[Chronic inflammatory bowel diseases in pediatric surgery]. / Chronisch entzündliche Darmerkrankungen in der Kinderchirurgie.

Out of 147 children suffering from Crohn's disease (CD), 34 needed surgery (23%) at an age of 12.5 years, usually 4.5 years after conservative treatment. Besides acute and planned indications for surgery, the relative indication during puberty requires further knowledge of the influence of growth velocity rates for weight and height, bone retardation, Tanner stage, chronological age and open epiphysial plates. Expecting 2.3 years of postoperative remission, the chance is often missed to operate on the prepubertal child at an optimal time leading to growth failure, retardation of pubertal development and diminished quality of life.

[Outcome of treatment of ingrown toe nails in the child]. / Behandlungsergebnisse eingewachsener Zehennägel beim Kind.

Difficulties encountered and long-term results of surgical treatment of ingrown toenails are well documented in the adult patient. In infants and children, however, little is known about this problematic entity. We therefore performed a follow-up study in 91 out of 99 ingrowing toenails in children up to 14 years. The patients were treated in our department from 1990 to 1994 mainly by wedge resection. 64 nail folds remained free of symptoms after single surgical treatment. Recurrence of infection or nail spikes was found in 21 out of 85 nail folds. In children, conservative treatments with antimicrobial ointments, gutter treatment, and in selected cases systemic antibiotics, are more promising than in adults. If these efforts remain unsuccessful, the only reliable surgical approach is a radical wedge resection.

Treatment of congenital abdominal wall defects -a 25-year review of 132 patients.

The outcome data of 132 patients treated at the Department of Pediatric Surgery in Mainz during the last 25 years were reviewed. Prenatal diagnosis of abdominal wall defects (AWDs) and associated malformations led to increasing selection of the patient population. The aim of primary closure of the abdominal wall can be achieved more frequently in gastroschisis (GS) than omphalocele (OC), while the postoperative course is more complicated and of longer duration in GS. Delayed or secondary closure extended the hospitalization period but had no negative effects on the outcome. Reoperations or planned secondary operations were performed in 23 patients with GS and 14 with OC. Early mortality was 15/55 for OC and 21/77 for GS over the period of 25 years. In recent years, a drastic reduction in mortality has occurred, and mortality is now mainly due to additional malformations. Further development and quality of life are not significantly reduced after survival of an isolated AWD. Malpositioning of parenchymatous organs after closure of AWDs has to be considered during pregnancy and abdominal operations.

[Kirner deformity]. / Die Kirner-Deformität.

A 14 years old boy with Kirner's deformity is demonstrated. He has the typical radial and volar deviation of the terminal phalanges of the 5th finger. Nature and inheritance of the disease are discussed. We assume inborn ossification disturbances. Most authors recommend to avoid any therapy. But we feel that nowadays it is possible to use plaster splints in young children or to do a corrective operation in older ones with good success.

7-Azabenzimidazolylcobamide and 5,6-dimethyl-7-azabenzimidazolylcobamide, new vitamin B12-analogs synthesized from 4(5)-aminoimidazole by Eubacterium limosum.

In anaerobic bacteria, glycine, formate, and the amide-N of glutamine are building blocks for the biosynthesis of the imidazole moiety of the vitamin B12-base 5,6-dimethylbenzimidazole. These building blocks are also used for the biosynthesis of the imidazole moiety of purine bases. Therefore we tested 4(5)-aminoimidazole, the base moiety of the purine nucleotide precursor 5-aminoimidazole ribonucleotide, for its putative function as precursor of 5,6-dimethylbenzimidazole. The anaerobic vitamin B12-producer Eubacterium limosum, grown in the presence of [2-13C]4(5)-aminoimidazole, synthesized nonlabeled vitamin B12, but also [2-13C]7-azabenzimidazolylcobamide and [2-13C]5,6-dimethyl-7-azabenzimidazolylcobamide. [2-13C]limidazole was used by E. limosum to form [2-13C]imidazolylcobamide. Simultaneously nonlabeled vitamin B12 was synthesized. This shows that 4(5)-aminoimidazole and imidazole are not intermediates in the biosynthesis of 5,6-dimethylbenzimidazole. However, 4(5)-aminoimidazole has obviously a structure similar to the structure of an as yet unknown precursor of the vitamin B12-base, and is therefore transformed into the aza analogs. In order to prepare a reference compound 4(5)-azabenzimidazole was added to a culture of Propionibacterium shermanii and to a culture of E. limosum, P. shermanil transformed this base mainly to 4-azabenzimidazolylcobamide, as determined by 1H NMR-spectroscopy (NOE experiment). In contrast E. limosum produced mainly 7-azabenzimidazolylcobamide. The reason for this difference is discussed.

[Diagnostic possibilities and treatment approaches for fracture of the of the intercondylar eminence in the growth period]. / Diagnostische Möglichkeiten und Behandlungsstrategien für die Fraktur der Eminentia intercondylica im Wachstumsalter.

Between 1970 and 1993 29 fractures of the intercondylar eminence were seen in children with almost the same number of cases showing no or minor displacement as those requiring open reduction for major dislocation. Combined knee injury must be suspected the higher the patient's age and the more pronounced the displacement of the fragment. Magnetic resonance imaging (MRI) has gained diagnostic predominance. Arthroscopy remains important for surgical management, especially of associated meniscus and cartilage damage. Early puncture of hemarthrosis is essential. Closed management is the therapy for nondisplaced fragments or those with bone contact or only tuberculum fractures--while displaced fragments require operative reduction. Arthroscopy-aided wire fixation is the preferred technique, followed by open reduction using absorbable suture material (wire in special cases). Traction screws should be used only in older children with large fragments. Our series show good late results because occasional function impairment with knee instability tends to normalize with growth. Corrective orthopedic procedures--if at all--are required only for juveniles or adults.

[New aspects in the treatment of complete and isolated diaphyseal fracture of the forearm in childhood]. / Neue Gesichtspunkte zur Behandlung der kompletten und isolierten diaphysären Unterarmfrakturen im Kindesalter.

From 1984 to 1992 153 children were treated at the pediatric surgical department of the University of Mainz, of whom 19 had fractures of the radius, 9 of the ulna and 125 had a combination of both in the diaphysis of the forearm. Factors like patient's age, type of fracture and therapeutic methods were analyzed. One hundred and forty-one children were treated conservatively, 12 by operation. One hundred and one of these patients were healthy, when discharged (about 8 weeks after accident). Follow-up was possible in 69 cases. We found that occasional a remaining dislocation angle does not impair function: in 65 cases the result was "good" and "very good", but only "moderate" in 4 cases. These 4 children had been treated conservatively by reposition and plaster cast; 2 of these 4 children showed bone reconstruction without dislocation. Twenty-two of the 56 X-ray follow-up's showed persisting dislocation. To prevent functional problems (2 of our cases) it is essential to obtain a very exact reposition of diaphyseal forearm fractures. Therefore we would recommend a more generous indication for operation, preferably using elastic-stable Nancy pins.

[MRT for surgical planning in anal atresia]. / MRT zur Operationsplanung bei Analatresien.

We evaluated in this study the value of preoperative examinations of anal atresia with an optimised MRI strategy. 13 patients with anorectal anomalies, most of them younger than one year, underwent an MRI examination of the pelvis. 10 of these patients were operated afterwards. Compared with the situs shown by the operation the results of the MRI examination were very exact in all cases in respect of the level of atresia and the development of the striated muscle complex. Fistulas could be completely described in most cases. MRI demonstrated additional lesions in some patients which were of great importance for planning the further treatment of the patients. As a consequence MRI can give valid information on anal atresia for planning the operative treatment.

[Surgical indications of funnel chest]. / Zur Operationsindikation der Trichterbrust.

Pathological findings in ECG represent indications for operation only if they are accompanied by subjective complaints and psychogenic problems. The extent of the abnormality usually does not correlate with the patient's complaints. Disappearance of such complaints after surgery does not be considered as a sign of successful surgery. Even a deep funnel chest is not necessarily an indication for operation if the patient has no complaints and can manage the situation. A flat funnel chest should not be operated on. The operation can be performed in patients between 4 and 24 years of age. If severe associated anomalies require operation as well, the choice is not for correction of the funnel chest first.

[Sonography of congenital abnormalities of the gastrointestinal tract]. / Sonographie kongenitaler Anomalien des Gastrointestinaltraktes.

In 12 children aged from 1 day to 15 years with various kinds of congenital gastrointestinal anomaly (atresia/stenosis in the duodenum, jejunum, or ileum; duplication cyst in the duodenum/Bauhin's valve; ectopic pancreas antropyloric) the almost invariably present disturbance of passage was sonographically documented and located and, in the cases with concomitant processes of the bowel wall, the causative lesion demonstrated. In 3 neonates, the diagnosis including complications (meconium peritonitis with calcifications secondary to small bowel perforation) had already been accurately made prenatally. Despite the always unequivocal ultrasound findings, additional x-ray examinations (only plain in 5, only with contrast medium in 1, plain and with contrast medium in 6 cases) were performed in all patients to confirm the diagnosis and reassure the operator. Comparison of the sonographic with the radiological and, later, with the surgical results showed that, in all cases, ultrasound had already provided the information essential to the surgical intervention. The results indicate that, in future, a substantial reduction of additive x-ray examinations is possible in such diseases and that their early intrauterine sonographic documentation should be attempted much more frequently.

[Surgical therapy of Crohn disease and ulcerative colitis in childhood]. / Chirurgische Therapie des Morbus Crohn und der Colitis ulcerosa im Kindesalter.

Surgery in children with Crohn's disease--like in adults--most frequently consists in the repair of stenoses, abscesses and fistulae. However, if growth and development are retarded, surgery must also be used to prevent irreversible impairment. Seventeen (of 32) patients were considerably retarded before surgery; 13 of these recovered to normal after operation. As regards ulcerative colitis, surgery is rarely needed in children, but if so, the indication and procedure is the same as for adults.