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Small bowel volvulus complicating intestinal ascariasis in children
INTERNATIONAL ABSTRACTS Small Bowel Volvulus Complicating Intestinal Ascariasis in Children. R. Wiersma and G.P. Hardy. Br J Surg 75:86-87, (January),
1988. This is a report of 29 children with intestinal ascariasis complicated by small bowel volvulus. Patients' ages ranged from 9 months to 10 years, and represented about 1% of total surgical admissions for sequelae of ascariasis over a 9-year period. In 17 patients, the need for emergency surgery was clear at presentation and included peritonitis (5), acute intestinal obstruction (10), and incomplete subacute obstruction (2). Of the remaining 12 children, nine were either vomiting or passing worms per rectum. In 38% of cases, a vermifuge had been administered and may have contributed to the development of volvulus. The mortality of 17% was attributable to delay in diagnosis and inadequate preoperative resuscitation. Seventy-two percent of patients required intestinal resection. The instillation of intraluminal vermifuge intraoperatively has minimized postoperative worm migration through suture lines and anastomoses .--Lewis Spitz Appendicitis in Children: A Systematic Approach for a Low Incidence of Complications. G. Stringel. Am J Surg 154:631-635,
(December), 1987. The author describes his personal series of 414 appendectomies performed over 6 years. Basic preoperative principles were employed. Antibiotics were routinely used preoperatively only when the exploration was negative--24 hours for non-perforated appendicitis, and 5 days for perforated appendicitis. Cefamandole was used, and Cleocin was added for suspected or documented perforation. Operative details are described, emphasizing minimal manipulation of the appendix. Cefamandole powder was applied in the wound. Of the 414 patients, 67% had acute, non-ruptured appendicitis, 19% had perforated appendicitis, and 14% had a normal appendix. There was one major complication--an early bowel obstruction 31/2weeks after surgery, which required laparotomy for lysis of adhesions. There were no wound or intraperitoneal infections. All incisions were closed primarily.-- Thomas V. Whalen Role of Surgical Treatment in the Management of Complications of the Gastrointestinal Tract in Patients W i t h Leukemia. H.V. ViHar,
J.A. Warneke, M.D. Peck, et al. Surg Gynecol Obstet 165:217-222, (September), 1987. The clinical course of patients with leukemia , specifically after treatment is complicated by opportunistic infections, often derived from the gastrointestinal tract. Four hundred thirty-eight patients with leukemia were treated at the Arizona Health Sciences Center from 1976 to 1985. Fifty-five (13%) developed 60 major gastrointestinal complications. Thirty-seven were treated medically with a mortality rate of 51%, while 18 who were treated surgically had a 17% mortality rate. A protocol to identify a subset of patients with septic leukemia who may require emergency surgical treatment is vital, since death in this group is most commonly from undiagnosed sepsis or progression of hematologic defects. This protocol should include repeated physical examinations, daily roentgenograms of the abdomen, liberal use of endoscopy, contrast roentgenography, and computed tomography or ultrasound. Extensive surgical procedures can be safely carried out in patients with leukemia. The diagnosis of leukemia should not be a deterrent to emergency surgical exploration.--George Holcomb, Jr Preservation of the Entire Anal Canal in Conservative Proctocolactomy for Ulcerative Colitis: A Pilot Study Comparing End-To-End lieo-Anal Anastomosis Without Mucosal Resection W i t h Mucosal Proctectomy and Endo-Anal Anastomosis. Br J Surg 74:940-944,
(October), 1987.
877 Mucosal proctectomy with endo-anal pull-through anastomosis (MP + PTA) for ulcerative colitis reduces resting anal pressure (RAP), and low RAP has been found to correlate with minor leakage of feces or mucus. The authors' hypothesis was that conservative proctocolectomy with an end-to-end ileo-anal anastomosis (EEA) would result in higher anal pressure and less leakage. Twelve patients were studied after EEA and 24 after MP + PTA. Each was in good health several months after operation. After EEA, maximal RAP decreased from a median 90 cmH20 (60 to 116 cmH20) to 70 cmH20 (25 to 104 cmH20, P < .01), whereas after MP + PTA, maximal RAP decreased from 85 cmH20 (70 to 125 cmH20 ) to 40 cmH20 (22 to 80 cmH20 , P < .003). RAP after EEA was significantly greater than RAP after MP + PTA (P < .001). The pressure profile of the anal sphincter in the EEA group did not differ significantly from that of the preoperative group at any point from 6 to 1 cm from the anal verge, and the sphincteric high-pressure zone averaged 4 cm in length both before and after operation. After MP + PTA, resting anal pressure at stations 1 to 4 cm from the anal verge was significantly less than preoperative pressure (P < .001), and the sphincteric high-pressure zone was only 3 cm in length compared with 4 cm before operation. Anal squeeze pressures were similar in the two groups of patients. After EEA, 11 of 12 patients achieved perfect continence, day and night, whereas after MP + PTA, 58% of patients experienced minor fecal leakage (P < .01). These findings suggest that the entire anal canal should be kept intact in the course of conservation proctolecotomy for ulcerative colitis .--Lewis Spitz ABDOMEN Cholelithiasis A f t e r Spinal Fusion for Scoliosis in Children. R.L.
Teele, A.R. Nussbaum, J.B. Wily, et al. J Pediatr 111:857-860, (December), 1987. The researchers obtained ultrasound studies of the gallbladder on 127 children and adolescents who underwent operative correction for scoliosis during the preceding 10 years. Of the original group of 127 patients, 29 (22%) had gallstones. Patients who had been pregnant and those who had undergone other nonorthopedic surgical interventions, such as creation of an ileal loop, were discarded because of the known association with the development of gallstones. Of the nine patients who had been pregnant, seven had gallstones. The final analysis was performed on 92 patients who had undergone a total of 107 surgical procedures for scoliosis, and in this group, 19.6% were found to have gallstones: There was no evidence of sickle celt disease or other hemolytic anemias. The type of surgical fusion played no role in the development of gallstones.--George Holcornb, Jr Bacterial Cholangitis A f t e r Surgery for Biliary Atresia. C. Ecoffey, E. Rothman, O. Bernard, et al. J Pediatr 111:824-829, (December), 1987.
Forty-six of 101 children who underwent hepatic portoenterostomy had a total of 105 episodes of cholangitis (range, one to eight episodes per child.) Most episodes occurred within 3 months of the operation. Factors associated with development of cholangitis included good or partial restoration of bile flow, abnormal intrahepatic bile ducts or cavities at the porta hepatis, and routine postoperative use of antibiotics. External jejunostomy was not effective in preventing cholangitis. In addition to fever and decreased bile flow, an increased erythrocyte sedimentation rate and signs of shock were frequently observed. The responsible organisms, most often gramnegative bacteria, were identified in 79 episodes (75%) by blood or liver cultures. Most were susceptible to trimethoprim-sulfamethoxazole and third-generation cephalosporins during the first episode, but only to cephalosporins during later episodes. The incidence of signs of portal hypertension in children with normal serum bilirubin values
1988. This is a report of 29 children with intestinal ascariasis complicated by small bowel volvulus. Patients' ages ranged from 9 months to 10 years, and represented about 1% of total surgical admissions for sequelae of ascariasis over a 9-year period. In 17 patients, the need for emergency surgery was clear at presentation and included peritonitis (5), acute intestinal obstruction (10), and incomplete subacute obstruction (2). Of the remaining 12 children, nine were either vomiting or passing worms per rectum. In 38% of cases, a vermifuge had been administered and may have contributed to the development of volvulus. The mortality of 17% was attributable to delay in diagnosis and inadequate preoperative resuscitation. Seventy-two percent of patients required intestinal resection. The instillation of intraluminal vermifuge intraoperatively has minimized postoperative worm migration through suture lines and anastomoses .--Lewis Spitz Appendicitis in Children: A Systematic Approach for a Low Incidence of Complications. G. Stringel. Am J Surg 154:631-635,
(December), 1987. The author describes his personal series of 414 appendectomies performed over 6 years. Basic preoperative principles were employed. Antibiotics were routinely used preoperatively only when the exploration was negative--24 hours for non-perforated appendicitis, and 5 days for perforated appendicitis. Cefamandole was used, and Cleocin was added for suspected or documented perforation. Operative details are described, emphasizing minimal manipulation of the appendix. Cefamandole powder was applied in the wound. Of the 414 patients, 67% had acute, non-ruptured appendicitis, 19% had perforated appendicitis, and 14% had a normal appendix. There was one major complication--an early bowel obstruction 31/2weeks after surgery, which required laparotomy for lysis of adhesions. There were no wound or intraperitoneal infections. All incisions were closed primarily.-- Thomas V. Whalen Role of Surgical Treatment in the Management of Complications of the Gastrointestinal Tract in Patients W i t h Leukemia. H.V. ViHar,
J.A. Warneke, M.D. Peck, et al. Surg Gynecol Obstet 165:217-222, (September), 1987. The clinical course of patients with leukemia , specifically after treatment is complicated by opportunistic infections, often derived from the gastrointestinal tract. Four hundred thirty-eight patients with leukemia were treated at the Arizona Health Sciences Center from 1976 to 1985. Fifty-five (13%) developed 60 major gastrointestinal complications. Thirty-seven were treated medically with a mortality rate of 51%, while 18 who were treated surgically had a 17% mortality rate. A protocol to identify a subset of patients with septic leukemia who may require emergency surgical treatment is vital, since death in this group is most commonly from undiagnosed sepsis or progression of hematologic defects. This protocol should include repeated physical examinations, daily roentgenograms of the abdomen, liberal use of endoscopy, contrast roentgenography, and computed tomography or ultrasound. Extensive surgical procedures can be safely carried out in patients with leukemia. The diagnosis of leukemia should not be a deterrent to emergency surgical exploration.--George Holcomb, Jr Preservation of the Entire Anal Canal in Conservative Proctocolactomy for Ulcerative Colitis: A Pilot Study Comparing End-To-End lieo-Anal Anastomosis Without Mucosal Resection W i t h Mucosal Proctectomy and Endo-Anal Anastomosis. Br J Surg 74:940-944,
(October), 1987.
877 Mucosal proctectomy with endo-anal pull-through anastomosis (MP + PTA) for ulcerative colitis reduces resting anal pressure (RAP), and low RAP has been found to correlate with minor leakage of feces or mucus. The authors' hypothesis was that conservative proctocolectomy with an end-to-end ileo-anal anastomosis (EEA) would result in higher anal pressure and less leakage. Twelve patients were studied after EEA and 24 after MP + PTA. Each was in good health several months after operation. After EEA, maximal RAP decreased from a median 90 cmH20 (60 to 116 cmH20) to 70 cmH20 (25 to 104 cmH20, P < .01), whereas after MP + PTA, maximal RAP decreased from 85 cmH20 (70 to 125 cmH20 ) to 40 cmH20 (22 to 80 cmH20 , P < .003). RAP after EEA was significantly greater than RAP after MP + PTA (P < .001). The pressure profile of the anal sphincter in the EEA group did not differ significantly from that of the preoperative group at any point from 6 to 1 cm from the anal verge, and the sphincteric high-pressure zone averaged 4 cm in length both before and after operation. After MP + PTA, resting anal pressure at stations 1 to 4 cm from the anal verge was significantly less than preoperative pressure (P < .001), and the sphincteric high-pressure zone was only 3 cm in length compared with 4 cm before operation. Anal squeeze pressures were similar in the two groups of patients. After EEA, 11 of 12 patients achieved perfect continence, day and night, whereas after MP + PTA, 58% of patients experienced minor fecal leakage (P < .01). These findings suggest that the entire anal canal should be kept intact in the course of conservation proctolecotomy for ulcerative colitis .--Lewis Spitz ABDOMEN Cholelithiasis A f t e r Spinal Fusion for Scoliosis in Children. R.L.
Teele, A.R. Nussbaum, J.B. Wily, et al. J Pediatr 111:857-860, (December), 1987. The researchers obtained ultrasound studies of the gallbladder on 127 children and adolescents who underwent operative correction for scoliosis during the preceding 10 years. Of the original group of 127 patients, 29 (22%) had gallstones. Patients who had been pregnant and those who had undergone other nonorthopedic surgical interventions, such as creation of an ileal loop, were discarded because of the known association with the development of gallstones. Of the nine patients who had been pregnant, seven had gallstones. The final analysis was performed on 92 patients who had undergone a total of 107 surgical procedures for scoliosis, and in this group, 19.6% were found to have gallstones: There was no evidence of sickle celt disease or other hemolytic anemias. The type of surgical fusion played no role in the development of gallstones.--George Holcornb, Jr Bacterial Cholangitis A f t e r Surgery for Biliary Atresia. C. Ecoffey, E. Rothman, O. Bernard, et al. J Pediatr 111:824-829, (December), 1987.
Forty-six of 101 children who underwent hepatic portoenterostomy had a total of 105 episodes of cholangitis (range, one to eight episodes per child.) Most episodes occurred within 3 months of the operation. Factors associated with development of cholangitis included good or partial restoration of bile flow, abnormal intrahepatic bile ducts or cavities at the porta hepatis, and routine postoperative use of antibiotics. External jejunostomy was not effective in preventing cholangitis. In addition to fever and decreased bile flow, an increased erythrocyte sedimentation rate and signs of shock were frequently observed. The responsible organisms, most often gramnegative bacteria, were identified in 79 episodes (75%) by blood or liver cultures. Most were susceptible to trimethoprim-sulfamethoxazole and third-generation cephalosporins during the first episode, but only to cephalosporins during later episodes. The incidence of signs of portal hypertension in children with normal serum bilirubin values