Reverse smooth muscle plasty: a new method of treating anorectal incontinence in infants with high anal and rectal atresia.

A new technique of treating anorectal incontinence in infants with high anal and rectal atresia is described. In the first stage of this new operation an abdominosacroperineal pull-through procedure according to Rehbein, Romualdi, and Kiesewetter is performed. In the next step of this new method the circular and longitudinal muscle layers of the pulled-through colon are turned back 180 degree and fixed to the pulled-through bowel. The mucosa of the turned back bowel is removed. Then the whole muscle cuff is re-pulled into the puborectalis sling. Pressure studies as well as X-ray investigations showed a good sphincter function of the newly established internal sphincter equivalent.

Deviated trachea in hypoplasia and aplasia of the right lung: airway obstruction and its release by aortopexy.

Three cases of male infants with hypoplasia and aplasia of the right lung and dextrocardia are reported. The infants developed increasing obstructive respiratory distress in the first 4 months of life. In all three cases, there was an opaque right hemithorax with overinflation of the left lung, a posterior deviation of the trachea with pulsatile stenosis, and a posteriorly located aortic arch. Hypoplasia (two cases) or aplasia (one case) of the right pulmonary artery and an absence or a remnant of the right main bronchus were also observed. Associated malformations were esophageal atresia with an abnormal high pouch of the proximal esophagus in case 1, and hypertelorismus syndrome in case 2. Because of severe respiratory distress in all three patients, an aortopexy was performed at the ages of 5 months (one infant) and 10 months (two infants). The obstructive respiratory signs disappeared postoperatively in the following weeks. It has been observed that tracheal stenosis in aplasia or hypoplasia of the right lung may be caused by the dislocated aortic arch. An aortopexy can release the airway compression in such cases. Because of associated malformations, a careful evaluation of the airway and vessels is recommended.

Ileus in the newborn: a study of decreasing mortality.

The authors' experience with operative therapy for ileus-duodenal, small intestinal, colon, and rectal-in newborns is presented with an analysis of the improvements in prognosis over the last 30 years. For the time period 1980-1989, the following survival rates were achieved: duodenum: 100%; small bowel: overall 96.8%, for uncomplicated cases 100%; congenital megacolon: overall 89%, for uncomplicated cases 100%; ileus of all intestinal portions together: 97.5%, for uncomplicated cases 100%.

Lobar emphysema and atelectasis syndrome, a nosological unity.

Shrinking and atelectatic pulmonary processes--atelectasis syndrome--and lobar emphysema show morphological similarities: congenital malformations of the bronchial structure, external compression of the bronchi as well as inflammatory processes. Ventilation mechanics determine whether in the described processes an atelectasis or an emphysema manifests itself clinically. Usually, one finds over-expansions in connection with atelectasis syndrome and atelectases together with lobar emphysema. Both processes can be reversible, if we are not dealing with bronchial malformations. Longer lasting processes as well as acute, life threatening forms require operation. The belief that atelectasis syndrome and lobar emphysema constitute a nosological unity is illustrated by our cases of 9 patients with atelectasis syndrome and 16 patients with lobar emphysema.

Clinical findings in middle lobe syndrome and other processes of pulmonary shrinkage in children (atelectasis syndrome).

Processes of atelectasis and pulmonary shrinkage are not confined to the right middle lobe. This fact is illustrated by case reports of five of our nine such patients. All cases shared common clinical and morphologic similarities: congenital malformations of the bronchial skeleton, compression, and chronic inflammation produce comparable pulmonary morphology that always includes atelectasis. Atelectasic processes of longer duration require surgical resection; this led to cures in all the authors' patients.

New morphological findings in so-called negative appendectomies.

Appendices of children operated on because of clinical signs of acute appendicitis and presenting normal histological findings were revised by means of special assays. These findings were then compared with appendectomies during abdominal surgery, catarrhal and early phlegmonous appendicitis. We found pathological changes of the epithelium and the lymphatic tissue in more than two thirds of the specimens originally classified as normal. Therefore the term of "negative appendectomy" has to be redefined.

[Postoperative pneumothorax following interventions for diaphragmatic hernias and defects]. / Postoperativer Pneumothorax nach Eingriffen wegen Zwerchfellhernien und -defekten.

Basing on the fact that postoperative pneumothorax occurred in a third of 47 patients with diaphragmatic hernias and defects, the mechanisms of progressive respiratory insufficiency and the occurrence of postoperative pneumothorax are debated as well as therapeutical measures for prevention. It is suggested as an important therapeutical principle in order to prevent any negative pressure on the operated thoracic side and to keep by all means the mediastinum in the middle. By the aid of these therapeutical principles, an improvement of the still high lethality of 40% - which postoperative pneumothorax is decisive for - can be achieved.

[Surgical closing of recto-vaginal, recto-urethral, urethro-vaginal and vesico-cutaneous fistulas by means of interposition of the gracilis muscle]. / Der operative Verschluss recto-vaginaler, recto-urethraler, urethro-vaginaler und vesico-cutaner Fisteln durch Interposition des Musculus gracilis.

Ten cases of recto-vestibular, recto-vaginal, recto-urethral, urethro-vaginal, and vesico-cutaneous fistulas in children are reported. The fistula was closed by an interposition of the gracile muscle in every case. No relapse has been observed to date, 1.5 to 6 years after the operation. The surgical technique is described.

[Surgical therapy of neonatal necrotizing enterocolitis]. / Die operative Therapie der neonatalen nekrotisierenden Enterocolitis.

Between 1972 and 1988, a total of 57 patients with an average birth weight of 1988 g and an average gestational age of 34.1 weeks were operated on for neonatal necrotizing enterocolitis. In 48% of the cases, the critical indication for surgery was determined by clinical examination; in 52% of the cases, the indication was based upon a radiological diagnosis of pneumoperitoneum. The affected intestinal portions were first resected. Then, the proximal and distal limbs were sewn together and brought out through a separate short incision. Utilizing this procedure, the lethal rate sank from above 80% to below 30%. Taking into account unrelated causes of death, no significant increase in risk has been associated with the use of this procedure on prematurely born patients and patients exhibiting acute intestinal perforations.