Pseudoaneurysm rupture after liver injury in a 14-year-old boy.

Today, haemodynamically stable children with blunt liver trauma are treated conservatively and can be discharged from hospital within one week. We report on a 14-year-old boy with a blunt hepatic trauma grade III, who showed a pseudoaneurysm with active bleeding into the abdominal cavity after mobilisation on day 9. Supraselective angiography of the right hepatic artery was performed and 2 titanium coils and gelatine sponge particles were placed for embolisation. In view of this complication, we suggest carrying out colour Doppler sonographic imaging to rule out pseudoaneurysm in children with blunt hepatic trauma before they are discharged from hospital.

Pitfalls in therapy of upside-down stomach.

The upside-down stomach (UDS) is a special form of gastric organoaxial volvulus in a supradiaphragmatic hernial sac. The authors report five cases treated between 1979 and 1998, and seek to point out possible problems and pitfalls in the surgical management of this uncommon anomaly. Retrospective analysis of these cases shows that brachyesophagus as described is not a problem in UDS, as the esophagus is of normal length. The hiatus, on the other hand, is always very large and needs proper narrowing, which may be achieved through a transabdominal approach more easily than through a transthoracic access. A common esophago-aortal hiatus is often present. In conclusion, the authors recommend a hiatal repair and gastropexy, i.e. fundophrenopexy and corpoventropexy along the esophageal axis to prevent recurrent gastric herniation or torsion. Transabdominal access should be chosen since brachyesophagus is not expected. Beware of a common hiatus when preparing the hiatal crura. An antireflux procedure is not necessary as gastro-esophageal reflux usually resolves spontaneously after hiatal repair and gastropexy.

The infantile inguinal hernia - a bilateral disease?

Controversy continues whether exploration of the contralateral, asymptomatic side should routinely be performed since Rothenberg and Barnett stated in 1955 that a contralateral hernia is present in three out of four children presenting with a symptomatic unilateral inguinal hernia (IH). In our institution, hernia operations are performed on the symptomatic side only, the exception being male infants under 1 year of age with a left-sided IH. To verify our concept and to evaluate the frequency of contralateral hernial development, the medical records of all infants under 1 year of age operated upon between 1984 and 1988 were reviewed and the children followed through December 1996. Included in the study were 882 infants, 616 boys (70%) and 266 girls (30%); 148 (17%) were born prematurely. Seventy percent were operated upon before the end of the 3rd month of life. In 761 infants clinical signs of a unilateral hernia were present, and in 121 symptomatic hernias were found on both sides; 665 infants were operated upon unilaterally. A second operation on the opposite side was necessary in 38 cases (5.7%). The highest incidence of contralateral hernial development was found in premature boys (11.5%). We conclude that even in infants below 1 year of age, IH is usually a unilateral disease and does not require routine exploration of the asymptomatic side.

Early vitamin K deficiency bleeding after maternal phenobarbital intake: management of massive intracranial haemorrhage by minimal surgical intervention.

UNLABELLED: Vitamin K deficiency bleeding within the first 24 h of life is caused in most cases by maternal drug intake (e.g. coumarins, anticonvulsants, tuberculostatics) during pregnancy. Haemorrhage is often life-threatening and usually not prevented by vitamin K prophylaxis at birth. We report a case of severe intracranial bleeding at birth secondary to phenobarbital-induced vitamin K deficiency and traumatic delivery. Burr hole trepanations of the skull were performed and the subdural haematoma was evacuated. Despite the severe prognosis, the infant showed an unexpected good recovery. At the age of 3 years, neurological examinations were normal as was the EEG at the age of 9 months. CT showed close to normal intracranial structures. CONCLUSION: This case report stresses the importance of antenatal vitamin K prophylaxis and the consideration of a primary Caesarean section in maternal vitamin K deficiency states and demonstrates the successful management of massive subdural haemorrhage by a limited surgical approach.

Lymphangioma of the right kidney in an infant boy.

A 9-month-old boy with a primary cystic lymphangioma of the right kidney is reported. The clinical and radiological features favored a malignant tumor. Histology revealed the lesion to be a lymphangioma; the diagnosis was confirmed by immunohistochemistry and chemical analysis of the intracystic fluid. Lymphangiomas of the kidney are rare in adults; they are even rarer in infants and children. Nevertheless, renal lymphangiomas should be considered in the differential diagnosis of multicystic, unilateral renal masses, independent of the age of the patient.

The role of surgery and lithotripsy in childhood urolithiasis.

From 1982 through 1993 36 interventions in 32 infants and children with urolithiasis have been performed in our department. There were 22 boys and 10 girls. The main cause for the interventions have been congenital malformations in 9, followed by recurrent urinary tract infections in 6, previous operations in 5 and hypercalciuria in 5 patients. In 7 children the cause of the urolithiasis remained unknown. As a therapeutic option extracorporeal shock-wave lithotripsy (ESWL) was available after 1988. The malformations as well as the postoperative conditions have been corrected surgically and the calculi were removed at the same time. For post-infectious, idiopathic or hypercalciuric calculi ESWL was used in the majority of patients after 1988. Therefore a total of 26 calculi were removed by operation and 13 by ESWL. Only 1 calculus was extracted endoscopically. There were no complications either after ESWL or after open surgery. Our results show that ESWL gains more and more importance in infants and children. Calculi in congenital malformations or as result of operations are still removed by open surgery. In the other cases ESWL is the method of choice.

Duplex ureteroceles: is radical surgery always necessary?

To answer the question about the best therapeutic procedure in duplex ureteroceles a prospective and retrospective study was performed. In a first group we summarized the patients operated from 1971 to 1986. These infants and children were compared to a group operated from 1987 to 1992. In the first group the operative procedure was chosen according to the presence or absence of reflux into the lower pole system. All patients with reflux were corrected radically in one operation. The control showed a reoperation rate of 45% (8 of 18 patients). 3 patients lost a functioning renal unit. In the second group the operative procedure was chosen according to the function of the upper pole. It was resected if its function was below 10% measured by DMSA-scintigraphy. In cases with functioning upper pole a pyeloureterostomy was performed. Only in two cases the ureterocele was resected primarily. In this group a second operation was necessary in only 3 of 16 patients and renal function was preserved in all cases. Our results show that radical surgery in duplex ureteroceles is seldom necessary and a staged procedure is the method of choice.

Surgical procedures in colonic strictures after necrotizing enterocolitis.

Between 1982 and 1992, 22 patients were treated with colonic strictures in the course of necrotizing enterocolitis (NEC). Fourteen newborns in whom a primary enterostomy and, when necessary, resection of necrotic bowel was performed developed strictures in the diverted colon. The strictures were detected by colon contrast enema study performed on average 3 months after the first intervention. Eight additional children suffered from an ileus due to primary strictures after conservatively treated NEC, which was surgically managed by enterostomy. Closure of the enterostomy and resection of the stenotic part of the colon was performed thereafter in all 22 children as a single stage procedure. There was no insufficiency of the anastomosis nor any late stricture at follow-up 2.7 years after NEC in our patients. It is concluded therefore that reanastomosis of the enterostomy and resection of an intestinal stricture can be performed as a single stage procedure without any risk after an interval of 3 months between onset of acute NEC and reevaluation. During this interval, a close monitoring and an appropriate management of adequate supplement of electrolytes and bicarbonates is necessary. Most of our babies could be nursed at home and showed a good weight gain during this period, despite the enterostomy.

[Reconstruction of external genitalia of the girl with adrenogenital syndrome]. / Die Rekonstruktion des äusseren Genitale bei Mädchen mit adrenogenitalem Syndrom.

Congenital adrenal hyperplasia (CAH) is the most common cause for female pseudohermaphroditism. In these patients uterus and Fallopian tubes are present and also in severe cases the clitoris cannot function as penis later in life. Therefore, a neonate with ambiguous genitalia due to CAH should be raised as female. To assess the degree of masculinization, a modification of Prader's classification was used. In 23 girls with ambiguous genitalia reduction clitoroplasty preserving the neurovascular bundle and creating a dorsal preputial skin flap and vaginoplasty with a perineal skin flap were performed. The phallic skin was used to create the labia minora and the anterior vaginal wall. The patients were reevaluated 1 to 14 years after the operation. The cosmetic and functional results have been excellent.

Surgical treatment of ovarian tumors in childhood.

From 1971 to 1988, 45 girls aged 1 week to 17 years were treated for a total of 46 solid and cystic tumors of the ovaries. Pathohistological examination revealed epithelial tumors in eight cases, a tumor originating from the ovarian stroma in one case, germinal tumors in 17 cases, 15 functional ovarian cysts, and five paraovarian cysts. The stroma tumor and four of the 17 germinal tumors were malignant. Surgical treatment for solid tumors consisted generally of a unilateral salpingo-oophorectomy, but in operations for cystic tumors as well, vital ovarian tissue could only rarely be preserved. Functional ovarian cysts were excised if they were larger than 5 cm. Subsequent to excision of malignant tumors, chemotherapy with cisplatin, vincristine and bleomycin was performed. On follow-up, all patients with benign lesions were well. One of the girls with malignancies died and another is undergoing chemotherapy for tumor recurrence in the contralateral ovary.

[Prenatally diagnosed intestinal obstruction--contribution of pediatric surgery]. / Zur pränatal diagnostizierten intestinalen Obstruktion--der Beitrag der Kinderchirurgie.

The diagnosis of a small intestinal obstruction was made prenatally between the 31st and 36th week of pregnancy in 7 patients with neonatal ileus. Five newborns showed a meconium-peritonitis, a meconium-ileus and the last a ileal atresia. These were compared with newborns with small intestinal obstruction, which had not been diagnosed prenatally. The analysis of our hospital information indicates, that primarily serious forms of ileus and intestinal perforations are diagnosed prenatally, whilst isolated small intestinal obstruction often avoids diagnosis. For this reason, diagnostic punctation of the foetal abdomen contribute little to the establishment of the etiology of the obstruction and should be avoided. On the other hand, punctation of a foetal ascites can, through pressure reduction of the abdomen, lengthen the duration of pregnancy and permit a spontaneous birth.

[Surgery of the female gonads]. / Die Chirurgie der weiblichen Gonade.

37 girls, 2 to 16 years of age, with 38 ovarian tumours or ovarian cysts were treated between 1971 and 1986. 14 patients had teratomas, 8 cystadenomas, 11 follicular cysts and 5 cysts of parovarian origin. 2 of the teratomas were malignant. Abdominal pain was the leading symptom in 32 patients, an abdominal mass was found by palpation in 18 patients. Most of the teratomas were found in prepubertal girls. With one exception all children with follicular cysts and cystadenomas were between 11 and 16 years of age. The patients with teratomas and cystadenomas were treated by ovariectomy, in the 2 patients with malignant teratomas followed by chemotherapy. The girls with ovarian or parovarian cysts were treated by cystectomy. All patients are doing well 1 to 15 years after operation.

[Denis-Browne corrective surgery of hypospadias: long-term results]. / Die Denis-Browne-Korrektur der Hypospadie: Langzeitergebnisse.

From 1971 through 1975, 59 children with hypospadias were operated upon at the Department of Paediatric Surgery of the University Children's Hospital Zürich. The external meatus was penile in 52 and scrotal or perineal in 7 cases. Average patient age at the time of definitive repair was 5 1/2 years. Fistulas or wound dehiscence developed in 22 patients (37.3%) requiring 28 reoperations. 27 patients were seen at a prearranged outpatient clinic 10 to 15 years after the last operation. All patients were satisfied with the result of the operation. None had persistent chordae or fistulas. In all patients the meatus was situated distal to the sulcus coronarius. The penis length was just below the normal range. Encouraged by the good functional and cosmetic results, we believe that the Denis Browne procedure has still its place among the other techniques for hypospadias repair.

[Fracture of the tibial apophysis--a typical sports injury in adolescents]. / Die Fraktur der Tibia-Apophyse--Eine typische Sportverletzung bei Jugendlichen.

Avulsion fractures of the tibial tuberosity occurred in 7 adolescents. Their ages ranged from 13 to 16 years. With one exception the fracture occurred while the patients were engaged in vigorous sports, particularly soccer and jumping. Open reduction was necessary in 4 patients with dislocation of the tibial tuberosity. Closed reduction was successful in 1 patient while two patients were treated via cast immobilisation. In all patients there was a total disappearance of symptoms within 3 months to 4 years. A classification scheme and the indications for surgery are discussed.

[Apophyseal fractures in adolescents]. / Apophysenfrakturen bei Jugendlichen.

Apophyseal fractures occurred in 14 adolescents. The patients, 13 boys and 1 girl, were between 13 and 16 years old. All the fractures occurred while the patients were engaged in vigorous sports, particularly soccer and athletics. We found avulsion fractures of the tibial tuberosity (5), the lesser trochanter (4), the anterior inferior iliac spine (3) and the anterior superior iliac spine (2). Open reduction was necessary in 6 patients with fractures of the tibial tubercle or a displacement of the superior or inferior iliac spine of more than 3 cm. Eight patients were treated with bed rest or cast immobilization. The follow-up examination 1-3 years later included a thorough survey of the mechanism of injury and clinical and X-ray investigations. In 12 patients there was total resolution of symptoms in 1-3 months. The remaining 2 patients, both with avulsion fractures of the tibial tubercle, were asymptomatic except for some discomfort when kneeling or long-distance running.

[Thoraco-abdominal intestinal duplications. Case report]. / Uber thorakoabdominale intestinale Duplikaturen. Ein Fallbericht.

The case of a 22-year-old patient with a thoracoabdominal duplication of the alimentary tract is described. The chest radiograph, with a large cyst in the posterior mediastinum and vertebral abnormalities and a barium swallow showing the abdominal part of the duplication, were diagnostic. At operation a malrotation of the midgut was found and the duplication was resected, leaving esophagus and small bowel intact. An explanation for association of the two malformations - vertebral abnormalities and malrotation - was sought in the literature, particularly that concerning embryogenesis. The following conclusions were reached: 1. Duplications of the alimentary tract are a heterogeneous group with three different embryological faults in development. 2. According to the so-called notochordal theory, vertebral abnormalities and malrotation of the midgut are usual and should be expected in thoracoabdominal duplications of the alimentary tract.