys, 7 girls) with tracheoesophageal fistula without esophageal atresia (H-type fistula) were treated at the Hôpital Sainte-Justine and Centre Hospitalier de l'Université Laval. The mean birth weight was 2.8 kg. Five infants were premature. All presented at first feeding with coughing, choking and cyanosis. Seven had abdominal distension and six had hypersalivation. Mean age at the time of definitive diagnosis was 39.1 days. The diagnosis was confirmed radiologically in all infants, a mean of 1.69 roentgenographic procedures per patient being required. Cervicothoracic (C7 to T2) fistulas were present in 14 and thoracic fistulas in 2 infants. Twelve were operated upon through a cervical and 4 through a thoracic approach. A Fogarty catheter was placed in two fistulas preoperatively. Two patients required gastrostomy. Feeding was started again 3 days postoperatively. One infant died and one had a recurrent fistula. One survivor had 20 episodes of cardiorespiratory arrest. None had dysphagia. The authors consider it imperative that fistulas be visualized before any operative procedure is performed. Catheterization of the fistula with a Fogarty catheter should be attempted preoperatively. It is dangerous to dissect a cervical fistula through a thoracotomy.
Between 1961 and 1982 sixteen patients with tracheo-oesophageal fistulae without oesophageal atresia (H type fistula) were treated at Hôpital Ste-Justine and Centre Hospitalier de l'Université Laval. Nine patients were male and seven female, with a mean birth weight of 2.8 kg. Five were premature. All presented at first feeding with coughing, choking and cyanosis. Seven had abdominal distension and six had hypersalivation. Mean age at time of definitive diagnosis was 39.1 days. The diagnosis was confirmed radiologically in all patients, a mean of 1.69 cine-radiographic procedures per patient being required. Cervical region (C7 - T2) fistulas were present in 14 and thoracic in 2 patients. Twelve patients were operated via a cervical approach and four via a thoracic approach. A Fogarty catheter was in place in 2 fistulae pre-op. Two patients required gastrostomy. Refeeding was started 3 days post-operatively. One died and one had fistula recurrence. Fifteen patients survived. One survivor had multiple episodes of cardio-respiratory arrest. None had major swallowing difficulties. We consider it imperative that fistulae be visualized before surgical intervention. Catheterization of the fistula utilizing a Fogarty catheter should be attempted prior to surgery. It is dangerous to dissect a cervical fistula via a thoracotomy.
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33 cases of hyperthyroidism have been treated at "L'Hôpital Sainte-Justine" of Montréal, during the period 1961-1974. Nearly all patients were submitted to medical treatment. 15 were cured with medical treatment only, and 18 had to be submitted to a subtotal thyroidectomy. These two groups are compared and show the clear advantage of surgery in the treatment of this disease. There was no major post-operative complication. Two patients became definitively hypothyroid. The mean follow-up is five years and six months.
Thirty-two uremic children were treated by chronic peritoneal dialysis (CPD) since February 1982. Fifteen chose chronic ambulatory peritoneal dialysis (CCPD) while the 17 others were treated by continuous cycle peritoneal dialysis (CCPD). To this day, 10 patients (31%) are alive with a functioning kidney transplant, 16 (50%) are still treated by CPD awaiting a transplant, 5 have died (16%) and one went back to hemodialysis (3%). Complication in ranking order were peritonitis, mechanical drainage problems of the catheter and hernias. Linear growth was from good to excellent in the majority of patients. Globally, CPD was found to be attractive mainly because it allows a good quality of life.
Between 1974-1979, 64 renal cadaveric transplants were performed in 54 pediatric recipients at our institution. Forty eight of these 64 transplants experienced at least one episode of acute rejection. These patients were divided in two equal groups including 24 transplants in 21 recipients, one group treated with chemical immunosuppression alone, the other group treated by chemical immunosuppression and radiotherapy. Kidney survival at 2 years was 54.1% (13/24) in the control group treated by chemical immunosuppression alone. In the group treated by radiotherapy and immunosuppression, kidney survival after 2 years gave a success rate of 45.8% (11/24). Thus, it would appear that addition of radiotherapy to standard immunosuppressive treatment exerted no beneficial long term effect in acutely rejected renal transplants. In view of the disappointing results obtained with radiotherapy, it is felt that this mode of treatment should be restricted to use in particular circumstances as a temporary means of immunosuppression where systemic immunosuppression is hazardous.
Four patients with total aganglionosis of the intestine had renal abnormalities. Two patients had cortical subcapsular cysts, one had unilateral renal agenesis and one other had unilateral renal dysplasia. The consistency of renal anomalies with total aganglionosis suggests the presence of a common genetic origin.