Jejunal interposition hepaticoduodenostomy for choledochal cyst

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showed no difference among the three groups. Although the numbers are small, there appear to be no psychosocial problems after stoma formation if there has been proper preparation and followup.--C.M. Doig Physiologic Assessment of the Four Commonly Performed Endorectal Pullthroughs. D.K. Stoller, A.G. Coran, R.A. Drongowski, et al. Ann Surg 206:586-594, (November), 1987.

Endorectal pullthrough has become the treatment of choice for ulcerative colitis, familial polyposis, and total colonic Hirschprung's disease. Several variations of the pullthrough have emerged (Parks S-shaped reservoir, J-pouch, lateral isoperistaltic pouch, and straight ileoanal). Reservoir proponents claim pouches improve stool frequency and continence. Four month old Beagle puppies were randomly assigned to four groups, underwent pullthrough construction (four animals each), and were compared. Parameters studied included general health, stool consistency, perineal irritation, soiling, body temperature, hydration, body weight, stool frequency, intestinal transit time, stool cultures, platelet count, hemoglobin concentration, hematocrit, white and red blood cell counts, water absorption, electrolyte absorption, rectal manometrics, and barium enemas. Animals were studied to 6 months. No differences were found between groups regarding hematocrit, mean corpuscular red cell volume, and platelet count. All groups developed an initial leukocytosis. Weight, appearance, behavior, and posturing all remained similar. Perineal irritation was found in over 50% (S-pouch 50%, J-pouch 75%, lateral and straight groups 100%). Mean water absorption and manometric data was similar between groups preoperatively and at 6 months. The four groups uniformly achieved 80% to 85% of control values for maximum volume or rectal capacitance. Intestinal transit time deereased in all groups at 1 month, with a gradual rise to similar levels at 6 months (approximately 1/2of the preoperative value). Stool frequency showed variation between groups and did not correlate with transit time. Consistency of stools did not correlate with frequency or transit time. Postoperative stool cultures were normal in all groups. The investigators discuss the advantages and disadvantages of straight v reservoir endorectal pullthroughs. In this series of evaluations no difference was found between groups, and their conclusions suggest that there is no clinical or physiologic advantage to the addition of a reservoir to the endorectal pullthrough. -Edward G. Ford Experience With the Straight Endorectal Pullthrough for the Management of Ulcerative Colitis and Familial Polyposis in Children and Adults. R.A. Morgan, P.B. Manning and A.G. Coran. Ann

Surg 206:595-599, (November), 1987. Seventy-two children and adults underwent endorectal pullthrough with straight ileoanal anastomosis from 1977 to 1986 for ulcerative colitis (61) or familial polyposis (11). Sixty patients have had ileostomy closure and are reported here. The investigators discuss preoperative preparation, operative technique, and followup. Mean age at operation was 22.7 years with follow-up from 3 months to 9 years (average, 12 months). Operative mortality was 1.5%, and complications included adhesive bowel obstruction (11), pelvic abscess (2) pelvic phlegmon (1), rectovaginal fistulas (2), and minor wound infections (2). There were no anastomotic leaks. Six patients required revision to a standard Brooke ileostomy, and one patient with familial polyposis was found to have anaplastic carcinoma of the anal margin requiring abdominal perineal resection. Daytime continence was achieved in all patients at 1 year (all but two at 3 months). No patients had had major soiling. Mean stool

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frequency declined progressively to eight semiformed stools per day at 3 years. A concise comparison of the straightforward ileoanal anastomosis v pouch type reconstruction is provided. Current experience suggests the straight anastomosis offers advantages of a shorter operation, complete spontaneous evacuation, absence of pouchitis, and a lower incidence of pelvic sepsis.--Edward G. Ford Bleeding Rectal Varices Following Injection Sclerotherapy of O e s o p h a g e a l V a r i c e s in a Child. A.A. Azmy. Z Kinderchir 42:252,

(August), 1987. Bleeding from esophageal varices accounts for most upper gastrointestinal bleeding in children. Repeat injection sclerotherapy has proven to be a practical and effective method to control the bleeding and to obliterate the varices. This report describes a 13-year-old girl with portal hypertension who developed massive rectal variceal bleeding after repeat injection sclerotherapy of esophageal varices. Injection sclerotherapy of the rectal varices and the residual varices was performed.-- Thomas A. Angerpointner Simple Help for Spina Bifida Children With Anal Incontinence A,

Pompino, H.J. Pompino, and B. Waidmann. Z. Kinderchir 42:4345, (December), 1987 (suppl 1). The search for an effective means of helping children with anal incontinence has been facilitated by tissue-compatible material which has already been in use for a long time in proctology. Polyvinyl alcohol foam is characterized by its elasticity, malleability under the influence of liquids, and its good tissue compatibility. Anal plugs manufactured in the shape of hourglasses were used. These are available in various sizes and can be adapted individually. The investigators consider their application to be indicated in about one third of myelomeningocele children who have either partial or complete fecal incontinence. The plugs were also tested in healthy children. Experience is available in eight children operated on for high anal atresia and 15 children with spina bifida. Results are thus far encouraging. Management is described in detaiL--Thomas A. Angerpointner ABDOMEN Biliary Calculi Caused by Hemobilia. F. Luzuy, O. Reinberg, D.

Kauszlaric, et aL Surgery 102:886-889, (November), 1987. The researchers describe two cases of their own and two collected from the literature of gall stones occurring 6 to 12 months following traumatic hemobilia. Three were children and one was a young adult. In three of the four patients, symptoms of gall bladder disease and/or common duct obstruction developed. In three cases operation confirmed the presence of gall stones which were of various types. Significant GI hemorrhage secondary to hemobilia occurred in two patients, while the other two had ultrasound evidence of blood filling the gall bladder and biliary tree. This study indicates that patients with known hemobilia, especially when there are clots noted in the gall bladder, should be followed closely for subsequent development of calculi.--Eugene S. Wiener Jejunal Interposition Hepaticoduodenostomy for Choledochal Cyst. K.L. Narasimha Rao, S.K. Mitra, R. Kochher, et al. Am J

Gastroenterol 82:1042-1045, (October), 1987. Four patients, aged 4 years, 13 years, 11 months, and 8 years, had excision of choledochal cysts and biliary tract reconstruction using a jejunal interposition limb between the common hepatic duct and duodenum, similar to the method described by Raffensperger in 1980. The authors did not favor the use of the intussusception valve

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as originally described, but rather created a flap-type valve by suturing the adjacent walls of the lower end of the jejunal loop and the duodenum. This effectively prevented reflux of duodenal contents into the loop as determined by upper GI series. All patients did well following this operation and none developed postoperative cholangitis.--Richard R. Ricketts Orthotopic Liver Transplantation in Patients With Cystic Fibrosis. K.L. Cox, R.E. Ward, T.L. Furgiuele, et al. Pediatrics 80:571-574,

(October), 1987. Liver transplantation is accepted treatment for certain causes of liver failure. Up to 10% of patients with cystic fibrosis have clinical evidence of cirrhosis, and some of these patients will die of hepatic failure. The investigators present the case of an 11-year-old boy with cystic fibrosis and a 2-year history of progressive hepatic deterioration. The postoperative course was complicated by transient renal failure, 2 bouts of respiratory failure, and multiple episodes of sepsis. Death occurred on the 47th postoperative day due to a massive intracerebral hemorrhage. The investigators provide a detailed discussion of the complications.--JeffreyL. Zitsman Hepatic Transplantation in Europe: First Report of the European Liver Transplant Registry. H. Bismuth, B.G. Ericzon, K. Rolles, et

al. Lancet 2:674-676, (September 19), 1987. At the 32 European centers where livers are transplanted, the actuarial survival rate for 1,218 patients was 44% at 1 year and 41% at 2 years. Perioperative mortality (30 days) was 30%. Recipients <15 years of age had a higher survival rate than those aged >15 years old; the differences were 22% at 1 year and 32% at 2 years. For the 97 patients who received two or more liver grafts, actuarial survival was 27.7% at 1 and 2 years. Two thirds of the transplantations were done since 1984. Since then, the best results have been obtained for biliary atresia (88 cases; survival rates at 30 days, 1 year, and 2 years were 87%, 74%, and 68%). Primary biliary cirrhosis was the most common benign indication for transplantation, with survival of 64% at 1 and 2 years. The proportion of transplantations that were done for patients with hepatocellular carcinoma was smaller after than before 1984. Among transplantations in adults after 1984, those performed because of hepatocellular carcinoma gave the best perioperative survival rate (76%), but the worst 2-year survival (30.8%).--Prem Purl Fetal Omphalocele: Associated Malformations and Chromosomal Defects. W. Gilbert and K. Nicolaides. Obstet Gynecol 70:633-635,

(October), 1987. Fetal karyotyping was performed in 35 cases of omphalocele diagnosed by ultrasonography at 16 to 36 weeks' gestation. Nineteen fetuses (54%) had chromosomal abnormalities; 17 had trisomies, one triploidy, and one Klinefelter's Syndrome. Twenty-six (74%) of the fetuses were male. Detailed ultrasound examination of the fetuses showed an additional malformation in 73% of the cases, the most frequent of which was congenital heart disease (47%). Twenty-two pregnancies were aborted electively, four resulted in intrauterine or neonatal death, and nine infants are alive. The investigators advocate that rapid karYotyping should be performed even in the third trimester of pregnancy, because information regarding chromosomal abnormalities may alter the management of labor and delivery. In the present study, the authors used fetal blood sampling to perform karyotyping, which has the advantage of providing accurate results rapidly, thereby alleviating the parental anxiety associated with long delays in obtaining results. These findings of a high incidence of associated chromosomal and anatomic abnormalities with omphalo-

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cele are in contrast with the low incidence of associated defects and high survival rates reported in the pediatric surgical literature.Scott Adzick Cantrell's Syndrome. Z. Zachariou, R. Daum, It. Roth, et al. Z

Kinderchir 42:255-259, (August), 1987. In 1958, Cantrell described a pentalogy of congenital defects which became known as Cantrell's syndrome. The fact that the affected organs develop from the mesoderm implies the existence of a specific syndrome. The pentalogy consists of (1) supraumbilical abdominal wall defects, (2) defects of the lower sternum, (3) deficiencies of the anterior diaphragm, (4) defects of the diaphragmatic pericardium, and (5) congenital intracardiac defects. The prognosis of this syndrome is extremely poor. This article summarizes the clinical data and reports on three cases of Cantrell's syndrome.-- Thomas A. Angerpointner The Seat-Belt Syndrome. R. Vandersluis and H,M.C. O'Connor.

Can Med Assoc .I 137:1023-1024, (December), 1987. Two children are presented with seat-belt injuries. The first, a 9-year-old girl in the back seat of a car wearing a lap belt, was involved in a high-speed head-on collision. She had a forehead laceration, a large midlumbar hematoma, and a seat-belt contusion above the umbilicus. There was abdominal distension, diffuse guarding, and depressed bowel sounds. Roentgenograms were negative except for an anterior wedge deformity and transverse fracture of the second lumbar vertebra. Laparotomy showed a seromuscular tear in the duodenum, a jejunal perforation plus transection of a jejunal segment, a small perforation of the ascending colon, and marked retroperitoneal and mesenteric bleeding. The jejunal segment was excised and a right hemicolectomy performed, both with primary anastomoses. The duodenal tear was oversewn. Internal fixation of the lumbar fracture was performed 17 days later. Recovery was uneventful. The second patient, a 7-year-old boy with a lap belt in the front seat of a car, was also involved in a high-speed collision, Abdominal examination showed a seat-belt contusion below the umbilicus with a diffusely tender, silent abdomen. A large hematoma was noted in the midlumbar area. Roentgenograms and CT scan showed no abdominal injury, but did show a fracture dislocation of the third lumbar vertebra on the fourth. Open reduction and internal fixation were performed immediately. Six days later, a laparotomy showed a midjejunal perforation which was treated by resection and primary anastomosis. Recovery was uneventful. The researchers note that the combination of gastrointestinal perforations and lumbar fracture-dislocations is more frequent among children than adults. Lumbar distraction or hance fractures occurred in seven out of nine (78%) children that they reviewed with seat-belt injuries. They urge physicians to be suspicious of significant abdominal and lumbar trauma when the seat-belt sign (contusions, petechiae, and a brand-like pattern of abrasions across the abdomen or chest) is present. Peritoneal lavage is recommended as part of the early diagnostic evaluation if the extent of abdominal injury is unknown. The researchers also note that the increased use of seat belts has changed the pattern of intraabdominal injuries. Liver lacerations have decreased, and the number of injuries to the diaphragm and gastrointestinal tract has increased.--John N. Schullinger Injuries to the Abdominal Vascular System: How Much Does Aggressive Resuscitation and Prelaparotomy Thoracotomy Really Help7 R.G. Wiencek, Jr, and R.F. Wilson. Surgery 102:731-736,

(October), 1987. One hundred fifty-four patients aged 15 to 82 years (average, 29 years) with abdominal vascular injuries, following gun shot wounds