Esophageal atresia--use of an anterior flap in the difficult anastomosis.

Fashioning an anterior full thickness flap when opening the upper pouch in infants with esophageal atresia may allow a wider gap to be bridged without tension at the anastomosis.

Undescended testis: the effect of treatment on subsequent risk of subfertility and malignancy.

The literature was reviewed for information on the long-term effects of cryptorchidism on fertility and cancer incidence. In unilateral cryptorchidism, treatment policies of orchidopexy alone, or of human chorionic gonadotrophin (hCG) therapy followed, if necessary, by orchidopexy, have resulted in similar levels of reduced fertility (15% azoospermia, and an additional 30% oligospermia, ie, sperm count less than 20 X 10(6)/mL). Very similar results were observed in unilateral cryptorchid men who had had no treatment (and were still cryptorchid at semen examination). In contrast, no untreated bilaterally cryptorchid men have normal fertility (sperm count greater than 20 X 10(6)/mL), whereas of those treated, a quarter have normal fertility. In some series, as many as half of the bilateral cryptorchid testes descended following hormonal treatment; a finding that could be attributed, at least in part, to the frequent difficulty in deciding on clinical examination, whether these testes are truly cryptorchid. There is little evidence that operation early rather than late within the age range of 4 to 14 years has any effect on subsequent fertility. Histologic studies suggest that orchidopexy should be carried out before age 2, but there are almost no follow-up data with which to evaluate the results of early operation. Since there is evidence that orchidopexy may result in testicular atrophy in a small proportion of cases, a trial of luteinizing hormone-releasing hormone (LHRH) may be advisable. There is little information available concerning the effect of age at orchidopexy on the subsequent risk of testicular cancer. Testes that cannot be brought into the scrotum should be excised.

The use of laparoscopy in the management of right iliac fossa pain.

Fourty-six patients with a clinical diagnosis of acute appendicitis were laparoscoped before exploration. As a result the diagnosis was revised in 10 patients (22%). With experience the laparoscopic features of appendicitis can be recognised confidently so reducing the number of normal appendices removed.

Submucosal arterial malformation of the stomach as the probable cause of recurrent severe haematemesis in a 16-year-old girl.

A 16-year-old girl who had previously been in good health suffered recurrent life-threatening haematemesis. The cause of this bleeding appeared to be the spontaneous rupture of an abnormally large submucosal artery in the stomach. The site of bleeding was eventually localized by coeliac angiography via an indwelling percutaneous femoral catheter.

The surgical treatment of hyperinsulinism in infancy and childhood.

Hyperinsulinaemic hypoglycaemia in infancy may be transient or persistent. Persistent hypoglycaemia is caused by nesidioblastosis of the pancreas, a diffuse pancreatic endocrine abnormality involving all the endocrine tissue, or by an islet cell adenoma. The cause of nesidioblastosis is not known but unless controlled its hypoglycaemic effects lead to convulsions, mental retardation or death. Patients with transient hyperinsulinaemic hypoglycaemia, and some with persistent hypoglycaemia, respond to medical therapy but those with an adenoma and many of those with nesidioblastosis will require partial or total pancreatectomy. The surgical treatment of six infants and a child is discussed. Five infants had nesidioblastosis; one infant and one nine-year-old girl had an islet cell adenoma. It is suggested that in the very young when there is no evidence of an insulinoma, resection at the initial operation should be greater--up to 90 per cent--than the previously recommended 75 per cent.

The effect of anti-thrombotic drugs on prosthetic grafts in the canine inferios vena cava.

The effect of phenylbutazone, an anti-thrombotic agent, on the occlusion rate of knitted Dacron grafts placed in the infrarenal inferior vena cava of dogs was studied. Grafts places in dogs treated with phenylbutazone remained patent significantly longer than those in untreated animals. All the grafts in the untreated group occluded, but 2 remained patent in the treated animals.

Dilemmas after ultrasonic diagnosis of fetal abnormality.

KIE: Several British case studies are presented to demonstrate the effects of antenatal diagnosis on treatment decisions and the pregnant woman. A woman diagnosed as carrying an abnormal fetus often develops intense feeling of fear, guilt, and inadequacy, sometimes resulting in rejection at birth of the baby and the hospital. Overly optimistic counseling lessens distress immediately after birth but may be counterproductive in the long term. Three of the cases demonstrate the dilemmas that arise when an incorrect diagnosis is made based on ultrasound.^ieng

A comparison of the traumatic effects of vascular clamps.

The mature and extent of damage to the wall of the femoral artery of the dog caused by five different vascular clamps is reported. This is related to the ability of the clamp to both occlude the vessel and to hold the wall without slipping. Intimal damage was assessed by supravital staining, scanning electron microscopy of the surface and the histological appearance of sagittal sections of the arterial wall. The Atraugrip, Satinski and Potts clamps caused more apparent damage to the vessel wall and achieved occlusion by holding of the vessel at higher pressures than did the Blalock and Fogarty clamps. There is a difference between the damage produced when closure is sufficient to just occlude the vessel and that produced when the clamp is fully closed.

Anatomical findings at orchiopexy.

The anatomical findings at orchidopexy for cryptorchid testis were recorded for 60 boys aged between 6 months and 18 years. In 11 patients (18.3%) bilateral cryptorchidism was present. At operation, atrophied testicular tissue was found in two patients and one testis was found to be absent; 69.1% (47/68) of the remaining testes were found in the superficial inguinal pouch at operation, 27.9% (19/68) were in the inguinal canal, one was in the femoral triangle and one was high in the scrotum. In 35 testes (51.5%) there was an associated hernial sac. In 54 testes (79.4%) the gubernaculum testis was attached to an anatomical site other than the lower scrotum. In 26 (38.2%) there was a fascial block to descent into the scrotum and one or other of these findings was present in 64 testes (94.1%). These findings suggest that failure to establish a patent route from the superficial inguinal region to the scrotum and the passage of the gubernaculum along this route are the abnormalities responsible for failure of testicular descent.

Intermittent sigmoid volvulus in the younger age groups.

Sigmoid volvulus is a well-recognized clinical entity, occurring more commonly in the male in middle or old age. In younger age groups the diagnosis is therefore often delayed. We report here 11 patients of an average age of 31 years (range 12-57 years), with a preponderance of females (7 : 4), who have presented to us in the past 2 years with intermittent sigmoid volvulus. The average age at onset of initial symptoms was 26 years. All had the diagnosis confirmed radiologically by colonoscopy or at operation. The diagnostic features of the condition are described.