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Undiversion in Children With Renal Failure
DIVERSION
inhibitors and their effect on hypothalamic epinephrine content as had been observed in other animal models of hypertension, for example spontaneously hypertensive rats. P. R. R. 2 tables, 17 references
TRANSPLANTATION Use of Cyclosporine in Pediatric Renal Transplant Recipients
S. B. CONLEY, S. M. FLECHNER, G. ROSE, C. T. VAN BUREN, E. BREWER AND B. D. KAHAN, Departments of Surgery and Pediatrics, Division of Immunology and Organ Transplantation, University of Texas Medical School at Houston, Houston, Texas J. Ped., 106: 45-49 (,Jan.) 1985 Cyclosporin and prednisone were used in combination to produce immunosuppression in 18 children who received renal allografts (10 received cadaveric and 8 received living related kidneys). Mean followup was 16.5 months. Patient and graft survival rates were 100 and 83 per cent, respectively. Two grafts were lost for nonimmunological reasons. Cyclosporin nephrotoxicity did not cause irreversible allograft injury nor lead to graft loss in this patient population. The use of this combination therapy and its success were achieved with a lowered incidence of rejection episodes, infectious complications and rehospitalizations. In addition, this regimen may permit the maximal opportunity for growth and development in these children. Longer followup will be necessary to confirm whether these advantages persist during time, and what may be the eventual effect on growth and development. W. Jo C. 1 figure, 1 table, 25 references
Editorial comment. This experience suggests that cyclosporin may not be as nephrotoxic in children after transplantation as it appears to be in adults. Cyclosporin seems clearly superior to azathioprine in the prevention of rejection following transplantation. L. R. K.
DIVERSION Undive:n,ion in Children With Renal Failure
R.
S. LAPOINTE, C. A. SHELDON AND M. S. and UniDepartment of Urologic versity of Minnesota Health Sciences Center, J\liinneapolis, Minnesota
J. Ped. Surg., 19: 632-636
1984
Diversion was done at an early age in 11 boys with posterior urethral valves and 2 with the prune belly syndrome to provide maximal urinary drainage. Renal failure ensued despite the early diversion by vesicostomy and/or ureterostomy. Urinary undiversion was performed in the patients to prepare them for renal transplantation. Nine patients received a renal transplant shortly after undiversion, including 8 who underwent nephroureterectomy at transplantation. Only 5 of 11 patients with vesicoureteral reflux underwent reimplantation at the time of undiversion. Three complications (pyelocutaneous fistula, distal ureteral obstruction and urethral scarring) required a second operation for definitive correction. The authors believe that transplantation is performed better with a sterile urinary tract in a bladder of adequate capacity. Undiversion in the setting
1131
described seemed to accomplish these goals with minimal morbidity. No decrease in already marginal renal function was found following the undiversion procedures. G. F. S. 1 figure, 1 table, 10 references
Editorial comment. I agree that undiversion often is warranted in children with incipient renal failure. As demonstrated in this series, renal function seldom deteriorates after successful undiversion even when large areas of intestinal mucosa come in contact with the urine. The native kidneys then can be used to refunctionalize the bladder, facilitating later definitive therapy with transplantation. One of the great successes of undiversion is that against all expectations the refunctionalized urinary tract, with urine storage as opposed to continuous free run off, generally has not resulted in an acute increase in the level of azotemia. Children with severe renal failure may require dialysis before and/or after undiversion until they restabilize. Alternately, many children with renal failure because of increasing body mass and who have diverted urine may undergo transplantation with anastomosis of the ureter into the bladder, accomplishing undiversion at the time of the transplantation. Of course, this maneuver requires careful assessment of the capabilities of the bladder but usually it is successful. When required, cystoplasty probably is better to perform as a separate operation before transplantation. L. R. K.
An Experimental Model of a Submucosally Tunnelled Valve for the Replacement of the Ileo-Cecal Valve
I.
VINOGRAD, P. MERGUERIAN, R. UDASSIN, P. MOGEL AND S. NISSAN, Department of Pediatric Surgery, Hadassah University Hospital, Jerusalem, Israel
J. Ped. Surg., 19: 726-731 (Dec.) 1984 The value of the ileocecal valve in preventing the short bowel syndrome following small bowel resection has been attributed to the avoidance of rapid transit of digested food in the ileum. Maximal absorption is permitted and reflux of colonic contents into the small bowel is prevented, thus, protecting the ileum from excessive bacterial colonization that interferes with absorption. This experimental study in dogs was done to determine if the urological technique of a submucosal tunnel to prevent vesicoureteral reflux could be applied to the gastrointestinal tract to form an effective ileocecal valve. The submucosal tunnel of the ileum into the ascending colon was created developing the submucosal plane over the colonic mucosa and bringing the ileum into this tunnel under the muscularis mucosa. The ileocecal valve was resected, and tunnels 2, 4 and 6 cm. long were made with a 2-layer bowel anastomosis in 20 dogs. A barium enema 3 months postoperatively showed no reflux except in 2 of the 6 dogs with a 2 cm. tunnel. No dog had evidence of intestinal obstruction. In 5 dogs an 80 per cent resection of the distal small bowel, including the ileocecal valve, was performed and a new 4 cm. long valve was constructed between the jejunum and the ascending colon. Intestinal transit time was measured by a bolus of barium at fluoroscopy. Mean transit time was 16.2 ± 1.5 minutes compared to 4.1 ± 1.0 minutes for dogs who underwent resection and simple jejuno ascending colostomy-a 4-fold increase in transit time. Antiperistaltic pressures in the new valves were 143 ± 22.7 and 141 ± 13.5 cm. water in dogs with a tunnel length of 4 and 6 cm., respectively. Two dogs with 2 cm. tunnels had colonic reflux at 30 cm. water. Isoperistaltic pressure studies showed that the valves opened at a mean
inhibitors and their effect on hypothalamic epinephrine content as had been observed in other animal models of hypertension, for example spontaneously hypertensive rats. P. R. R. 2 tables, 17 references
TRANSPLANTATION Use of Cyclosporine in Pediatric Renal Transplant Recipients
S. B. CONLEY, S. M. FLECHNER, G. ROSE, C. T. VAN BUREN, E. BREWER AND B. D. KAHAN, Departments of Surgery and Pediatrics, Division of Immunology and Organ Transplantation, University of Texas Medical School at Houston, Houston, Texas J. Ped., 106: 45-49 (,Jan.) 1985 Cyclosporin and prednisone were used in combination to produce immunosuppression in 18 children who received renal allografts (10 received cadaveric and 8 received living related kidneys). Mean followup was 16.5 months. Patient and graft survival rates were 100 and 83 per cent, respectively. Two grafts were lost for nonimmunological reasons. Cyclosporin nephrotoxicity did not cause irreversible allograft injury nor lead to graft loss in this patient population. The use of this combination therapy and its success were achieved with a lowered incidence of rejection episodes, infectious complications and rehospitalizations. In addition, this regimen may permit the maximal opportunity for growth and development in these children. Longer followup will be necessary to confirm whether these advantages persist during time, and what may be the eventual effect on growth and development. W. Jo C. 1 figure, 1 table, 25 references
Editorial comment. This experience suggests that cyclosporin may not be as nephrotoxic in children after transplantation as it appears to be in adults. Cyclosporin seems clearly superior to azathioprine in the prevention of rejection following transplantation. L. R. K.
DIVERSION Undive:n,ion in Children With Renal Failure
R.
S. LAPOINTE, C. A. SHELDON AND M. S. and UniDepartment of Urologic versity of Minnesota Health Sciences Center, J\liinneapolis, Minnesota
J. Ped. Surg., 19: 632-636
1984
Diversion was done at an early age in 11 boys with posterior urethral valves and 2 with the prune belly syndrome to provide maximal urinary drainage. Renal failure ensued despite the early diversion by vesicostomy and/or ureterostomy. Urinary undiversion was performed in the patients to prepare them for renal transplantation. Nine patients received a renal transplant shortly after undiversion, including 8 who underwent nephroureterectomy at transplantation. Only 5 of 11 patients with vesicoureteral reflux underwent reimplantation at the time of undiversion. Three complications (pyelocutaneous fistula, distal ureteral obstruction and urethral scarring) required a second operation for definitive correction. The authors believe that transplantation is performed better with a sterile urinary tract in a bladder of adequate capacity. Undiversion in the setting
1131
described seemed to accomplish these goals with minimal morbidity. No decrease in already marginal renal function was found following the undiversion procedures. G. F. S. 1 figure, 1 table, 10 references
Editorial comment. I agree that undiversion often is warranted in children with incipient renal failure. As demonstrated in this series, renal function seldom deteriorates after successful undiversion even when large areas of intestinal mucosa come in contact with the urine. The native kidneys then can be used to refunctionalize the bladder, facilitating later definitive therapy with transplantation. One of the great successes of undiversion is that against all expectations the refunctionalized urinary tract, with urine storage as opposed to continuous free run off, generally has not resulted in an acute increase in the level of azotemia. Children with severe renal failure may require dialysis before and/or after undiversion until they restabilize. Alternately, many children with renal failure because of increasing body mass and who have diverted urine may undergo transplantation with anastomosis of the ureter into the bladder, accomplishing undiversion at the time of the transplantation. Of course, this maneuver requires careful assessment of the capabilities of the bladder but usually it is successful. When required, cystoplasty probably is better to perform as a separate operation before transplantation. L. R. K.
An Experimental Model of a Submucosally Tunnelled Valve for the Replacement of the Ileo-Cecal Valve
I.
VINOGRAD, P. MERGUERIAN, R. UDASSIN, P. MOGEL AND S. NISSAN, Department of Pediatric Surgery, Hadassah University Hospital, Jerusalem, Israel
J. Ped. Surg., 19: 726-731 (Dec.) 1984 The value of the ileocecal valve in preventing the short bowel syndrome following small bowel resection has been attributed to the avoidance of rapid transit of digested food in the ileum. Maximal absorption is permitted and reflux of colonic contents into the small bowel is prevented, thus, protecting the ileum from excessive bacterial colonization that interferes with absorption. This experimental study in dogs was done to determine if the urological technique of a submucosal tunnel to prevent vesicoureteral reflux could be applied to the gastrointestinal tract to form an effective ileocecal valve. The submucosal tunnel of the ileum into the ascending colon was created developing the submucosal plane over the colonic mucosa and bringing the ileum into this tunnel under the muscularis mucosa. The ileocecal valve was resected, and tunnels 2, 4 and 6 cm. long were made with a 2-layer bowel anastomosis in 20 dogs. A barium enema 3 months postoperatively showed no reflux except in 2 of the 6 dogs with a 2 cm. tunnel. No dog had evidence of intestinal obstruction. In 5 dogs an 80 per cent resection of the distal small bowel, including the ileocecal valve, was performed and a new 4 cm. long valve was constructed between the jejunum and the ascending colon. Intestinal transit time was measured by a bolus of barium at fluoroscopy. Mean transit time was 16.2 ± 1.5 minutes compared to 4.1 ± 1.0 minutes for dogs who underwent resection and simple jejuno ascending colostomy-a 4-fold increase in transit time. Antiperistaltic pressures in the new valves were 143 ± 22.7 and 141 ± 13.5 cm. water in dogs with a tunnel length of 4 and 6 cm., respectively. Two dogs with 2 cm. tunnels had colonic reflux at 30 cm. water. Isoperistaltic pressure studies showed that the valves opened at a mean