Surgical and critical care management of children with life-threatening injuries: the Swiss experience.
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Abdominal Injuries↗
Biomedical subjects
U G Stauffer
Publications and source records attributed to U G Stauffer.
Achalasia in childhood and adolescence.
We analysed the charts of paediatric patients suffering from oesophageal disorders in 5 departments of paediatric surgery in Switzerland from 1972-1993 finding only 16 patients with proven achalasia (0.6%). The personal history showed a wide gap of several years from the first symptoms until diagnosis and treatment due to false interpretation of symptoms. Dilatations alone have never been definitely successful. In 16 patients, a Heller's procedure was done, 2 had an additional Thal, 12 a Nissen fundoplication, one a hiatoplasty and one no antireflux procedure. 3 patients needed further postoperative dilatations for several months up to 3 1/2 years. One patient suffering from an AAA syndrome (Achalasia/Alacrimia/ACTH deficiency) did not improve after Heller's procedure with Nissen fundoplication and dilatations. We finally had to resect the oesophagus and replace it by gastric transposition. Two children were lost for long-term follow-up. In 14 patients the follow-up is more than 10 years. 14 patients take normal food and are in the normal percentiles for length and height. Achalasia in childhood shows a wide spectrum of oesophageal dysmotility. In many cases, the propulsive force might be so weak that only a very lose antireflux procedure is tolerated. Occasionally, the whole oesophagus is without appropriate function and has finally to be resected as in our patient suffering from AAA syndrome. This child is now free of clinical pathological symptoms since several years.
Adolescent↗
Management of petrous bone fractures in children: analysis of 127 cases.
Petrous bone fractures (PBF) in children are relatively frequent. They are mostly diagnosed after collisions and falls. The complications typically associated with PBF were different types of hearing disorders in 69.1% of the patients who had audiometry, liquorrhea in 16.5%, palsy of cranial nerves in 10.8% (facial nerve palsy in 9.4%), bacterial meningitis, stenosis of the external ear canal, and posttraumatic cholesteatoma in 0.7% of the fractures each. Most complications were transient; 8.6% of the patients underwent surgery because of PBF-related complications and 9.4% suffered from severe, irreversible sequelae. Management of PBF in children requires an interdisciplinary approach between pediatric surgeons and pediatric ear, nose, and throat (ENT) specialists. It basically includes daily examination for cranial nerve palsy, liquorrhea, and meningitis during hospitalization as well as routine audiometric examination and antibiotic prophylaxis. Routine vaccination against Streptococcus pneumoniae as a new standard procedure and subtotal petrosectomy after transverse fracture as a new surgical modality are strongly recommended in order to lower the incidence of posttraumatic meningitis. Severe complications such as persistent hearing loss, persistent liquorrhea, cranial nerve palsy, and posttraumatic meningitis require aggressive diagnostic and therapeutic measures in order to minimize further morbidity and irreversible deficits.
Adolescent↗
Necrotizing enterocolitis.
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Enterocolitis, Pseudomembranous↗
Complications and long-term results of the Nissen fundoplication.
The Nissen fundoplication is the operative therapy of choice in children with symptomatic gastroesophageal reflux. In recent years several reports on specific complications of the Nissen fundoplication have been published. This report summarizes the complications in 45 patients on whom a Nissen fundoplication was performed in our clinic between 1979 and 1989. 18 patients (40%) showed early or late complications. In 10 patients (22%) reoperation was necessary. However, at follow-up with a mean period of 4 1/2 years after surgery, 36 patients (92%) showed good results without any residual symptoms. The Nissen fundoplication had in our hands a rather high rate of complications. However, late results were excellent and our healing rate (92%) was higher than reported in other series with different techniques.
Adolescent↗
Cranioplasties for congenital and acquired skull defects in children--comparison of new concepts with conventional methods.
From 1974 to 1992 fifty-two patients with congenital or acquired skull defects were operated at the Department of Pediatric Surgery of the University Children's Hospital of Zurich. By 1988, in 26 patients conventional methods with PMMA (polymethyl methacrylate) plasties or rib plasties were performed. After 1988, in 26 patients skull reconstruction was done by skull splitting, application of lyophilized bone or cartilage or a combination of both. In the latter period, stabilization and fixation was always provided by biodegradable screws and bands. The results of the different techniques were compared in a retrospective fashion. PMMA plasties provided immediately full stability and good cosmetic results. Another advantage was their availability. In one patient (= 4.8%), a wound infection required the removal of the plasty. In two other patients (9.5%), an increasing mobility of the plasty could be observed during skull growth. Rib plasties were not satisfying. Skull splitting or reconstruction with lyophilized bone or cartilage showed good results with a stable integration within 3-4 months. In one patient (4%), a superficial wound infection occurred, but it did not affect the plasty. From the present study, we conclude that skull splitting or the reconstruction of skull continuity by means of lyophilized bone or cartilage with fixation through biodegradable screws and bands are the methods of first choice in children, because they are fully integrated, avoid foreign material and might have a slightly lower risk of infection. In addition, removal of the implants may be avoided.(ABSTRACT TRUNCATED AT 250 WORDS)
Biodegradation, Environmental↗
Liaison psychiatry in pediatric surgery--a promising approach.
Liaison psychiatry in pediatric surgery is described and the experiences at the University Children's Hospital in Zurich are reported. The patients seen by the child psychiatrist in surgery are specified and compared with those seen in pediatrics. For the most part the same psychiatric diagnoses were made in both groups with some differences in frequency. It is concluded that liaison psychiatry should be implemented in pediatric surgery, as has long been the case in pediatrics.
Accidents↗
20 years of functional reconstructive surgery in bladder exstrophy--balance 10 years after a preliminary report.
This is an update of a consecutive series of 19 patients with bladder exstrophy presented as a preliminary report 10 years ago with a follow-up of 6 years. The average time of follow-up now is 14 years. In difference to the former report several additional procedures have been performed in most patients. 3 early "good" patients stay "good and continent". Only 3 out of 5 patients categorized as "fair" are now "good and continent" and only one without further intervention. 3 out of 6 patients who were classified as "poor" are now diverted. The overall rate of secondary diversions is 40% including 2 patients with ureterosigmoidostomies. All patients have normal renal function and normal blood pressures. These results show that an early "good" result generally remains "good" but additional surgery may be warranted. The initially "fair" results usually necessitate a secondary procedure, e.g. augmentation cystoplasty or/and bladder neck tightening to show an improvement. Patients with early "poor" results unfortunately remain "poor" and have a great chance to get diverted.
Bladder Exstrophy↗
Surgical treatment of ovarian tumors in childhood.
From 1971 to 1988, 45 girls aged 1 week to 17 years were treated for a total of 46 solid and cystic tumors of the ovaries. Pathohistological examination revealed epithelial tumors in eight cases, a tumor originating from the ovarian stroma in one case, germinal tumors in 17 cases, 15 functional ovarian cysts, and five paraovarian cysts. The stroma tumor and four of the 17 germinal tumors were malignant. Surgical treatment for solid tumors consisted generally of a unilateral salpingo-oophorectomy, but in operations for cystic tumors as well, vital ovarian tissue could only rarely be preserved. Functional ovarian cysts were excised if they were larger than 5 cm. Subsequent to excision of malignant tumors, chemotherapy with cisplatin, vincristine and bleomycin was performed. On follow-up, all patients with benign lesions were well. One of the girls with malignancies died and another is undergoing chemotherapy for tumor recurrence in the contralateral ovary.
Adolescent↗
Characteristics and prognosis of extradural hematomas in children.
This is a report on 31 children with operated extradural hematoma. The aim of the study was to elucidate the characteristics of extradural hematoma in childhood and the different clinical pattern and outcome compared to adults. For that reason the charts of the patients seen at the Department of Surgery of the Children's University Hospital Zurich between 1972 and 1990 have been revised. Follow-up criteria were recorded according to the Glasgow Outcome Scale. Most hematomas have been provoked by minor injuries and almost all children presented with at least one typical clinical sign. Associated intracranial injuries have been found in four patients, while two were polytraumatised. 30 of the 31 patients survived. One patient died of malignant brain edema. The mean range of follow-up was seven years. 28 patients had a "good recovery", "moderate disability" and "severe disability" was found in a patient one each. Our results demonstrate that the long-term outcome in children with extradural hematoma is far better than in adults regarding survival as well as quality of life. The causes may be minor traumas with fewer associated lesions and presentation with typical clinical findings and therefore early diagnosis and treatment.
Adolescent↗
Is intestinal lengthening effective in treating extreme short bowel syndrome?
Our report concerns a child with short bowel syndrome who had 20 cm of small intestine distal to the pylorus (duodenum and jejunum) which remained after subtotal intestinal resection; the resection was necessitated by intrauterine volvulus with intestinal necrosis as a result of gastroschisis. In addition, only 25 cm of the colon remained. Despite continuous enteral nutrition with a semi-elementary diet and conservative therapy, it was not possible to provide within six months at least occasionally half of the caloric intake required on an enteral basis. In such cases treatment is usually discontinued. As final alternative to a small intestine transplantation, we conducted an operation to lengthen the intestine (method according to Bianchi) when the patient was 8 months old. The massively dilatated jejunum section of the intestine was lengthened from 20 cm to 37 cm. Postoperatively enteral caloric intake could be increased from 11 kJ/kg/m to 20 kJ/kg/m. Unfortunately, at 14 months of age, the child died from hepatobiliary complications arising from aggravation of the cholestasis and acidosis. This case shows, nevertheless, that intestinal lengthening had a positive influence on intestinal resorption.
Colostomy↗
[Reconstruction of external genitalia of the girl with adrenogenital syndrome].
Congenital adrenal hyperplasia (CAH) is the most common cause for female pseudohermaphroditism. In these patients uterus and Fallopian tubes are present and also in severe cases the clitoris cannot function as penis later in life. Therefore, a neonate with ambiguous genitalia due to CAH should be raised as female. To assess the degree of masculinization, a modification of Prader's classification was used. In 23 girls with ambiguous genitalia reduction clitoroplasty preserving the neurovascular bundle and creating a dorsal preputial skin flap and vaginoplasty with a perineal skin flap were performed. The phallic skin was used to create the labia minora and the anterior vaginal wall. The patients were reevaluated 1 to 14 years after the operation. The cosmetic and functional results have been excellent.
Adolescent↗
[Resorbable implants in craniofacial surgery in childhood. A contribution to the development of poly(lactide) implants].
After research on minipigs we use since 2 1/2 years our polylactid and polydixanon implants for stabilisation after osteoplastic trepanation and in craniofacial reconstructions. The presented set with headless screws and nuts and woven bands are described in detail. Biodegradable osteosynthesis was done in 15 patients aged 11 months to 17 years and two months (m: 6 years four months). The results are at least as well as with conventional steel implants (plates, screws and wires). We did not see infections in any instant, and no patient had a second operation for explantation of fixation devices. After this encouraging prospective trial we are going to simplify the construction as well as the implantation procedure and to enlarge the spectrum of indications by using plates.
Adolescent↗
The Shaw haemostatic scalpel in paediatric surgery: clinical report on 3000 operations.
This report presents the experience in a prospective series of 100 operative procedures in all fields of paediatric surgery with the Shaw haemostatic scalpel, which we have subsequently used in more than 3000 further operations. The Shaw scalpel proved to be advantageous in about 80% of major cases. The scalpel cuts tissue with a sharp steel edge, like a cold scalpel, and simultaneously seals blood vessels by heat thermally conducted to the tissue from heated blade which is electrically insulated from the patient. The heat seals most small blood vessels (under 2 mm) as they are cut. Since no electric current passes through the patient, a grounding pad is not needed and the risk of accidental electrical current burns at grounding sites is eliminated. Muscle stimulation associated with the use of a normal cautery is avoided, improving surgical precision of cutting. The Shaw haemostatic scalpel minimizes damage to the tissue as compared with other thermocoagulating instruments. Since it seals small vessels as it cuts tissue, it largely eliminates the flow of blood into the incised area and allows better visibility of the surgical field. The use of the scalpel requires a different cutting technique which is however easy to learn. The Shaw haemostatic scalpel reduces blood loss and overall operating time in major cases. It is relatively inexpensive and can be recommended for use in paediatric surgery.
Adolescent↗
The Herbst triad: report of two cases.
We report two patients with hypoproteinemia and finger clubbing in whom the underlying gastroesophageal reflux was only detected after symptoms of esophageal stenosis became apparent. Ignorance of gastroesophageal reflux as a possible cause of these impressive symptoms led to complications and delayed surgery.
Child, Preschool↗
[Biodegradable osteosynthesis applied to craniofacial surgery].
Since skin problems as decubitus and infections are well known risks in osteoplastic trepanations in congenital malformations in children, we searched for a reduction in size of the implants and the possibility to use biodegradable materials. After design of special constructions regarding dimension and stability purposes for children below one year, we performed osteoplastic trepanations in 27 minipigs. In 78% the healing was uneventful and the osteoplasty remained in place whereas in 22% (= 6 animals) we observed a local infection which lead to loss of implants as well as cranioplasty in 3 animals. Based on this research, we used our biodegradable implants in osteoplastic trepanations of congenital craniostenosis in children. The postoperative follow-up is now from 3 to 6 months in 4 children and the results are perfect in all. We did not observe any local infection, neither cutaneous problems, even not in bilateral frontal advancement and floating forehead procedures. The implants are presented as well as the results in animal research and the first follow-up in 4 children.
Acrocephalosyndactylia↗
[Prenatally diagnosed intestinal obstruction--contribution of pediatric surgery].
The diagnosis of a small intestinal obstruction was made prenatally between the 31st and 36th week of pregnancy in 7 patients with neonatal ileus. Five newborns showed a meconium-peritonitis, a meconium-ileus and the last a ileal atresia. These were compared with newborns with small intestinal obstruction, which had not been diagnosed prenatally. The analysis of our hospital information indicates, that primarily serious forms of ileus and intestinal perforations are diagnosed prenatally, whilst isolated small intestinal obstruction often avoids diagnosis. For this reason, diagnostic punctation of the foetal abdomen contribute little to the establishment of the etiology of the obstruction and should be avoided. On the other hand, punctation of a foetal ascites can, through pressure reduction of the abdomen, lengthen the duration of pregnancy and permit a spontaneous birth.
Adult↗
[Treatment of femoral and lower leg shaft fractures in adolescents].
In adolescents dynamic-compression-plate osteosynthesis is an excellent modality for treating femoral shaft fractures. It provides anatomical stabilisation as well as short hospitalisation and rehabilitation. In contrast, fractures of the tibial shaft are usually treated with casts or by extension. Primary operation is rarely necessary, for example in cases of an impaired neurovascular system. In third degree open fractures we usually recommend external fixation. In our department clinical and radiological late-term controls are performed over a period of at least two years for tibial and four years for femoral shaft fractures.
Adolescent↗