Circumcision in paediatric surgery using an ultrasound dissection scalpel.

In contrast to electrocautery, the ultrasound dissection scalpel allows tissue dissection and haemostasis to be performed without the danger of thermal tissue damage or burning caused by uncontrolled active current. In a clinical application study performed on 24 boys with an average age of six years, we examined whether the use of this instrument is also practical in a routine operation such as circumcision. It was possible to perform all operations with the ultrasound dissection scalpel (Ultracision, manufactured by Ethicon) by the classic technique without the additional use of electrocautery for haemostasis. Although dissecting speed is slower than with conventional instruments, the fact that simultaneous haemostasis is possible meant that operations could be carried out quickly and with minimal bleeding. There were no perioperative complications such as haemorrhaging or burning. All children were examined postoperatively over an average of 3 weeks (range 1-8 weeks). Wound healing was completely without complications for 22 patients (92%). One patient (4%) suffered a candidal infection in the first postoperative week. One further patient (4%), who was already suffering preoperatively from an extended chronic inflammation of the prepuce, developed pronounced swelling postoperatively. Heavy scarring occurred subsequently in both cases. Our results show that the advantages of the ultrasound dissection scalpel, e.g. gentle tissue dissection with simultaneous haemostasis, can also be used to advantage for a technically simple operation such as circumcision without having to fear the risks of electrocautery.

Hirschsprung's disease and intestinal neuronal dysplasia--a frequent association with implications for the postoperative course.

Between 1991 and 1993, 106 newly diagnosed cases of Hirschsprung's disease (HD) were prospectively analyzed for the association of HD and intestinal neuronal dysplasia (IND) at ten pediatric surgical departments in central Europe. Hirschsprung-associated IND (HaIND) was found in 40% of cases. IND was disseminated in one-third and localized in two-thirds of the patients. Initial clinical symptoms were related to the length of the aganglionic segment, but not to the presence of HaIND. An enterostomy performed in 72 cases (67.9%) was located in a segment of pathologically innervated bowel in 50% of all cases, but in 72% of cases of HaIND. The proximal margin of the resected bowel showed pathological innervation in 44% of cases. Supplemental biopsies from the intestine (apart from diagnostic suction biopsies and biopsies at the enterostomy site) led to the first identification or definition of length of associated IND in 17.9% of cases. Postoperatively, the presence of long-segment aganglionosis or associated IND implied a delay in the restoration or normal defecation. Persistent constipation was found in 40% of patients with associated disseminated IND at follow-up at 6 months, compared to 20.6% in patients with isolated HD. These children needed secondary interventions more often than patients with associated localized IND or isolated HD. HaIND thus has clinical implications for the postoperative course if IND is disseminated.

Sacrococcygeal teratoma: clinical course and prognosis with a special view to long-term functional results.

From 1976 to 1995, 23 children, 4 boys and 19 girls, were treated at our department for sacrococcygeal teratomas (SCT). Their records were analyzed retrospectively, considering age at operation, histopathology, recurrences, and long-term evolution. One died on the 1st day of life following tumor rupture with hemorrhagic shock without surgical intervention. All others were operated upon at a mean age of 4.2 days for those 19 (= 82%) who were diagnosed in the neonatal period and whose histology proved benign. In the remaining 3 children, in whom tumor manifestation did not occur before 11 months, 13 months, and 10 years of age, respectively, histopathologic evaluation revealed 2 carcinomas and 1 yolk-sac tumor, and all 3 recurred. Overall, 5 patients died, the 1 mentioned above, 1 due to volvulus after laparotomy, and 1 from multiple associated congenital malformations. Two deaths were related to malignancy, whereby only 1 was a malignant teratoma diagnosed at the original operation. Eight children had recurrences, 2 were benign and 6 malignant, with 3 of the latter having been graded benign on histology of the primary tumor. Of the 18 surviving patients, 17 (93.5%) returned for clinical review following a standardized protocol. The average interval from the primary surgery was 12.3 years (range 3.5-22 years). Four had malignant tumors with a recurrence-free period of from 9 to 14 years; 5 (29.4%) had urinary or anorectal functional impairment. One child with a patulous anus presented with fecal soiling. Two reported nocturnal enuresis, 1 associated with perineal anesthesia. One had a neurogenic bladder with overflow voiding and bilateral third-degree vesicoureteral reflux. Second-degree reflux was found in the last patient. We conclude that follow-up after surgery for SCT should not only search for tumor recurrence but include the diagnosis and treatment of possible secondary urinary and/or fecal incontinence.

Hypospadias repair using a modification of Beck's operation: followup.

PURPOSE: We reviewed the results of 64 cases of hypospadias repair using a modified Beck's operation with mobilization of the anterior urethra. MATERIALS AND METHODS: Patient age at correction ranged from 10 months to 12 years (mean 3.83 years). Six patients had undergone previous surgical treatments. Uroflowmetry and evaluation of the urinary stream, meatus, glans, shaft and scar formations were used as objective criteria, and grading of management and results by parents was considered subjective criteria. RESULTS: An average of 2.1 years postoperatively 59 patients were available for this followup study. The urethral meatus was positioned satisfactorily onto the distal glans in all cases and no urethrocutaneous fistulas developed. Meatal stenosis requiring meatal dilation occurred in 2 boys. In 2 cases a curved glans, and curved penis and glans, respectively, were caused by cicatricial tissue, necessitating surgical correction. Uroflowmetry was possible in 46 cases (78%). One patient with meatal stenosis had pathological flow values. All other flow rates were within the normal range. In the second case of meatal stenosis objective evaluation was impossible. In 55 cases (93%) parents judged management and results as optimal. CONCLUSIONS: Mobilization of the anterior urethra for correction of distal hypospadias with or without chordee is highly successful, less extensive, and provides an excellent cosmetic and functional result with a minimal risk of complication. Uroflowmetry is a noninvasive, objective diagnostic tool for evaluating the functional results of hypospadias repair.

Detection of low-grade vesicoureteral reflux in children by color Doppler imaging mode.

Vesicoureteral reflux (VUR) is common in children with urinary tract infections (UTI) and may result in renal scarring or reflux nephropathy. To date, the primary diagnostic tool has been voiding cystourethrography (VCUG). A new technique for evaluation of grade 1 and 2 VUR is described using color Doppler imaging-mode cystography (CDIMC): 77 children, aged 7 months to 14 years, were examined for VUR by CDIMC and standard VCUG. According to the established reflux sonography (US) using a real-time mode, all patients selected for this study had a normal urinary tract on conventional gray-scale US. We studied 154 ureters, and a total of 31 were found to be refluxing on CDIMC and 30 on VCUG. A positive sonogram was defined as visualization of Doppler signals from the bladder to the ureter during the course of bladder filling. Taking VCUG as the gold standard, we had ten false-positive findings. The false-positive rate of 18.5% may have been due to the shorter observation time of fluoroscopy. Comparison of the two methods shows CDIMC to be 70% sensitive with a specificity of 92% in the detection of VUR grade 1 and 2. To evaluate the incidence of asymptomatic low-grade VUR in a non-infected population, a second series of 38 children (19 males, 19 females) aged 3 to 15 years (mean 8.8 years) with normal urologic status and urine cultures were studied by color Doppler imaging mode (CDIM) for detection of asymptomatic low-grade VUR. Four children were found to have a unilateral refluxing ureter. The incidence of VUR in children with a normal urinary tract and no prior UTI was 10.5%. In conclusion, CDIMC can be used as a possible alternative to standard VCUG for the screening and follow-up of low-grade VUR. In addition, our study indicates that asymptomatic grade 1 and 2 reflux might be a physiological condition.

Torsion of a normal adnexa in a premenarcheal girl: MRI findings.

Torsion of the adnexa can be the cause of abdominal pain. An immediate diagnosis is very important because early surgical intervention is the only way to save the ovary from necrosis. Torsion of a normal adnexa is rare, but occurs more frequently than is generally appreciated. If US findings are equivocal, MRI can provide additional information. In our case the MRI findings leading to the diagnosis of ovarian torsion were: (a) A medial ovarian mass existed with dislocation of the uterus to the affected side with hyperintense, cystic lesions on T2-weighted images at the periphery of the ovary. (b) Beaked protrusion of the mass continuing in a band-like structure connecting it with the uterus obviously represented the Fallopian tube. (c) Low and inhomogeneous signal intensity of the stroma on T1- and T2-weighted images and lack of gadolinium uptake were indicative of infarction.

Ascent of the testis in children.

Among 460 children who had an orchiopexy (ORP), we identified 72 children who had attended our institution 1-12 years earlier and in whom the testicular position had been specified. Of the 72 boys 19 were had ascended testes (26%). The age at ORP of the children with ascent of the testes was 7.0 years (1.8-14.0 years). Light and electron microscopy of 13 testicular biopsies taken at ORP, showed alterations of germ cells and Sertoli cells, similar but less pronounced than alterations seen in congenital undescended testes. Conclusion. A normally positioned testis may ascend into the inguinal region or upper scrotum and remain there fixed. This secondary cryptorchidism does not usually respond to human chorionic gonadotropin treatment and must be corrected by orchiopexy.

Problems of ileostomy in necrotizing enterocolitis.

Exteriorization of the intestine and resection of the gangrenous bowel are major therapeutic regimens for necrotizing enterocolitis (NEC). Ileostomy associated complications are well known, therefore the time of ileostomy closure is a matter for discussion. Between 1975 and 1992, 84 patients with NEC were treated surgically. Ileostomies were performed in 37 children (44%). Of these 37 neonates, 9 (7M, 2F) died. In the remaining 28 patients (16M, 12F) with a mean gestational age of 35.8 weeks and a mean birth weight of 2412 g, ileostomies were performed between the 2nd and 11th days after birth. On average, the stomies were in function for 91 days, and within this period the average weekly weight gain was 153 g. Nineteen patients of this group did not show any problems attributable to the ileostomy. In 9 patients (32%) complications occurred, requiring a preplanned closure of the stoma. Postinflammatory strictures of bowel were diagnosed in 9 patients and resection of the stenotic intestine was performed at the same time as stoma closure. In conclusion, an appropriate weight gain can be achieved in patients with an ileostomy with an adequate feeding regimen. In otherwise uncomplicated cases, ileostomy closure can be delayed by up to 10 weeks when simultaneous surgical correction of additional intestinal strictures is possible. In one-third of patients with an ileostomy, however, complications may occur and urge a preplanned closure of the stoma.

A fetal lamb model of partial urethral obstruction: experimental protocol and results.

The functional effects of bladder outlet obstruction in the developing urinary tract are well recognized in patients born with posterior urethral valves, in whom a spectrum of bladder dysfunction has been described. To better understand the changes occurring in the partially obstructed developing lower urinary tract, a fetal lamb model of partial urethral obstruction was developed. Fetal lambs at 90 days' gestation underwent surgical placement of a silver ring (ex utero) at the level of the proximal bladder neck, with concomitant ligation of the urachus. Control animals underwent urethral ligation only. The lambs were then allowed to go through normal gestation, and ewes were delivered spontaneously. The animals were studied between 2 and 7 days after birth. The postmortem examination showed that the ring was just distal to the bladder neck, around the proximal urethra. This resulted in gradual, partial occlusion of the urethra. Bladder weights, bladder wall thickness, and bladder capacity were significantly increased in the partially obstructed animals as compared with the controls. There was little or no upper tract dilatation in the obstructed group. This animal model, the first to produce gradual outflow obstruction in the fetus, provides a reproducible model of partial urethral obstruction. The model can be used to assay the biochemical and physiological changes found in the developing urinary tract of fetal lambs submitted to intravesical obstruction.

Biliovenous fistula in children after blunt liver trauma: proposal for a simple surgical treatment.

Biliovenous fistula (BVF) with subsequent leakage of bile into the venous system is a rare but serious complication of blunt liver trauma. Nine cases have been reported since 1975. Surgical therapy is indicated; however, there are still controversies as to which operative method should be applied. Based on experience gained in adult surgery, resection of the BVF together with necrotic liver tissue is also recommended in children. We describe both an organ-saving and technically simple method that was applied in two male patients, 2 and 10 years old, respectively, suffering from BVF. After debridement and tamponade of a necrotic cavity of the liver, drainage was carried out. This prevented bilious leak into the venous system. Based on the case history of these two patients, management of BVF fistula will be described. Pathophysiology of bilhemia and the drainage effect will be discussed in light of a review of the literature.

[Foreign body aspiration in children. The advantages of emergency endoscopy and foreign body removal]. / Fremdkörperaspiration im Kindesalter. Vorteile der notfallmässigen Endoskopie und Fremdkörperentfernung.

In the last 15 years, 124 children with a history and clinical signs of aspiration have been managed by emergency rigid endoscopy under general anesthesia. In 115 (93%) of them a foreign body could be identified, which was successfully removed by forceps extraction in 114. Only 1 patient required a thoracotomy for removal of a distally located aspirated needle. The remaining 9 patients (7%) had a typical history and clinical signs of an aspiration, but no aspirated foreign body was found on endoscopy. Most of the children (102, or 82%) were admitted within 12 h after aspiration, while 22 (18%) had a history of foreign body aspiration between 2 days and 5 weeks before. Complications occurred in only 3% (3 children) of the 102 who underwent endoscopy within 12 h as against 50% (11 patients) of the 22 children in whom this was delayed. In all cases of foreign body aspiration and endoscopical removal within 12 h, the patients were discharged after a plain chest X-ray the following day. In children with chronic endotracheal foreign bodies, in 80% a second endoscopy after 48 h was indicated, and the mean stay in hospital was extended to 7 days. Emergency rigid tracheobronchoscopy and forceps removal of aspirated foreign bodies under general anesthesia and with meticulous perioperative monitoring is a safe and effective procedure with no mortality. Even in suspected aspiration or chronic bronchopulmonary infections, liberal use of endoscopy is recommended.

[Results of conservative treatment of ligament lesions of children's ankle joint--a prospective study]. / Ergebnisse der konservativen Behandlung von Bandläsionen des kindlichen Sprunggelenkes--Eine prospektive Studie.

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.

[Treatment of femoral hernia in children]. / Die Behandlung der Hernia femoralis im Kindesalter.

From 1975 to 1988 at the Department of Pediatric Surgery in Graz 20 femoral hernias in 16 children were diagnosed and treated by an operative technique, described by Sauer in 1964. Under this method the femoral canal is closed in level of the femoral ring by a pedicle flap, constructed from the transversalis fascia. All patients underwent follow-up examination and were symptom-free. No relapse occurred. For the development of femoral hernias the previous inguinal hernia repair could be a favored factor.

[Flexor tendon injuries in childhood]. / Beugesehnenverletzungen im Kindesalter.

Follow-up examinations were performed on 41 children with 51 flexor tendon injuries of the hand. Eighty per cent of the accidents were caused by a cut mostly from broken glass. The results were classified according to Buck-Gramcko. Primary repair (n = 32) was followed in 72% of an acceptable, good or optimal result. Half on these patients had been treated according to Kleinert's method. Secondary repair (n = 19) showed a good or optimal result in 53%. A more detailed analysis gives no evidence that the patient's age or the localisation of the injury are of major importance in achieving good results. However, primary repair, optimal surgical technique and early mobilisation according to Kleinert seem to be essential for an adequate outcome. Therefore, acute flexor tendon injuries in childhood should only be treated under optimal circumstances (e.g., daytime, surgical team). Otherwise, surgical repair should be delayed for 12 to 48 hours until the best circumstances are available. Furthermore, exact surveillance of the postoperative mobilisation is of crucial importance. In patients who need a flexor tendon transplant, early mobilisation according to Kleinert also seems to produce favourable results.