- Email: [email protected]
Use of the Appendix to Replace a Ureter. Case Report
1254
DIVERSION
produced by metabolism of dopamine to norepinephrine by dopamine-B-hydroxylase. The presence of this enzyme has been well documented in the normal adrenal gland and in cases of pheochromocytoma. The presence of phenylethanolamineN-methyltransferase in the normal adrenal gland for conversion of norepinephrine to epinephrine also is documented. Its presence in epinephrine-secreting pheochromocytomas has not been shown clearly. The authors studied 16 cases of pheochromocytomas for dopamine-B-hydroxylase and phenylethanolamineN-methyltransferase, and all tumors contained both enzymes. Phenylethanolamine-N-methyltransferase activity correlated well with epinephrine concentration of the tissue, whereas no correlation was noted between phenylethanolamine-N-methyltransferase and norepinephrine concentration, nor between dopamine-B-hydroxylase activity and norepinephrine or dopamine concentration. Of the 16 tumors 10 were from cases with multiple endocrine neoplasia and 6 were from sporadic tumors. As would be expected high phenylethanolamine-N-methyltransferase content of tumor was associated with predominant epinephrine excretion (urine) and paroxysmal hypertension. J.H.N. 21 references
TRANSPLANTATION
urethral valves was seen because of complications after multiple operations on the urinary tract, resulting in the loss of the entire right ureter and bilateral hydronephrosis with borderline renal function. A right nephrostomy was present. After the left ureteroneocystostomy the ureter was dilated but without obstruction or reflux. An 8 cm. appendix was used as a retroperitoneal isoperistaltic conduit from the right renal pelvis to the left ureter. Six months later stenosis of the proximal anastomosis was revised and the nephrostomy tube was removed. The boy was asymptomatic without medication 3½ years postoperatively. Blood urea nitrogen is stable at 36 mg./dl. and creatinine at 1.3 mg./dl. Radiographically, the hydronephrotic kidneys remain stable. M.G.F. l figure, 2 references
Editorial comment. This case report demonstrates another use of bowel-this time the easily harvested functionless appendix-to make good some lost ureteral length. The appendix appears to have been used as a successful alternative to renal autotransplantation, since one would like to avoid an ileal ureter in a child who is already azotemic because of the increased reabsorption of urinary wastes. L.R.K. The Use of Antire:fluxing Intestinal Segment§ in Pediatric Urinary Reconstruction CROOKS, Section of Urology, Department of Pediatric Surgery, Children's Hospital and Division of Urology, Department of Surgery, Ohio State University College of Medicine, Columbus, Ohio
Reversal of Possible Marrow Graft Rejection W:i.th Plasma Exchange Therapy. A Case Report D. J. HIGBY AND D. BURNETT, Department of Medical Oncology, Roswell Park Memorial Institute, Buffalo, New York
K. K.
J. Med., 12: 455-461, 1981
J. Ped. Surg., 16: 801-805 (Dec.) 1981
The authors report on a 39-year-old woman with severe aplastic anemia. She received a bone marrow transplant from her identical sister after conditioning with cyclophosphamide and methotrexate. Four weeks after transplantation a maculopapular rash developed over the body, with elevation of serum glutamic oxaloacetic transaminase and lactic dehydrogenase. Prednisone was given to suppress a probable graft versus host disease that resolved completely. Eight weeks after transplantation the hemoglobin, white blood count and platelet count had decreased and continued to do so despite high dose steroid therapy. The patient then underwent 2 plasma exchanges. The blood counts returned to normal and continued to be normal 7 months after the transplant. The possible explanation of the apparent reversal of graft rejection in this patient was that the plasma exchange might have lowered the level of a circulating inhibitor responsible for graft rejection. The authors believe that plasma exchange therapy may be useful in the treatment of graft rejection, and since it is safe, inexpensive and relatively easy to perform it may serve as an alternative to a second transplant. F. T.A. 10 references
Because of inadequate ureteral length or disease preventing direct ureterovesical anastomoses, antirefluxing intestinal segments were used in 8 children undergoing urinary tract reconstruction. Six patients had been diverted previously by ileal conduit or loop cutaneous ureterostomy. One patient with a solitary kidney had an obstructive megaureter and 2 previous attempts at repair had failed. A patient with a neurogenic bladder and bilateral complete ureteral duplications previously had undergone ureteral reimplantation that had failed and resulted in severe reflux on the right side and secondary obstructive megaureters on the left side. In 5 of the children bladder augmentation also was performed because of nondistensible fibrotic bladders. Intestinal segments used were ileal, ileocecal and sigmoid. The ileal segment was tapered and reimplanted into the bladder with a long cross-trigonal submucosal tunnel and psoas bladder hitch to prevent reflux. Reflux was prevented in the ileocecal segments by plication of the ileocecal valve. Of the 4 patients with ileal reimplantations 3 have satisfactory results without reflux or obstruction. Creatinine and electrolyte studies were normal. The repair of the other patient was complicated by partial obstruction at the new bladder hiatus, resulting in hyperchloremic acidosis and an increase in serum creatinine from 2.8 to 3.5 mg./dl., necessitating a secondary revision. Acidosis improved but creatinine remained elevated at 3.5 mg./dl. Renal function and serum electrolytes have improved or remained stable in all other patients. Reflux has not been seen postoperatively in any patient. Chronic bacteriuria is present in l patient with sacral agenesis and a neurogenic bladder managed with intermittent catheterization. All of the other patients have normal urinalyses and sterile urine cultures, and all are maintained on prophylactic antimicrobial therapy. Postoperative small bowel obstruction requiring surgical inter-
DIVERSION U§e of the Appendix to Replace a Ureter. Ca§e Report
L. W. MARTIN, Division of Pediatric Surgery, Department of Surgery, College of Medicine, University of Cincinnati, and Pediatric Surgical Service of Children's Hospital, Cincinnati, Ohio J. Ped. Surg., 16: 799-800 (Dec.) 1981 An 8-year-old boy with the initial diagnosis of posterior
DIVERSION
produced by metabolism of dopamine to norepinephrine by dopamine-B-hydroxylase. The presence of this enzyme has been well documented in the normal adrenal gland and in cases of pheochromocytoma. The presence of phenylethanolamineN-methyltransferase in the normal adrenal gland for conversion of norepinephrine to epinephrine also is documented. Its presence in epinephrine-secreting pheochromocytomas has not been shown clearly. The authors studied 16 cases of pheochromocytomas for dopamine-B-hydroxylase and phenylethanolamineN-methyltransferase, and all tumors contained both enzymes. Phenylethanolamine-N-methyltransferase activity correlated well with epinephrine concentration of the tissue, whereas no correlation was noted between phenylethanolamine-N-methyltransferase and norepinephrine concentration, nor between dopamine-B-hydroxylase activity and norepinephrine or dopamine concentration. Of the 16 tumors 10 were from cases with multiple endocrine neoplasia and 6 were from sporadic tumors. As would be expected high phenylethanolamine-N-methyltransferase content of tumor was associated with predominant epinephrine excretion (urine) and paroxysmal hypertension. J.H.N. 21 references
TRANSPLANTATION
urethral valves was seen because of complications after multiple operations on the urinary tract, resulting in the loss of the entire right ureter and bilateral hydronephrosis with borderline renal function. A right nephrostomy was present. After the left ureteroneocystostomy the ureter was dilated but without obstruction or reflux. An 8 cm. appendix was used as a retroperitoneal isoperistaltic conduit from the right renal pelvis to the left ureter. Six months later stenosis of the proximal anastomosis was revised and the nephrostomy tube was removed. The boy was asymptomatic without medication 3½ years postoperatively. Blood urea nitrogen is stable at 36 mg./dl. and creatinine at 1.3 mg./dl. Radiographically, the hydronephrotic kidneys remain stable. M.G.F. l figure, 2 references
Editorial comment. This case report demonstrates another use of bowel-this time the easily harvested functionless appendix-to make good some lost ureteral length. The appendix appears to have been used as a successful alternative to renal autotransplantation, since one would like to avoid an ileal ureter in a child who is already azotemic because of the increased reabsorption of urinary wastes. L.R.K. The Use of Antire:fluxing Intestinal Segment§ in Pediatric Urinary Reconstruction CROOKS, Section of Urology, Department of Pediatric Surgery, Children's Hospital and Division of Urology, Department of Surgery, Ohio State University College of Medicine, Columbus, Ohio
Reversal of Possible Marrow Graft Rejection W:i.th Plasma Exchange Therapy. A Case Report D. J. HIGBY AND D. BURNETT, Department of Medical Oncology, Roswell Park Memorial Institute, Buffalo, New York
K. K.
J. Med., 12: 455-461, 1981
J. Ped. Surg., 16: 801-805 (Dec.) 1981
The authors report on a 39-year-old woman with severe aplastic anemia. She received a bone marrow transplant from her identical sister after conditioning with cyclophosphamide and methotrexate. Four weeks after transplantation a maculopapular rash developed over the body, with elevation of serum glutamic oxaloacetic transaminase and lactic dehydrogenase. Prednisone was given to suppress a probable graft versus host disease that resolved completely. Eight weeks after transplantation the hemoglobin, white blood count and platelet count had decreased and continued to do so despite high dose steroid therapy. The patient then underwent 2 plasma exchanges. The blood counts returned to normal and continued to be normal 7 months after the transplant. The possible explanation of the apparent reversal of graft rejection in this patient was that the plasma exchange might have lowered the level of a circulating inhibitor responsible for graft rejection. The authors believe that plasma exchange therapy may be useful in the treatment of graft rejection, and since it is safe, inexpensive and relatively easy to perform it may serve as an alternative to a second transplant. F. T.A. 10 references
Because of inadequate ureteral length or disease preventing direct ureterovesical anastomoses, antirefluxing intestinal segments were used in 8 children undergoing urinary tract reconstruction. Six patients had been diverted previously by ileal conduit or loop cutaneous ureterostomy. One patient with a solitary kidney had an obstructive megaureter and 2 previous attempts at repair had failed. A patient with a neurogenic bladder and bilateral complete ureteral duplications previously had undergone ureteral reimplantation that had failed and resulted in severe reflux on the right side and secondary obstructive megaureters on the left side. In 5 of the children bladder augmentation also was performed because of nondistensible fibrotic bladders. Intestinal segments used were ileal, ileocecal and sigmoid. The ileal segment was tapered and reimplanted into the bladder with a long cross-trigonal submucosal tunnel and psoas bladder hitch to prevent reflux. Reflux was prevented in the ileocecal segments by plication of the ileocecal valve. Of the 4 patients with ileal reimplantations 3 have satisfactory results without reflux or obstruction. Creatinine and electrolyte studies were normal. The repair of the other patient was complicated by partial obstruction at the new bladder hiatus, resulting in hyperchloremic acidosis and an increase in serum creatinine from 2.8 to 3.5 mg./dl., necessitating a secondary revision. Acidosis improved but creatinine remained elevated at 3.5 mg./dl. Renal function and serum electrolytes have improved or remained stable in all other patients. Reflux has not been seen postoperatively in any patient. Chronic bacteriuria is present in l patient with sacral agenesis and a neurogenic bladder managed with intermittent catheterization. All of the other patients have normal urinalyses and sterile urine cultures, and all are maintained on prophylactic antimicrobial therapy. Postoperative small bowel obstruction requiring surgical inter-
DIVERSION U§e of the Appendix to Replace a Ureter. Ca§e Report
L. W. MARTIN, Division of Pediatric Surgery, Department of Surgery, College of Medicine, University of Cincinnati, and Pediatric Surgical Service of Children's Hospital, Cincinnati, Ohio J. Ped. Surg., 16: 799-800 (Dec.) 1981 An 8-year-old boy with the initial diagnosis of posterior