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Pneumatosis intestinalis of infancy
579
ABSTRACTS
wound infection with ( 1) increasing age, (2) the severity of the disease, worse in the gangrenous and perforated cases, (3) use of drainage, (4) use of antibiotics and (5) with paramedian and extended grid-iron incisions. These findings are as one would expect since the more severe cases are likely to have the latter three measures instituted.--J. Lari SYMPOSIUM ON RESULTS OF TREATMENTIN HIRSCHSPRUNG’S DISEASE. Ann. Chir. infant. 11:5-152, 1970. In the tradition of the meetings of the French Society of Pediatric Surgery, the annual meeting of January 1969 was devoted to one topic, the problem of megacolon and the results of treatment. After a short review on pathophysiology (B. Duhamel) and histology (J. P. Gubler), the first papers were dedicated to the treatment of Hirschsprung’s disease in the newborn and in early infancy: nursing versus colostomy (Pellerin, Aubrespy), intestinal perforation (Bodart), enterocolitis (Daudet) , ileo-coecoplication (Monereo) were discussed. Many authors (Bensahel, Bourrea, Prevot, Valayer) layed stress on the difficulty of treatment in total aganglionosis. Only Duhamel and Pages supported early definitive operation. In a second group of articles the results of the definitive treatment of megacolon were reported. The different techniques were discribed (Valayer, Pellerin. Prevot, Soave, Duhamel, Campo Paysaa, Rehbein, Bodart). Many early complications may occur, like dehiscence of anastomosis, stenoses, ileus, etc. (Aubrespy, Soave, Rehbein, Pellerin), with a mortality rate varing from 44 per cent in early infancy to 3.7 per cent later “II.
Functional results were the object of the last group of papers. In a series of 61.5 patients, 75 per cent have excellent or good defecation function. The residual troubles in the remaining 25 per cent were discussed by Aubrespy. Vervat, Rehbein, Saint-Sup&y, Lasserre. Pages. Mollard and Daudet.M. Better
PNEUMATOSISINTESTINALISOF INFANCY. H. Harlan Michael
Stone, H. Warner Webb and T. Kovalchik, III. Surg. Gynec.
Obstet. 130:806-812
(May),
In a previous experimental
1970.
study by Stone
and his associates, it was demonstrated that a clinical and pathologic condition similar to pneumatosis intestinalis in the infant can be produced in the guinea pig by the injection of bacterial suspension into the wall of the intestine. Accordingly it was decided to compare a IO-year experience with enterocolitis in the newborn to a series of babies with pneumatosis intestinalis. From July I. 1959 through June 30, 1969, 46 babies less than 2 months of age were diagnosed as having enterocolitis in the nursery. During the same period 18 babies with pneumatosis intestinalis were encountered on the pediatric service at Grady Memorial Haspital. Three additional babies were seen in consultation in another hospital. Clinical findings were essentially similar except abdominal distention and blood in the stools or vomiting were uncommon in enterocolitis but were noted in almost every instance of pneumatosis intestinalis. Roentgenograms of the abdomen, when obtained, were essentially negative in babies with enterocolitis. However, roentgenograms of infants with pneumatosis intesinalis demonstrated, in addition to gas bubbles within the intestinal wall, a paralytic ileus in every instance, free peritoneal air in four, and gas within the portal vein in three. Cultures of stools were positive for pathogenic gramnegative bacteria in both conditions. Treatment for both conditions consisted of intravenous fluid and electolyte therapy with systemic antibiotics, and in four instances, intramuscular administration of gammaglobulin. Two of the babies with enterocolitis died, both from generalized sepsis (mortality rate of 4.3% ). Nine of the 21 infants with pneumatosis intestinalis died, thereby resulting in a mortality rate of 42.9 per cent. The cause of death was a generalized sepsis in each instance. Intestinal perforation occurred in four babies. The only fat tor that appeared to be responsible tor . differences in mortality rates among in fants with pneumatosis intestinalis was the slxcific antibiotic given. Two of the nine babies treated with intramuscular kanamycin lived. However, there was but one death in the group of 11 to whom gentamicin sulfate was administered. It appears that pneumatosis represents the most severe form of enterocolitis. Management directed at the causative gram-negative enterocolitis and invasive sepsis reduced the
580
ABSTRACTS
mortality rate from 80 to 9.1 per cent.George Holcomb, Jr. ABDOMEN GALLBLADDERDISEASE IN CHILDHOOD.H. N. Bars. Clin. Ped. 9:229 (April), 1970.
Four patients under 15 years of age with gallbladder disease are reported. Two of these patients had associated hematologic diseases.-h&he1 Gilbert THE ROLE OF RADIATION THERAPY IN THE MANAGEMENT OF HEMANGIOMAS OF THE LIVER. W. C. Park and R. Phillips.
JAMA 212: 1496-1498
(June 1), 1970.
Five cases of nonresectable hemangioma of the liver were treated with radiation therapy. Four of the five patients had good results with control of the disease and preservation of normal liver function. One patient was 4 months old. Although 2000 rads delivered in 10 days is recommended in adults, 400 to 600 rads is recommended in infants.-.I. Eugene Lewis, Jr. LIVER TRANSPLANTATION IN MAN. THE SIGNIFICANCE,PATTERNS AND CONTROL OF INFECTION. I. M. Murray-Lyon, D. B. Evans, W. D. Forter, R. J. Holden, H. 0. Rake, H. Stern, R. Y. Caine and R. Williams. Brit. .I. Surg. 57:280-284 (April),
1970. In spite of strict precautions, including barrier nursing, infection is a major problem in all transplant operations including hepatic transplantation mainly due to the use of immunosuppressive drugs. Only one out of nine patients who survived the immediate postoperative period did not develop a serious infection, and six died as a result of it. Pulmonary infection was the most serious problem occurring in all but one case. Staphylococcus aureus was the organism in three cases who were also nasal carriers. Five out of six cases where bile specimens could be obtained had positive cultures with the usual intestinal organisms, and in all five patients these organisms appeared in blood cultures. Not all cases with positive bile or blood cultures were necessarily ill. Cytomegalovirus infection occurred in six patients but in none was there evidence that the virus did any harm.
Prophylactic antibiotics were not used and were thought to encourage resistant organisms and fungal infection. Broad-spectrum antibiotics were used freely even in minor infections and with little success to clear the bile of organisms. This was often followed by superinfection with resistant organisms and fungi. The present policy is to use antibiotics sparingly and to rely on narrow spectrum drugs wherever possible.-./. _L~J+
GENITOURINARY
TRACT
DRIP INFUSION UROGRAPHY IN PATIENTS WITH RENAL DISEASE. R. D. Ensor, E. Anderson and R. R. Robinson. J. Urol.
103:267-271
(March),
1970.
This is a report based on 188 studies performed in 174 patients whose blood urea nitrogen was 40 mg. per 100 ml. or higher, plasma creatinine concentration was 1.5 mg. per 100 ml. or more whose endogenous creatinine clearance was less than 80 ml. per minute per 1.73 sq. meters body surface. Fifty per cent Sodium Diatrizoate (1 ml. per lb. of body weight) was given with an equal volume of 5 per cent Dextrose and water IV rapidly. Films were exposed at 2 minutes after starting the infusion and 2 minutes and 10 minutes after its completion. Occasionally, delayed films were obtained at 24 hours. As there is little tubular reabsorption of Sodium Diatrizoate, its concentration increases allowing visualization by X ray. In patients with diminished renal function, the filtered load of contrast medium is limited due to marked filtration rate reduction. There may also be an endogenous osmotic diuresis and a decrease in the rate of water absorption further minimizing intratubular concentration of the dye. Drip infusion urography allows greater volumes of dye to be used making visualization of the kidney even when its functions are depressed. When the creatinine clearance was more than 10 ml. per minute, the plasma creatinine concentration was less than 8 mg. per 100 ml. or the BUN concentration was less than 80 mg. per 100 ml., 75 per cent of the urograms were satisfactory. There were only a few adverse reactions all of which were transient. In no case was there evidence of adverse effects of the dye on renal functions.-Bruce M. Henderson
ABSTRACTS
wound infection with ( 1) increasing age, (2) the severity of the disease, worse in the gangrenous and perforated cases, (3) use of drainage, (4) use of antibiotics and (5) with paramedian and extended grid-iron incisions. These findings are as one would expect since the more severe cases are likely to have the latter three measures instituted.--J. Lari SYMPOSIUM ON RESULTS OF TREATMENTIN HIRSCHSPRUNG’S DISEASE. Ann. Chir. infant. 11:5-152, 1970. In the tradition of the meetings of the French Society of Pediatric Surgery, the annual meeting of January 1969 was devoted to one topic, the problem of megacolon and the results of treatment. After a short review on pathophysiology (B. Duhamel) and histology (J. P. Gubler), the first papers were dedicated to the treatment of Hirschsprung’s disease in the newborn and in early infancy: nursing versus colostomy (Pellerin, Aubrespy), intestinal perforation (Bodart), enterocolitis (Daudet) , ileo-coecoplication (Monereo) were discussed. Many authors (Bensahel, Bourrea, Prevot, Valayer) layed stress on the difficulty of treatment in total aganglionosis. Only Duhamel and Pages supported early definitive operation. In a second group of articles the results of the definitive treatment of megacolon were reported. The different techniques were discribed (Valayer, Pellerin. Prevot, Soave, Duhamel, Campo Paysaa, Rehbein, Bodart). Many early complications may occur, like dehiscence of anastomosis, stenoses, ileus, etc. (Aubrespy, Soave, Rehbein, Pellerin), with a mortality rate varing from 44 per cent in early infancy to 3.7 per cent later “II.
Functional results were the object of the last group of papers. In a series of 61.5 patients, 75 per cent have excellent or good defecation function. The residual troubles in the remaining 25 per cent were discussed by Aubrespy. Vervat, Rehbein, Saint-Sup&y, Lasserre. Pages. Mollard and Daudet.M. Better
PNEUMATOSISINTESTINALISOF INFANCY. H. Harlan Michael
Stone, H. Warner Webb and T. Kovalchik, III. Surg. Gynec.
Obstet. 130:806-812
(May),
In a previous experimental
1970.
study by Stone
and his associates, it was demonstrated that a clinical and pathologic condition similar to pneumatosis intestinalis in the infant can be produced in the guinea pig by the injection of bacterial suspension into the wall of the intestine. Accordingly it was decided to compare a IO-year experience with enterocolitis in the newborn to a series of babies with pneumatosis intestinalis. From July I. 1959 through June 30, 1969, 46 babies less than 2 months of age were diagnosed as having enterocolitis in the nursery. During the same period 18 babies with pneumatosis intestinalis were encountered on the pediatric service at Grady Memorial Haspital. Three additional babies were seen in consultation in another hospital. Clinical findings were essentially similar except abdominal distention and blood in the stools or vomiting were uncommon in enterocolitis but were noted in almost every instance of pneumatosis intestinalis. Roentgenograms of the abdomen, when obtained, were essentially negative in babies with enterocolitis. However, roentgenograms of infants with pneumatosis intesinalis demonstrated, in addition to gas bubbles within the intestinal wall, a paralytic ileus in every instance, free peritoneal air in four, and gas within the portal vein in three. Cultures of stools were positive for pathogenic gramnegative bacteria in both conditions. Treatment for both conditions consisted of intravenous fluid and electolyte therapy with systemic antibiotics, and in four instances, intramuscular administration of gammaglobulin. Two of the babies with enterocolitis died, both from generalized sepsis (mortality rate of 4.3% ). Nine of the 21 infants with pneumatosis intestinalis died, thereby resulting in a mortality rate of 42.9 per cent. The cause of death was a generalized sepsis in each instance. Intestinal perforation occurred in four babies. The only fat tor that appeared to be responsible tor . differences in mortality rates among in fants with pneumatosis intestinalis was the slxcific antibiotic given. Two of the nine babies treated with intramuscular kanamycin lived. However, there was but one death in the group of 11 to whom gentamicin sulfate was administered. It appears that pneumatosis represents the most severe form of enterocolitis. Management directed at the causative gram-negative enterocolitis and invasive sepsis reduced the
580
ABSTRACTS
mortality rate from 80 to 9.1 per cent.George Holcomb, Jr. ABDOMEN GALLBLADDERDISEASE IN CHILDHOOD.H. N. Bars. Clin. Ped. 9:229 (April), 1970.
Four patients under 15 years of age with gallbladder disease are reported. Two of these patients had associated hematologic diseases.-h&he1 Gilbert THE ROLE OF RADIATION THERAPY IN THE MANAGEMENT OF HEMANGIOMAS OF THE LIVER. W. C. Park and R. Phillips.
JAMA 212: 1496-1498
(June 1), 1970.
Five cases of nonresectable hemangioma of the liver were treated with radiation therapy. Four of the five patients had good results with control of the disease and preservation of normal liver function. One patient was 4 months old. Although 2000 rads delivered in 10 days is recommended in adults, 400 to 600 rads is recommended in infants.-.I. Eugene Lewis, Jr. LIVER TRANSPLANTATION IN MAN. THE SIGNIFICANCE,PATTERNS AND CONTROL OF INFECTION. I. M. Murray-Lyon, D. B. Evans, W. D. Forter, R. J. Holden, H. 0. Rake, H. Stern, R. Y. Caine and R. Williams. Brit. .I. Surg. 57:280-284 (April),
1970. In spite of strict precautions, including barrier nursing, infection is a major problem in all transplant operations including hepatic transplantation mainly due to the use of immunosuppressive drugs. Only one out of nine patients who survived the immediate postoperative period did not develop a serious infection, and six died as a result of it. Pulmonary infection was the most serious problem occurring in all but one case. Staphylococcus aureus was the organism in three cases who were also nasal carriers. Five out of six cases where bile specimens could be obtained had positive cultures with the usual intestinal organisms, and in all five patients these organisms appeared in blood cultures. Not all cases with positive bile or blood cultures were necessarily ill. Cytomegalovirus infection occurred in six patients but in none was there evidence that the virus did any harm.
Prophylactic antibiotics were not used and were thought to encourage resistant organisms and fungal infection. Broad-spectrum antibiotics were used freely even in minor infections and with little success to clear the bile of organisms. This was often followed by superinfection with resistant organisms and fungi. The present policy is to use antibiotics sparingly and to rely on narrow spectrum drugs wherever possible.-./. _L~J+
GENITOURINARY
TRACT
DRIP INFUSION UROGRAPHY IN PATIENTS WITH RENAL DISEASE. R. D. Ensor, E. Anderson and R. R. Robinson. J. Urol.
103:267-271
(March),
1970.
This is a report based on 188 studies performed in 174 patients whose blood urea nitrogen was 40 mg. per 100 ml. or higher, plasma creatinine concentration was 1.5 mg. per 100 ml. or more whose endogenous creatinine clearance was less than 80 ml. per minute per 1.73 sq. meters body surface. Fifty per cent Sodium Diatrizoate (1 ml. per lb. of body weight) was given with an equal volume of 5 per cent Dextrose and water IV rapidly. Films were exposed at 2 minutes after starting the infusion and 2 minutes and 10 minutes after its completion. Occasionally, delayed films were obtained at 24 hours. As there is little tubular reabsorption of Sodium Diatrizoate, its concentration increases allowing visualization by X ray. In patients with diminished renal function, the filtered load of contrast medium is limited due to marked filtration rate reduction. There may also be an endogenous osmotic diuresis and a decrease in the rate of water absorption further minimizing intratubular concentration of the dye. Drip infusion urography allows greater volumes of dye to be used making visualization of the kidney even when its functions are depressed. When the creatinine clearance was more than 10 ml. per minute, the plasma creatinine concentration was less than 8 mg. per 100 ml. or the BUN concentration was less than 80 mg. per 100 ml., 75 per cent of the urograms were satisfactory. There were only a few adverse reactions all of which were transient. In no case was there evidence of adverse effects of the dye on renal functions.-Bruce M. Henderson