Biomedical subjects
Publications and source records attributed to T M Holder.
The technique of anterior fundoplication for gastroesophageal reflux originally described by Alan Thal has been used in our institution in 605 patients. The description of the technique is the purpose of this paper. A brief description of the results in these 605 patients are also presented.
Ureteropelvic junction (UPJ) obstruction is a common cause of hydronephrosis in infants. Newborns with severe obstruction often have marked improvement following correction; therefore early diagnosis and operation is important. From 1973 to 1983, 21 patients were operated on for UPJ obstruction diagnosed under 6 weeks of age. Six patients (29%) had antenatal ultrasonographic diagnosis. The remaining patients were diagnosed by IVP or radionuclide scan for palpable renal enlargment or for associated anomalies. Seventeen had unilateral and four had bilateral obstruction. Twenty-three pyeloplasties, one primary nephrectomy, and one cutaneous pyelostomy with subsequent nephrectomy were done. All pyeloplasties were dismembered, with tailoring of the renal pelvis. Postoperative renal function was followed with radionuclide scan or IVP. Postoperative complications included a single urinary tract infection in three patients and two bowel obstructions. One early postoperative death occurred in an infant with bilateral obstruction who developed congestive heart failure secondary to severe uncontrollable hypertension. There were two other unrelated late deaths. Documented functional improvement with minimal complications follow unilateral or simultaneous bilateral pyeloplasty in newborns with UPJ obstruction.
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Neonatal sepsis due to group B beta-hemolytic Streptococcus (GBS) is reported to occur in about 1 out of 330 live births. Right-sided Bochdalek hernia (RBH) occurs in about 1 of 20,000 live births. The combination of group B streptococcal sepsis and delayed appearance of a right Bochdalek hernia is an infrequently reported phenomenon--18 patients have been previously reported in the English literature. We add four patients from our own experience to these previous reports. Since approximately 10% to 15% of the newborn population are exposed to group B Streptococcus we suspect that the inadequate diaphragmatic motion on the side of the Bochdalek hernia predisposes the child to development of septicemia and/or pneumonitis. Once the etiology has been established and appropriate antibiotic therapy instituted, progressive improvement in the patient's course should be seen. This is in contrast to a very significant mortality rate in many of the patients having early onset GBS. Any child, therefore, surviving early onset GBS only to deteriorate again, should be suspected of having an associated right Bochdalek hernia, and diagnostic steps should be taken to evaluate the integrity of the right diaphragm.
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Ecchymosis of the scrotum and lower abdominal wall occurred in four newborn boys. All were anemic. Three had coagulation abnormalities and evidence of sepsis. In two, group B streptococcal septicemia was documented. Intraperitoneal hemorrhage from a ruptured subcapsular hematoma of the liver was the source of blood in the scrotum in three, and most probably in the fourth as well. Two infants died in spite of antibiotics, vigorous blood replacement, including exchange transfusion, and desperation laparotomies for continued intraperitoneal hemorrhage. Newborns with scrotal ecchymosis should be examined for intraperitoneal hemorrhage, ruptured subcapsular hematoma of the liver being the most probable source. Their coagulation status should also be evaluated, and sepsis should be suspected, especially in those with a demonstrated coagulopathy. Group B Streptococcus is a likely primary etiologic agent in these critically ill neonates. Nonoperative treatment, as given the two survivors in this experience, is preferred.
Two critically ill neonates with severe renovascular hypertension as a complication of aortic monitoring catheter are presented. They did not respond to intensive medical therapy for hypertension. In spite of their precarious general condition, nephrectomy was undertaken with complete relief of symptoms.
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The anterior fundoplication described by Thal has been used in treating gastroesophageal reflux surgically in 362 children at The Children's Mercy Hospital and at St. Luke's Hospital in Kansas City, Missouri, because medical therapy had failed or was inappropriate. Long-term results have been evaluated in regard to relief of reflux and relief of symptoms attributed to reflux. Of the 335 patients followed from 1 to 8 years, 90% had a satisfactory initial result. Five percent required reoperation for a recurrence of reflux due to failure of the fundoplication or development of a hiatus hernia. All recurrences developed with 5 months of the initial operation. Fifteen of 335 patients (4.5%) had persistent symptoms despite correction of the gastroesophageal reflux; in these patients, attributing the symptoms to reflux was incorrect. There were no deaths in this series of patients as a result of operation. The success rate of the Thal fundoplication in children compares favorably with that of the Nissen Fundoplication.
Necrotizing enterocolitis (NEC) usually occurs in low birth weight infants who have had perinatal stress, and the mortality remains significant. There are a few reports of NEC in the postoperative period, especially in young infants. Nine neonates developed NEC following operations and form the basis of this report. The interval between operation and the diagnosis of NEC varied from 3 days to 4 mo. The surgical lesions included one case each of esophageal atresia, tetralogy of Fallot, supralevator rectal atresia with rectourethral fistula, and multiple intestinal atresias. Three babies had gastroschisis and two had "apple peel" intestinal atresia. Only 3 of the 9 survived. The usual clinical findings of NEC, abdominal distention, bile stained gastric residuals and diarrhea (with or without blood), can occur in the postoperative period without NEC and are, therefore, not reliable diagnostic signs. Significant changes in the clinical course of these babies occurred from 7 hr to 5 days before the diagnosis was established. In these patients the roentgen findings that established the diagnosis of NEC included intestinal ileus, pneumatosis intestinalis, and portal vein gas. Pneumatosis intestinalis and portal vein gas were the most reliable diagnostic signs, but appeared relatively late in the course of the disease. In one case pneumatosis was seen only in retrospect. None of the patients had definite pneumoperitoneum. Awareness of NEC as a potential postoperative complication may result in early recognition, treatment and survival.
Tracheal agenesis is a rare cause of respiratory distress in the neonatal period. Temporary survival depends on ventilation through the esophagus. Thirty-eight case reports of tracheal agenesis (including one from this institution) have appeared in the literature. In this paper, we present the case reports of our 2 patients and review the literature. Tracheal agenesis is associated with a wide variety of congenital anomalies, the most frequent being ventricular septal defect. A new classification encompassing seven types of tracheal agenesis is described.
Radiation injury to arteries can represent a significant complication of therapeutic irradiation, even when the dosage used has not been excessive as judged by approved protocols. Children in whom therapeutic abdominal irradiation has been used should be monitored indefinitely for the development of hypertension. The presence of hypertension in such children with normal blood urea nitrogen (BUN) and creatinine, and without proteinuria, should prompt investigation for a renovascular lesion. Standard bypass procedures are usually effective, although the long-term success may be compromised by continuing changes in affected vessels.
One hundred patients with complications of severe gastroesophageal reflux were treated surgically by the Thal fundoplication. In all patients the symptoms of reflux were eliminated by the operation, although 4 recurred within 8 months. Two of these were due to disruption of the fundoplication and two were due to hiatus hernia not recognized and repaired at initial operation. There were 8 deaths, none related to gastroesophageal reflux or the operation. Four patients required re-operation for intestinal obstruction. The Thal fundoplication is a simple procedure which fixes the distal esophagus within the abdomen and produces an acute angle of His. It is effective in prevention of reflux and the patient is able to burp and vomit if necessary. It has not been associated with dysphagia or "gas bloat" which may follow the Nissen fundoplication.
Ninety cases of esophageal atresia (EA) with double tracheoesophageal fistula (TEF) from the literature and 4 new cases are examined. The incidence may be more common than is generally recognized with incidences up to 5.3% reported. The pre-, intra-, and postoperative diagnosis may be difficult, and half have been missed initially with almost half of these being first recognized at autopsy. During repair of EA and TEF the proximal esophagus should be mobilized looking for a proximal fistula. Many proximal TEF are missed at the initial operation and discovered in the postoperative period. The symptoms, diagnosis and treatment of the unrecognized proximal TEF are similar to that for isolated TEF. Results should be good since this problem occurs in large babies with fewer and less complex associated conditions.
A case of congenital posterior urethral perineal fistula is reported. The English literature is reviewed and anatomical findings, embryology, presenting signs and symptoms, and treatment are discussed.
Twelve patients with gastroesophageal reflux following repair of esophageal atresia are presented. Reflux produced recurrent stricture, failure to thrive, repeated pneumonitis, and in one patient, respiratory arrest and nearly death. Treatment consists of positional therapy or fundoplication operation both of which seem less successful in this combination of lesions than with GER and a normal esophagus. There was one death as a late postoperative complication of fundoplication.
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An operative procedure for the management of rectal prolapse is described. It has the advantanges of simplicity, relative safety, short hospitalization, and lack of recurrence in the four patients presented.