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Orchidopexy: The younger the better?
INTERNATIONAL
1252
cholestasis, the prehilar structure of the bile ducts, and the histopathologically defined features of the intralobular bile ducts. The total diameter of all the prehilar bile duct structures is unmistakingly the most dominant of all findings. A total diameter of more than 400 pm indicates a favorable prognostic subtype, whereas a total diameter of less than 400 km indicates an unfavorable subtype. However, even if the prognostically favorable findings are present, the actual prognosis is finally determined by the histopathologic features of the intralobular bile ducts. Therefore, these four characteristic groups must be taken into consideration when rationally evaluating the prognosis--Thomas A. Angerpointner Assessment of the Nutritional Status of Infants and Children With Biliary Atresia. S. Cywes and A.J. W. Millar. S Afr Med J
77:131-135, (February), 1990. The nutritional status of 11 infants and children was assessed over a 4-month period. AI1but one had severe cholestasis throughout the period of assessment. In spite of more than adequate documented nutrient intake, all the patients over 3 months of age with cholestasis (8/11) showed evidence of significant growth retardation. Serum levels of vitamins A, D, E, and zinc indicated severe deficiency. Three of 4 receiving cholestyramine had very low levels of vitamin E despite supplementation. These findings confirm the presence of severe nutritional depletion in this cholestatic disease of infancy and childhood. The importance of adequately preparing those patients assessed as suitable for liver transplantation is stressed.-Aiastair
Millar
Endoscopic Retrograde Cholangiopancreatography in Infantile Cholestasis. M.L. Wilkinson, G. Mieli-Vergani, C. Ball, et al.
Arch Dis Child 66:121-123, (January), 1991. The authors report the use of endoscopic retrograde cholangiopancreatography (ERCP) in 9 patients of a total group of 159 infants with neonatal cholestasis. Laparotomy was avoided in four patients in whom bile ducts were definitively visualized. Three of four patients in whom bile ducts were not visualized were found to have extrahepatic biliary atresia. There were no major complications of the procedure, and the authors feel that in appropriately selected patients, ERCP may prove to be a useful tool. In particular, it seems to be useful in patients, such as the study group, with evidence of complete cholestasis but equivocal liver histology. -D.M.
Burge
A 27-Year Experience With Splenectomy for Gaucher’s Disease. P.R. Fleshner, A.H. Aufses, Jr, G.A. Grabowski, et al. Am J
Surg 161:69-75, (January), 1991. This is the largest reported series of splenectomy for Gaucher’s disease, which is an inherited disorder of sphingolipid metabolism that leads to hypersplenism with intraabdominal pressure symptoms. In the past, splenectomy has been a traditional surgical approach. However, this has been accompanied by accelerated bone and hepatic disease, along with the constant risk of overwhelming sepsis. In this series, 35 of 48 patients had total splenectomy. Thirteen had partial splenectomy in an attempt to avoid the adverse side effects of total splenectomy. No patients having partial splenectomy were noted to develop accelerated bone disease. However, 11 patients developed accelerated bone disease after total splenectomy. There were also four deaths due to malignant disease in the group of patients following total splenectomy. The authors confirm that either total or partial splenectomy can be performed with minimal morbidity and mortality. However, total splenectomy is accompanied by a predisposition to malignancy, as well as aggressive bone disease. They advocate prospective, random-
ABSTRACTS
ized trials to determine whether partial splenectomy should become the treatment of choice for Gaucher’s disease. Although the average age in the patient study group was 33 ‘_ 3 years, the paper is important for pediatric surgeons who continue to follow patients with Gaucher’s disease.--Thomas F. Tracy, Jr Continued Need for Pneumococcal Prophylaxis After Splenectomy. LA. Murdoch and R. DOS Anjos. Arch Dis Child 65:1268-
1269, (November), 1990. The authors report two children dying from pneumoccal infection. The first child underwent splenectomy for trauma at age 8 years, was not vaccinated against pneumococci, and stopped taking prophylactic penicillin 2 years later. At the age of 13 years he died of pneumococcal meningitis. The second child had a splenectomy performed following trauma at age 4 years. He was not vaccinated and had prophylactic penicillin, which was stopped at age 8 years. At age 12 he died of pneumococcal septicemia. The authors conclude that vaccination should be performed with revaccination at 6-year intervals and that penicillin should be continued indefinitely or until the child has left school or university.-D. M. Burge Controversies in the Management of Gastroschisis: A Study of 40 Patients. M.D. Stringer, R.J. Brereton, and V.M. Wright. Arch
Dis Child 66 (Fetal and Neonatal Ed): 34-36, (January), 1991. In a study of 40 infants with gastroschisis seen over a 13-year period, some interesting differences were noted between the 9 patients transferred in utero and the 31 referred postnatally. Despite the statistical limitations, the prenatal transfer group had more frequent successful primary closure, less postoperative ventilation, and reduced hospital stay. The overall smvival was 90%. The authors conclude that earlier optimal management may have been available to the prenatal group and this may be the reason for improved results with these patients.-D.M. Burge Abdominal Aneurysms in Childhood: Report of a Case and Review of the Literature. R.S. Sarkar, R.E. Cilley, and A.G. Coran. Surgery 109:143-148, (February), 1991.
The least common category of childhood abdominal aneurysms is that of true idiopathic aneurysms. This is the fourth case report in the literature of an idiopathic abdominal aneurysm in a child, a 4-year-old girl with a right common iliac aneurysm. There was no prior history of arterial catheter placement or other trauma and no evidence of connective tissue disease or other diseases associated with childhood aneurysms. She underwent resection of the aneurysm. Reconstruction of the right iliac artery was performed by an end-to-end anastomosis with the left distal internal iliac artery. Pathological examination of the aneurysm showed no evidence of inflammation or medial degeneration.-Thomas F. Tracy, Jr GENITOURINARY
TRACT
Orchidopexy: The Younger the Better? D. Wilson-Storey, K. McGenity, and J.A.S. Dickson. J R Co11 Surg (Ed) 35:362-364,
(December), 1990. In an attempt to resolve the question “should orchidopexy be carried out before 2years of age,” the authors report the findings in 100 children operated on before 2 years of age and 100 children after 2 years of age. All patients had an ectopic or high scrotal testis. There was no difference in the side of undescent or presence of an associated patent processus between the two groups. Group A ranged in age from 1 to 23 months and group B from 2 to 16 years.
INTERNATIONAL
ABSTRACTS
1253
Orchidopexy was the same in all cases using a standard dartos or scrotal pouch. All patients were seen at 6 weeks and 6 months after operation. Twenty from each group were seen at 5 years. Five testes were found to be atrophied in group A and 4 in group B. Atrophy was found within 6 weeks of operation and was attributed to either damage to the vascular supply at operation or excessive tension on vessels. One testis in group A, thought initially to be atrophied, was found to be of normal size at 5 years. In view of the morphological changes noted in the undescended testis after 2 years, the authors recommend early operation and follow-up for 6 months or longer.-lV.G. Scobie Testicular Development Following Unilateral Orchiopexy Measured by a New Orchiometer. H. Takihara, Y. Baba, K. Ishizu, et al. Urology 36:370-372, (October), 1990.
Orchiopexy was performed on 170 patients between the years 1968 and 1983. Of these, 90 patients agreed to participate in the authors’ study. Testicular size was measured in 55 patients using an accurate and practical orchiometer that the authors developed. In boys under 10 years of age (prepubertal), testicular development was minimal, and the operated and contralateral testes were not significantly different. With the onset of puberty, both testes enlarged and no significant differences were observed. However, by age 14 years, the operated testis was significantly (P < .05) less well-developed than the contralateral testis. The results suggest that only limited development of the operated testis occurs at puberty and raise questions regarding the current role for the surgical correction of cryptorchism in preserving fertility.-George W. Holcomb III One Hundred Years of Splenogonadal
Fusion. A.M. Carragher.
Urology 35471-475, (June), 1990. This article reviews the embryology of the formation of the spleen and gonads and the classification of splenogonadal fusion. In addition, it includes a brief description of all cases of this entity along with associated congenital abnormalities, histopathology, and treatment. It provides a nice review of this topic.-George B! Holcomb
III
Management of Posterior Urethral Strictures Secondary to Pelvic Fractures in Children. M.A. Al-Rifael, S. Gaafar, and M. Abdel-Rahman. J Urol145:353-356. (February), 1991.
Bulboprostatic anastomotic urethroplasty was performed in 20 children with posterior urethral strictures secondary to bony pelvic fractures. The approach was perineal in 4 children and transpubic abdominoperineal in 16. There were good postoperative results in 62.5%. In some children the urethral disruption occurred within the prostate itself and not at the prostatomembranous junction. In such cases, the proximal sphincteric mechanism may be at risk and immediate repair of the injury is advisable. In the case of common prostatomembranous disruption, displacement of the urethra may be significant. In such cases, a transpubic approach is preferable. If the proximal sphincteric mechanism is deranged, it can be managed at the same time.-George Holcomb, Jr Congenital Urethral-Perineal Fistula: Diagnosis and New Surgical Management. WC. Brown, I? W. Dillon, and T W He&e.
Urology 36:157-159, (August), 1990. Congenital posterior urethral-perineal fistula is a rare anomaly of which there have been only 6 reported cases. This report outlines the clinical presentation of another case and a unique surgical approach to its management. A review of the English literature is presented.-George W. Holcomb III
Persistent Miillerian Duct Syndrome. E. 1: Fernandes, R.S. Hollabaugh, J.A. Young, et al. Urology 36:516-S& (December), 1990.
The authors report a case of a phenotypically normal male with persistent Miillerian structures that consisted of a bicornuate uterus, fallopian tubes, and upper third of the vagina. These structures were found in association with bilateral cryptorchism and a right inguinal hernia while repairing the hernia in the neonatal period. The uterus and fallopian tubes were removed via laparotomy when the child was 18 months old. At the same time, a bilateral orchiopexy was performed. To avoid damage to the vas deferens, which lay close to the Miillerian structures and could not be separated from the vaginal wall, a small segment of the upper third of the vagina was retained. The testicles, although normal on pathological examination, have shown poor response to hormonal stimulation with human chorionic gonadotropin. The authors emphasize that long-term follow-up for these patients is necessary because they have an increased risk of testicular tumors--George w. Holcomb III Continence in Bladder Exstrophy: Determinants of Success. P.A. Merguerian, G.A. McLorie, N.D. McMullin, etal. J Ural 145:350-
352, (February), 1991. Nineteen female and 18 male patients with bladder exstrophy were evaluated. Each had completed staged reconstruction, required no further surgery, and underwent urodynamic studies. Of the male population, 61% were continent based on a significantly higher urethral continence length (25.8 2 6.4 mm) and a higher urethral closing pressure (69.4 2 5.8 cm H,O) compared with the incontinent male population (11.4 2 3.1 mm and 43.4 rt 4.6 cm H,O). No significant difference was noted in the bladder capacity of these two groups. Of the female population, 57.9% were continent. They also demonstrated a higher urethral continence length (21.1 ? 4.4 mm) and a higher urethral closing pressure (62.7 ? 10.2 cm H,O) compared with the incontinent female subjects (8.4 -+ 2.5 mm and 32.7 2 6.9 cm HZO). Moreover, those who were continent had a significantly higher bladder capacity (201.2 2 39.5 mL) than those who were incontinent (84.3 + 23.6 mL). These findings support a multifactorial mechanism in achieving continence, but they suggest that of all the factors urethral length may be the most important.-George Holcomb, Jr Cecal Tubularization: Lengthening Technique for Creation of Catheterizable Conduit. WJ. Cromie, J. H. Barada, and J.L. Weingarten. Urology 37:41-42, (January), 1991.
The creation of a continent, catheterizable stoma is an integral component of a successful continent urinary diversion. The authors describe a technique that allows lengthening of a continent appendicovesicostomy. This technique extends the applications of the Mitrofanoff principle for urinary tract reconstruction.-George IV Holcomb III Endopyelotomy for Secondary Ureteropelvic Junction Obstruction in Children. L.R. Kavoussi, S. Meretyk, S.M. Die&s, et al.
J Ural 145:345-349, (February), 1991. Percutaneous endopyelotomy has been shown to be successful in treating ureteropelvic junction (UPJ) obstruction in adults. Few data have been published regarding this procedure in children. Four patients 6.5 weeks to 5.5 years of age are described who underwent percutaneous endopyelotomy to treat ureteropelvic junction obstruction following failed open dismembered pyeloplasty. Preoperative obstruction was demonstrated by a nephrostogram, diuretic renogram, and/or ultrasonography. Percutaneous endopyelotomy was successful in relieving the obstruction in all
1252
cholestasis, the prehilar structure of the bile ducts, and the histopathologically defined features of the intralobular bile ducts. The total diameter of all the prehilar bile duct structures is unmistakingly the most dominant of all findings. A total diameter of more than 400 pm indicates a favorable prognostic subtype, whereas a total diameter of less than 400 km indicates an unfavorable subtype. However, even if the prognostically favorable findings are present, the actual prognosis is finally determined by the histopathologic features of the intralobular bile ducts. Therefore, these four characteristic groups must be taken into consideration when rationally evaluating the prognosis--Thomas A. Angerpointner Assessment of the Nutritional Status of Infants and Children With Biliary Atresia. S. Cywes and A.J. W. Millar. S Afr Med J
77:131-135, (February), 1990. The nutritional status of 11 infants and children was assessed over a 4-month period. AI1but one had severe cholestasis throughout the period of assessment. In spite of more than adequate documented nutrient intake, all the patients over 3 months of age with cholestasis (8/11) showed evidence of significant growth retardation. Serum levels of vitamins A, D, E, and zinc indicated severe deficiency. Three of 4 receiving cholestyramine had very low levels of vitamin E despite supplementation. These findings confirm the presence of severe nutritional depletion in this cholestatic disease of infancy and childhood. The importance of adequately preparing those patients assessed as suitable for liver transplantation is stressed.-Aiastair
Millar
Endoscopic Retrograde Cholangiopancreatography in Infantile Cholestasis. M.L. Wilkinson, G. Mieli-Vergani, C. Ball, et al.
Arch Dis Child 66:121-123, (January), 1991. The authors report the use of endoscopic retrograde cholangiopancreatography (ERCP) in 9 patients of a total group of 159 infants with neonatal cholestasis. Laparotomy was avoided in four patients in whom bile ducts were definitively visualized. Three of four patients in whom bile ducts were not visualized were found to have extrahepatic biliary atresia. There were no major complications of the procedure, and the authors feel that in appropriately selected patients, ERCP may prove to be a useful tool. In particular, it seems to be useful in patients, such as the study group, with evidence of complete cholestasis but equivocal liver histology. -D.M.
Burge
A 27-Year Experience With Splenectomy for Gaucher’s Disease. P.R. Fleshner, A.H. Aufses, Jr, G.A. Grabowski, et al. Am J
Surg 161:69-75, (January), 1991. This is the largest reported series of splenectomy for Gaucher’s disease, which is an inherited disorder of sphingolipid metabolism that leads to hypersplenism with intraabdominal pressure symptoms. In the past, splenectomy has been a traditional surgical approach. However, this has been accompanied by accelerated bone and hepatic disease, along with the constant risk of overwhelming sepsis. In this series, 35 of 48 patients had total splenectomy. Thirteen had partial splenectomy in an attempt to avoid the adverse side effects of total splenectomy. No patients having partial splenectomy were noted to develop accelerated bone disease. However, 11 patients developed accelerated bone disease after total splenectomy. There were also four deaths due to malignant disease in the group of patients following total splenectomy. The authors confirm that either total or partial splenectomy can be performed with minimal morbidity and mortality. However, total splenectomy is accompanied by a predisposition to malignancy, as well as aggressive bone disease. They advocate prospective, random-
ABSTRACTS
ized trials to determine whether partial splenectomy should become the treatment of choice for Gaucher’s disease. Although the average age in the patient study group was 33 ‘_ 3 years, the paper is important for pediatric surgeons who continue to follow patients with Gaucher’s disease.--Thomas F. Tracy, Jr Continued Need for Pneumococcal Prophylaxis After Splenectomy. LA. Murdoch and R. DOS Anjos. Arch Dis Child 65:1268-
1269, (November), 1990. The authors report two children dying from pneumoccal infection. The first child underwent splenectomy for trauma at age 8 years, was not vaccinated against pneumococci, and stopped taking prophylactic penicillin 2 years later. At the age of 13 years he died of pneumococcal meningitis. The second child had a splenectomy performed following trauma at age 4 years. He was not vaccinated and had prophylactic penicillin, which was stopped at age 8 years. At age 12 he died of pneumococcal septicemia. The authors conclude that vaccination should be performed with revaccination at 6-year intervals and that penicillin should be continued indefinitely or until the child has left school or university.-D. M. Burge Controversies in the Management of Gastroschisis: A Study of 40 Patients. M.D. Stringer, R.J. Brereton, and V.M. Wright. Arch
Dis Child 66 (Fetal and Neonatal Ed): 34-36, (January), 1991. In a study of 40 infants with gastroschisis seen over a 13-year period, some interesting differences were noted between the 9 patients transferred in utero and the 31 referred postnatally. Despite the statistical limitations, the prenatal transfer group had more frequent successful primary closure, less postoperative ventilation, and reduced hospital stay. The overall smvival was 90%. The authors conclude that earlier optimal management may have been available to the prenatal group and this may be the reason for improved results with these patients.-D.M. Burge Abdominal Aneurysms in Childhood: Report of a Case and Review of the Literature. R.S. Sarkar, R.E. Cilley, and A.G. Coran. Surgery 109:143-148, (February), 1991.
The least common category of childhood abdominal aneurysms is that of true idiopathic aneurysms. This is the fourth case report in the literature of an idiopathic abdominal aneurysm in a child, a 4-year-old girl with a right common iliac aneurysm. There was no prior history of arterial catheter placement or other trauma and no evidence of connective tissue disease or other diseases associated with childhood aneurysms. She underwent resection of the aneurysm. Reconstruction of the right iliac artery was performed by an end-to-end anastomosis with the left distal internal iliac artery. Pathological examination of the aneurysm showed no evidence of inflammation or medial degeneration.-Thomas F. Tracy, Jr GENITOURINARY
TRACT
Orchidopexy: The Younger the Better? D. Wilson-Storey, K. McGenity, and J.A.S. Dickson. J R Co11 Surg (Ed) 35:362-364,
(December), 1990. In an attempt to resolve the question “should orchidopexy be carried out before 2years of age,” the authors report the findings in 100 children operated on before 2 years of age and 100 children after 2 years of age. All patients had an ectopic or high scrotal testis. There was no difference in the side of undescent or presence of an associated patent processus between the two groups. Group A ranged in age from 1 to 23 months and group B from 2 to 16 years.
INTERNATIONAL
ABSTRACTS
1253
Orchidopexy was the same in all cases using a standard dartos or scrotal pouch. All patients were seen at 6 weeks and 6 months after operation. Twenty from each group were seen at 5 years. Five testes were found to be atrophied in group A and 4 in group B. Atrophy was found within 6 weeks of operation and was attributed to either damage to the vascular supply at operation or excessive tension on vessels. One testis in group A, thought initially to be atrophied, was found to be of normal size at 5 years. In view of the morphological changes noted in the undescended testis after 2 years, the authors recommend early operation and follow-up for 6 months or longer.-lV.G. Scobie Testicular Development Following Unilateral Orchiopexy Measured by a New Orchiometer. H. Takihara, Y. Baba, K. Ishizu, et al. Urology 36:370-372, (October), 1990.
Orchiopexy was performed on 170 patients between the years 1968 and 1983. Of these, 90 patients agreed to participate in the authors’ study. Testicular size was measured in 55 patients using an accurate and practical orchiometer that the authors developed. In boys under 10 years of age (prepubertal), testicular development was minimal, and the operated and contralateral testes were not significantly different. With the onset of puberty, both testes enlarged and no significant differences were observed. However, by age 14 years, the operated testis was significantly (P < .05) less well-developed than the contralateral testis. The results suggest that only limited development of the operated testis occurs at puberty and raise questions regarding the current role for the surgical correction of cryptorchism in preserving fertility.-George W. Holcomb III One Hundred Years of Splenogonadal
Fusion. A.M. Carragher.
Urology 35471-475, (June), 1990. This article reviews the embryology of the formation of the spleen and gonads and the classification of splenogonadal fusion. In addition, it includes a brief description of all cases of this entity along with associated congenital abnormalities, histopathology, and treatment. It provides a nice review of this topic.-George B! Holcomb
III
Management of Posterior Urethral Strictures Secondary to Pelvic Fractures in Children. M.A. Al-Rifael, S. Gaafar, and M. Abdel-Rahman. J Urol145:353-356. (February), 1991.
Bulboprostatic anastomotic urethroplasty was performed in 20 children with posterior urethral strictures secondary to bony pelvic fractures. The approach was perineal in 4 children and transpubic abdominoperineal in 16. There were good postoperative results in 62.5%. In some children the urethral disruption occurred within the prostate itself and not at the prostatomembranous junction. In such cases, the proximal sphincteric mechanism may be at risk and immediate repair of the injury is advisable. In the case of common prostatomembranous disruption, displacement of the urethra may be significant. In such cases, a transpubic approach is preferable. If the proximal sphincteric mechanism is deranged, it can be managed at the same time.-George Holcomb, Jr Congenital Urethral-Perineal Fistula: Diagnosis and New Surgical Management. WC. Brown, I? W. Dillon, and T W He&e.
Urology 36:157-159, (August), 1990. Congenital posterior urethral-perineal fistula is a rare anomaly of which there have been only 6 reported cases. This report outlines the clinical presentation of another case and a unique surgical approach to its management. A review of the English literature is presented.-George W. Holcomb III
Persistent Miillerian Duct Syndrome. E. 1: Fernandes, R.S. Hollabaugh, J.A. Young, et al. Urology 36:516-S& (December), 1990.
The authors report a case of a phenotypically normal male with persistent Miillerian structures that consisted of a bicornuate uterus, fallopian tubes, and upper third of the vagina. These structures were found in association with bilateral cryptorchism and a right inguinal hernia while repairing the hernia in the neonatal period. The uterus and fallopian tubes were removed via laparotomy when the child was 18 months old. At the same time, a bilateral orchiopexy was performed. To avoid damage to the vas deferens, which lay close to the Miillerian structures and could not be separated from the vaginal wall, a small segment of the upper third of the vagina was retained. The testicles, although normal on pathological examination, have shown poor response to hormonal stimulation with human chorionic gonadotropin. The authors emphasize that long-term follow-up for these patients is necessary because they have an increased risk of testicular tumors--George w. Holcomb III Continence in Bladder Exstrophy: Determinants of Success. P.A. Merguerian, G.A. McLorie, N.D. McMullin, etal. J Ural 145:350-
352, (February), 1991. Nineteen female and 18 male patients with bladder exstrophy were evaluated. Each had completed staged reconstruction, required no further surgery, and underwent urodynamic studies. Of the male population, 61% were continent based on a significantly higher urethral continence length (25.8 2 6.4 mm) and a higher urethral closing pressure (69.4 2 5.8 cm H,O) compared with the incontinent male population (11.4 2 3.1 mm and 43.4 rt 4.6 cm H,O). No significant difference was noted in the bladder capacity of these two groups. Of the female population, 57.9% were continent. They also demonstrated a higher urethral continence length (21.1 ? 4.4 mm) and a higher urethral closing pressure (62.7 ? 10.2 cm H,O) compared with the incontinent female subjects (8.4 -+ 2.5 mm and 32.7 2 6.9 cm HZO). Moreover, those who were continent had a significantly higher bladder capacity (201.2 2 39.5 mL) than those who were incontinent (84.3 + 23.6 mL). These findings support a multifactorial mechanism in achieving continence, but they suggest that of all the factors urethral length may be the most important.-George Holcomb, Jr Cecal Tubularization: Lengthening Technique for Creation of Catheterizable Conduit. WJ. Cromie, J. H. Barada, and J.L. Weingarten. Urology 37:41-42, (January), 1991.
The creation of a continent, catheterizable stoma is an integral component of a successful continent urinary diversion. The authors describe a technique that allows lengthening of a continent appendicovesicostomy. This technique extends the applications of the Mitrofanoff principle for urinary tract reconstruction.-George IV Holcomb III Endopyelotomy for Secondary Ureteropelvic Junction Obstruction in Children. L.R. Kavoussi, S. Meretyk, S.M. Die&s, et al.
J Ural 145:345-349, (February), 1991. Percutaneous endopyelotomy has been shown to be successful in treating ureteropelvic junction (UPJ) obstruction in adults. Few data have been published regarding this procedure in children. Four patients 6.5 weeks to 5.5 years of age are described who underwent percutaneous endopyelotomy to treat ureteropelvic junction obstruction following failed open dismembered pyeloplasty. Preoperative obstruction was demonstrated by a nephrostogram, diuretic renogram, and/or ultrasonography. Percutaneous endopyelotomy was successful in relieving the obstruction in all