Elective neurectomy during open, "tension free" inguinal hernia repair.

Chronic postoperative inguinal pain syndromes are potentially debilitating sequelae following elective inguinal hernia repair. Diagnosis and definitive treatment constitute challenging issues for both the surgeon and the patient. In this prospective trial, we evaluated the impact of elective iliohypogastric and ilioinguinal nerve resection on the incidence of pain, numbness, and sensory loss following anterior, "tension-free" herniorrhaphy. One hundred ninety-one patients were enrolled and were reviewed 1 month, 6 months, and 1 year postoperatively. Pain, numbness, or any loss of sensation were recorded and categorized on a "mild," "moderate," or "severe" scale. No persistent pain syndrome was encountered. Numbness was found in 9.42% of the patients at the first month and in 6.28% of the patients after 1 year. Sensation loss (1.04%) was never bothersome or incapacitating at the end of the follow-up period. Elective neurectomy is safe to perform, well tolerated by patients, and is not associated with chronic postoperative inguinal pain.

The use of expandable metallic stents for acute tracheal stenosis in the growing lamb.

PURPOSE: Expandable metallic stents (Palmaz stents) have been used in the treatment of tracheobronchial obstruction in children and adults. The authors investigated their utility in the management of acute airway stenosis in a growing animal model. METHODS: A model for tracheal stenosis was developed in young lambs (mean age, 4 weeks; mean weight, 8.6 kg). Via an anterior tracheotomy, a circumferential mucosal injury to the trachea was produced with electrocautery in 31 lambs. In the control group (n = 10) no further intervention was used. In the treatment groups, either serial balloon dilatation of the stricture was performed (n = 6), or expandable metallic stents were inserted across the stricture (n = 15). All animals were monitored daily for signs of respiratory distress. Body weights, fluoroscopic airway measurements and rigid bronchoscopy were performed at least weekly. RESULTS: The average weekly rate of airway growth was 8.2% +/- 5.5% of the tracheal cross-sectional area (CSA). All animals displayed severe stenosis (mean, 90.2% +/- 7.5% of CSA) within 13.1 +/- 4 days after the injury. All animals in the control group had severe respiratory distress, weight loss and died within 14.6 +/- 2.8 days after injury. Serial balloon dilatation of the stricture alone failed to relieve symptoms in all six animals in this group, who died within 20 +/- 1 days after the injury, despite two to three dilatations each. With placement of expandable metallic stents, only 3 of 15 lambs died (two of pneumonia, one of iatrogenic perforation). The remaining 12 remained symptom-free and gained weight during a 2-month follow-up period. However, fluoroscopic examination showed partial collapse of the stents in all of these animals (mean, 44.7% +/- 21.6% of CSA) requiring an average of 2 +/- 0.7 bronchoscopic dilatations. Pathological evaluation showed more pronounced granulation tissue in the stented animals. CONCLUSIONS: The authors conclude that expandable metallic stents provide an effective tool in the management of acute tracheal stenosis. However, airway growth, tissue reaction, and the mechanical properties of the stent require close monitoring and stent adjustment.

Intramural post-traumatic haematomas of the duodenum: are there any late sequelae of operative intervention?

The data of nine children with post-traumatic intramural haematoma of the duodenum treated in Aghia Sophia Children's Hospital of Athens from 1967 to 1980 were retrospectively analysed. Diagnosis was preoperative in all but two children, in whom diagnosis was made during laparotomy. All but one were managed by operative intervention which consisted of simple evacuation of the haematoma and closure of the serosal incision in two out of eight children. Six out of eight children operated on were followed up for 15 years, during which they were free of symptoms. Hypotonic duodenography performed in the above patients was negative for deformity or stricture of the duodenum.

Respiratory insufficiency at birth: a predictor of mortality for infants with omphalocele.

For infants with omphalocele, the size of the defect and the presence of associated anomalies are well known prognostic factors. However, the prognostic importance of the respiratory status at birth has not been well defined. The authors reviewed the records of 30 infants with omphalocele (treated during a 10-year period) to determine whether respiratory insufficiency at birth affected survival. Eighteen infants did not require ventilatory support before repair of the omphalocele. The mean gestational age and birth weight were 38.2 +/- 2.6 weeks and 3.4 +/- 0.6 kg, respectively. Cardiac or other major associated anomalies were present in six infants (33%). Seven (39%) had a "giant" omphalocele (ie, liver-containing and/or omphalocele sac > 5 cm in diameter). The average length of ventilatory support was 3.2 days. All infants in this group were managed by primary (14) or staged closure of the omphalocele (4) immediately after birth. One infant died, but the remainder survived without any significant complications. Twelve infants had severe respiratory distress at birth and required positive pressure ventilation (mean peak inspiratory pressure, 31.4 +/- 1.2 cm H2O; mean FiO2, 0.8 +/- 0.1). The mean gestational age and birth weight were 32.7 +/- 3.5 weeks and 1.9 +/- 0.8 kg, respectively. Cardiac or other major associated anomalies were present in nine infants (75%), and eight (67%) had a giant omphalocele. The average length of ventilatory support was 57.7 days, which was significantly longer than for the previous group (P < 0.001). Two infants died of respiratory failure within 48 hours of birth, before the initiation of any treatment for the omphalocele. Six were managed with surgical repair of the omphalocele, primary or staged, immediately after birth. In four, topical treatment was used to allow improvement in the respiratory status. Only one of the six infants initially managed by surgical repair survived, whereas three of the four infants managed nonsurgically recovered. Stepwise logistic regression analysis showed that the presence of respiratory distress at birth was the only significant predictor of mortality, independent of gender, gestational age, birth weight, presence of other anomalies, or size of the omphalocele (odds ratio = 25.48; likelihood ratio test = 13.86; P < .001). In conclusion, respiratory failure at birth in infants with omphalocele is a significant predictor of mortality. Initial conservative management of the omphalocele until there is improvement in the respiratory status may result in a better outcome.

Acalculous cholecystitis in children.

Acalculous cholecystitis (AC) is a rare disease in children, and its spectrum has not been well established. Twenty-five children with AC were identified (treated between 1970 and 1994) by retrospective clinical and pathological review. The authors recognized two distinct forms of this disease: acute (duration of symptoms < 1 month) and chronic (duration > 3 months). Thirteen children had acute AC. Seventy-five percent were males; the age range was from 2 months to 20 years. Of these cases, six occurred in the immediate postoperative period, five were in association with a systemic medical illness, and two had an infectious cause (Salmonella). The mean time of onset of symptoms ranged from 4 to 30 days after surgery or hospitalization (mean, 16 days). All children presented with fever, right-upper-quadrant pain, and vomiting. Other manifestations included jaundice (38%) and right-upper-quadrant mass (23%). Most had leukocytosis (76%) and abnormal liver function test results (62%). Ultrasonography was the most commonly used radiological test, and all 10 cases tested met the ultrasonographic criteria for acute AC. Cholecystectomy was performed in nine children, and pathological examination confirmed cholecystitis. No postoperative complications occurred. The other four children were managed nonoperatively with intravenous antibiotics. One died, but the other three recovered fully. Twelve children had chronic AC. Sixty-seven percent were females; the age range was 7 to 18 years. All presented with chronic symptoms of right-upper-quadrant pain and nausea or vomiting. The leukocyte count and results of liver function tests were normal. Seventy-five percent had evidence of abnormal gallbladder function (noted by a radionuclide hepatobiliary scan or cholecystography). All children in this group underwent cholecystectomy, with pathological confirmation of chronic inflammation. No complications occurred, and all patients had complete resolution of symptoms. The authors conclude that AC in children occurs in two distinct patterns. The acute and chronic forms differ in their clinical setting and presentation. Cholecystectomy is effective treatment of AC, although there may be a role for nonoperative management in selected cases.

Splenic preservation in the management of splenic epidermoid cysts in children.

Splenic epidermoid cysts are a rare entity. The traditional treatment was splenectomy, performed to prevent infection, hemorrhage, or rupture of the cyst. The authors reviewed their series of 19 children with congenital splenic cysts from 1914 to 1993 to assess the change in management of these lesions. The age of time of presentation ranged from newborn to 17 years (median, 12.0 years) The male:female ratio was 1.0:1.1. Five cysts were found incidentally at the time of autopsy. The cysts were 0.5 to 24 cm in diameter (median, 12.0 cm). Only cysts greater than 8 cm presented with clinical symptoms: 64% with an abdominal mass and/or 78% with abdominal pain. One patient presented with a left varicocele. There were no complications related to the cysts. A variety of radiographic studies were performed, but ultrasonography provided all required diagnostic information. All patients treated before 1971 (n = 9) underwent splenectomy, and five patients treated since 1983 had hemisplenectomy or cystectomy. Postoperative spleen scans (obtained in three of these patients) and platelet counts showed preservation of splenic function. Pathological examination showed epidermoid cysts in all cases. There were no postoperative complications. In conclusion, in this series of epidermoid splenic cysts in children, (1) the cysts presented with an abdominal mass and/or abdominal pain only if they were greater than 8 cm in size, and there were no complications owing to the cysts; (2) ultrasonography was the most cost-effective and least invasive method of evaluation; and (3) splenic preservation by hemisplenectomy or cystectomy, used to avoid the long-term risks of splenectomy, proved to be a safe, easy procedure, with maintenance of splenic function.

Association of imperforate anus with occult spinal dysraphism.

Neurological deficits may occur in some children with imperforate anus produced by unrecognized spinal cord anomalies amenable to neurosurgical correction. Although this association has been well described, its frequency has not been defined. The authors prospectively studied 45 infants with imperforate anus from 1985 to 1992 to establish the frequency of this association. Eighteen infants (40%) had high imperforate anus, 24 had low imperforate anus (53%), and 3 had anal stenosis (7%). All underwent radiographic spinal cord imaging in early infancy, which consisted of radiographs (45), ultrasound (26), magnetic resonance imaging (29), computed tomography (1), and myelography (1). Thirty-three percent of the patients with imperforate anus had bony sacral abnormalities. Eight infants were discovered to have spinal cord abnormalities. Two of those infants had obvious myelomeningocele at birth, and 6 infants (14%) had occult spinal dysraphism consisting of tethered cord with or without associated lipoma of the cord. There was no correlation between the presence of tethered cord and the gender of the infants, the type of malformation (high versus low imperforate anus), or the presence of sacral dysplasia (Fisher's exact test). Five of the infants who were found to have tethered cord underwent neurosurgical intervention and repair of the defect, and 1 infant was followed up clinically. The mean follow-up time of all the infants was 2.5 +/- 0.9 (+/- SD) years. No neurological sequelae occurred in the infants who had surgical correction. The frequency of occult spinal dysraphism with imperforate anus was 14%. It was independent of the type of imperforate anus or the coexistence of bony sacral anomalies.(ABSTRACT TRUNCATED AT 250 WORDS)