Because of the marked elasticity of healthy blood vessels in children and adolescents, vascular trauma is very rare. In penetrating injuries, arteriography is not usually necessary but this procedure is essential in cases of blunt trauma to the blood vessels. The type of reconstructive procedure depends on the injury and its extent and can be performed by direct vascular anastomosis, by the insertion of a vein patch or by the transplantation of an autogenic venous segment. General anaesthesia is usually essential. Interrupted one-layer end-to-end anastomosis is advocated. The surgical technique of vascular repair must be meticulous. 12 children and adolescents (most of them had severe multiple injuries including vascular injuries) were followed up clinically and via arteriography. In 11 patients, the reconstructed vessels were found to be functioning normally.
With regard to different paediatric urological diseases nuclear-medical urokinetography using the tracer 99m-Tc-DTPA can identify typical functional patterns. By means of 261 investigations on 240 children, retroperistaltic waves, initial pyeloureteral and the final ureterovesical conus, dysperistaltic waves and interrupting empty strips with lacing, constrictive peristalsis can be shown in comparison with the normal anterograde "stair" pattern. Moreover, UKG as a functional method makes it possible to control the therapeutic success of antibiotics in urinary inflammations, the situation after stone discharges and application of vegetative systemic drugs. In our opinion the operative procedure and the prognosis of megaureters can be assessed. Consequently urokinetography is among the important preoperative investigations in paediatric urology and in the follow-up programme after reconstructive urological operations. Nuclear-medical isotope investigation is without significant risk and yields many diagnostic details. The method can be recommended for functional urological diagnosis in children or teenagers with high frequency of follow-up investigations or in patients with contrast medium allergy. Finally, ureter physiology can be checked in patients subjected to bone scintigraphy. Clinical research is possible via UKG without additional radiation exposure.
Since 1987 we perform a new technique of colorectal anastomosis in 6 babies resected because of severe Hirschsprung's disease. The operation was done electively in the seventh to eight month of age. In the method of the so-called compression anastomosis the instrument is inserted through the anorectal canal at the head fitted with two plastic rings (see illustrations). In the rectal stump the instrument is opened up, the rectal bowel edge is slipped over the distal ring. The prepared proximal bowel edge is slipped over the second white coloured ring. The rings are approached to one another and the instrument is released. The knife on the inside cuts the bowel. The two rings are then joined by means of springs. The compression anastomosis is completed. The two bowel edges are joined by compression via the two intraluminal plastic rings. These rings will pass spontaneously with the faeces days after operation. The diameter of the rings is 18 mm. Different diameters are available. Our good experiences in more than 160 compression anastomoses in colorectal surgery of adults encouraged us to use the method also in children. We saw one complication of a rectovaginal fistula 4 weeks after the operation followed by a severe stenosis of the anastomosis. The passing of the plastic rings was without any problem in all the cases. In the follow-up a bouginage was required only in the case mentioned above.
Within the framework of a joint follow-up we report on the treatment of 57 infants with urethral valves (35 babies from Munich and 22 from Siegen) in the first year of life, studied between 1974 and 1986. In 16 newborn the diagnosis and initiation of treatment was effected during the first four weeks of life (Group I) and in 41 babies during the 2nd to 12th month (Group II). In three cases, diagnosis of suspected urethral valve was made prenatally. Primary management and the concept of further treatment are described. Primary therapy is determined by the general condition after birth, presence of urosepsis and the extent of any existing renal insufficiency. 2 children died, both from Risk Group I. 5 children are in a state of compensated renal insufficiency. In 2 newborn we were compelled to perform supravesical urinary drain and in 3 children a suprapubic drain. Secondary nephrectomy became necessary in 4 children, 3 of whom belonged to Risk Group I. In 23 of 57 children valve resection followed by transurethral drainage was the only therapy. In 22 of 57 children corrective surgery was performed subsequently (neo-implantation, with and without modellage, stenosis of the ureter exit). The article reports on the course in each case.
We report on a five-year-old patient with a chronic pneumonia of the upper left lobe of the lung, in whom a broncho-enteric sequestration with ectopic pancreas was found in the mediastinum. Reviewing the literature, different theories on the embryogenesis of this extremely rare anomaly are discussed.
To achieve the best possible late results in valve treatment we think the following procedure would be mandatory: 1. Immediate transfer to a specialised hospital. 2. Acute diagnostics with correction of the water and electrolytes balance. 3. Suprapubic procedure is preferable over the transurethral approach if the catheter is expected to remain indwelling for a length of time. 4. The obstructing urethral valve is the primary object. 5. Resection is done only in 12 o'clock position in dorsosacral (lithotomy) position. 6. In rare cases with a severely constricted neck of the bladder it may be necessary to perform resection after Turner-Warwick. 7. In most cases it is possible to avoid surgical intervention at the upper urinary tract. 8. Regular follow-up checks are urgently recommended (sonography, x-ray, endoscopy, urodynamics).
Based on the experience with 57 neonates with NEC, the significance of diagnostic methods (especially ultrasonography, paracentesis, intraoperative photometry) for treatment and results is discussed.
Haematobilia is caused by a pathological linking of the arterial vascular system and intrahepatic or extrahepatic bile ducts. This report presents the case of a traumatic haematobilia in a child. Possibilities to achieve safe diagnosis are discussed and suggestions for treatment are considered. In the case presented here, occlusion of the arteriobiliar shunt is effected by means of a rejectable balloon catheter according to Serbinenko. This method has been successfully tried in neurosurgery and developed further, and can be applied to similar disease patterns in disciplines other than neurosurgery.
There is disagreement in the literature about the ideal treatment of ligamentous injuries of the ankle in children. We examined the results of controlled conservative treatment by means of a prospective study in 28 children, each with a fresh ligamentous ankle injury. In all patients the supinatory talus tilt was between 7 and 15 degrees as compared with the noninjured side. The children were treated with a plaster cast for 6 weeks. The results of the present study were compared with results of two other earlier investigations from our department. In one group the patients had been treated not uniformly conservatively for 1-5 weeks. In another group, patients were treated by operative ligamentous repair (5, 8). At the follow-up examination 82% of the children of the present study showed ligamentous stability, which is approximately the same percentage as it was found in operatively treated children (84%), but lies significantly higher than in inconsequentially conservatively treated patients (74%), (p greater than 0.05). 50% of the children in the present study complained about some discomfort, a number that is significantly higher than that found after operative treatment (30%), (p greater than 0.05). We assume that conservative treatment of fibular ankle lesions is justified in children with supinatory talus tilts between 7-15 degrees as compared with the noninjured side. Ligamentous stability can be expected in 80% of the patients.
Morphological changes of the oesophageal wall, induced by injection sclerotherapy of oesophageal varices, may produce functional disturbances which are difficult to evaluate especially in children. Therefore manometric studies in 33 consecutive patients with portal hypertension (age: 2-18 years) were performed and functional parameters as of the oesophagus and oesophageal sphincter were recorded in different stages of treatment. The results were compared to findings in healthy children. From our studies we could conclude that functional disturbances seen in sclerolised patients must be set in relation to functional changes which we could see in patients without treatment of oesophageal varices. Endosclerosis affects essential parameters of oesophageal function; however, a large reversibility after termination of the treatment could be documented. The clinical relevance of the recorded findings and the diagnostic value of oesophageal manometry are discussed.
Based on our clinical experience, we postulate that the unilateral "posttraumatic genu valgum" develops on the grounds of an unreduced primary valgus deformity. This induces a disturbance of the consolidation on the medial aspect of the fracture. Subsequently, a partial medial stimulation of the epiphyseal plate develops resulting in a secondary valgus deformity. We succeeded in proving experimentally this postulate using the Mini Pig as an experimental model. We investigated 33 tibiae of 17 Mini Pigs. With radiological follow-up studies we were able to show that the operatively created primary valgus deformity induces an increased valgus deformity of functional significance. This is a model of the unreduced fracture in men. However, the transection of the pes anserinus and the periost per se did not provoke a significant valgus formation. Based on these experimental results and our clinical findings we postulate the following treatment for the metaphyseal bending fractures of the proximal tibia in men: 1. Accurate, usually conservative, reduction of any primary valgus malposition of the fracture. 2. Retention of the corrected position of the tibia in a plaster cast. 3. Compression of the medial aspect of the fracture to prevent disturbance of consolidation and subsequent development of valgus deformity.
The method of treatment and fate of 41 button batteries ingested by 34 children were analysed; 31 batteries were in the stomach and 10 beyond the pylorus. In 31 batteries situated in the stomach, removal by magnet tube technique was attempted in 30 batteries, 25 being successfully taken out, while 5 failed passing through the pylorus at the duodenum. One was removed endoscopically, since a magnet tube was not available. The remaining 10 batteries in 10 children were found at different levels from the duodenum to the rectum. In addition, 5 batteries were pushed down from the stomach during magnet tube removal. These 15 batteries, located in the intestine were excreted during 35 hours. In contrast to other asymptomatic foreign bodies that are allowed to pass through the GI tract spontaneously, we feel that button batteries should be removed by magnet tube technique to avoid complications such as GI tract perforation with associated bleeding, possible mercury poisoning and burns. Magnet tube removal is a simple and safety method requiring neither anaesthesia nor admission.
Catamnestic investigations on the course of pregnancy, family history and genetics were carried out in 141 children suffering from congenital hydrocephalus. The results were compared with those obtained from a group of non-malformed controls investigated by the same criteria. There was a considerably higher incidence of pregnancy disturbances (i.e. diseases, drugs, haemorrhage etc.) in mothers who later gave birth to a child with congenital hydrocephalus, than mothers of the control group (congenital hydrocephalus: 61.3% vs. controls: 30.1%). This high incidence of pregnancy disturbances could be particularly referred to a sevenfold increased rate of diseases and a fourfold increased rate of drug intake during the first trimester. There was also a higher rate of malformed relatives in children with congenital hydrocephalus (16.7%) than in controls (6.4%); not only were malformations of the central nervous system found to be increased but also malformations of other organ systems in relatives. This is interpreted as a hint not only at genetic influences but also at a generally higher incidence of malformations in a relatively small group of persons. Calculated figures of recurrence risk were in accordance with empirical data used in genetic counselling.
A potential relationship between duration and severity of obstructive hydronephrosis and the histological structure of the upper urinary tract smooth musculature has been studied in a series of prenatally diagnosed cases. Between 1981 and 1988, fifty-five monolateral pyelo-ureteral junction obstructions (PUJO), prenatally diagnosed (16th-37th week of gestational age), underwent pyeloplasty between 4 and 90 days of life. Gestational age at the diagnosis, delta t (duration of hydronephrosis from first detection in utero to surgery) and V (volume of the hydronephrotic kidney) were related to the frequency of muscle hypotrophy and fibrosis of both pelvis and ureter just above and below the junction. A close correlation between duration (delta t) and the severity of the involvement of the smooth musculature of the upper urinary tract was found. The larger the volumes (V), the more severe the muscular damage. In the long-term follow-up, poor results were obtained only in 5 of the 19 newborn who had severe hypotrophy and fibrosis of the pelvis. In conclusion, in PUJO, the shorter the delta t and the lower the V, the better one expects the smooth musculature of the upper urinary tract to be.
Ten cases of the Dandy-Walker syndrome are presented. The clinical manifestations are analyzed. Almost 80 percent of these children had associated anomalies. The characteristic findings are based on the magnetic resonance image scan. Satisfactory treatment of our patients had mostly consisted in shunting the lateral ventricular system to the peritoneum. The incidence of the complications was high.
To evaluate the quality of life of patients with oesophageal atresia we studied 122 questionnaires about children operated on in several centres of the Federal Republic of Germany. On the basis of this information, the literature, and our own cases, we found that early childhood is complicated by operations, dilatations, difficulties in swallowing and frequent pulmonary infections. These problems improved in most cases during the first years of life. Later on the quality of life can be regarded as good.
Malignancy in gastric teratomas is extremely rare. Such teratomas are widely accepted and treated as benign lesions. A malignant gastric teratoma treated by total excision is presented. According to our knowledge, this is the second case of gastric teratoma having a malignant histology.
Perforation of the oesophagus is a surgical emergency that is usually lethal if untreated and commonly fatal if treatment is delayed. The most common type of trauma causing oesophageal perforation is a penetrating injury. Oesophageal ruptures due to external blunt or air-blast injuries are very rare. We report for the first time a case of oesophageal rupture related to air-blast injury to the chest and upper abdomen in a child.
Three children were operated upon for congenital epithelial cysts of the spleen in the five-year period 1983-1987. Their mean age was 9.8 +/- 2.3 years. Two of them were boys. They comprise 1.6% of the surgical pathology of the spleen in our hospital, which is a Reference Centre for congenital haemolytic diseases. Two of the children had been suffering from intermittent colic pain in the left hypochondrium with a tender palpable mass for a short while to the present day. The third patient was asymptomatic; a splenic cyst with calcification of its wall was accidentally revealed by a plain x-ray of the abdomen. Contrast gastrointestinal studies and intravenous pyelography helped us with the diagnosis; they indicated a splenic mass that caused visceral displacement adjacent to the spleen. Ultrasonography proved the cystic nature of the enlargement of the spleen in all the cases. Marsupialization was performed in one patient and removal of the cysts in the other two. All three patients were followed up and re-checked 1-5 years postoperatively (May-June 1988). In one boy who underwent removal of the cyst four years ago, recurrence of the splenic cyst was revealed by ultrasonography, CT scan and radionuclide scan. Subtotal splenectomy was performed. The remaining upper pole is supplied with blood by the short gastric arteries. The recurrence was attributed to coexistence of invisible tiny cysts that had remained in the splenic tissue after the dissection of the major cyst during the previous operation. Subtotal splenectomy is an acceptable alternative procedure for splenic cysts.
Thirteen children with spina bifida (mean age 11 yrs 11 mths) and a mean reading comprehension reading deficit of 10.5 mths were enrolled into a remedial programme. The withdrawal single case study methodology was used (baseline--5 weeks, treatment--5 weeks, withdrawal--12 weeks). Each child was seen twice a week for 15 minutes during both the baseline and treatment stages. A teaching programme based on a close technique was utilized only during the treatment stage. The technique involved teaching each child a strategy for systematically examining a text for meaning. A halving of the comprehension deficit was observed by the end of the treatment stage, with a mean regression of almost 3 months at the end of the withdrawal stage. No relationship between IQ and gains in reading comprehension was observed. The results may indicate that, in part, reading comprehension deficits are performance deficits which, in turn, may be mediated by attentional strategies.
