Progress in pediatric surgery最新文献

In a retrospective survey of vascular access by means of central venous catheters, those inserted via a tunnel lasted four times longer than those inserted directly into a vein. The latter were four times more likely to become infected. The general health of patients receiving chemotherapy resulted in frequent episodes of sepsis and one-third of all catheters were removed because of presumed infection. There were no complications relating to insertion, which was by direct exposure of a central vein, preferably the right internal jugular. Long-term atrial catheters were not associated with major venous thrombosis or cardiac complications. Safe vascular access is an important contribution to the management of children with malignant disease, notwithstanding the high infection rate. A specially trained nurse, working closely with experienced play leaders and social workers, minimises the technical and psychological problems associated with long-term central venous catheters.

Over a 33-month period, 31 infants and children had surgery for neuroblastoma. Twenty-three of the total had stage IV disease at the time of presentation and all but five had an abdominal primary tumour. In only two children was the tumour considered unresectable. The operative mortality was 3%. Neither ultrasound nor CT scanning could accurately predict resectability.

Now that reconstructive surgery has taken the exstrophy and epispadias patient beyond the stage of merely saving life and even preserving bladder function, it is essential that proper attention is paid to the penis. Careful surgery in early life may well give a good cosmetic appearance during the important years of schooling. It may also produce a penis with a satisfactory angle of erection for sexual intercourse. In those patients who are not so fortunate in infancy or who were born before the era of modern reconstructive surgery, careful assessment must be made at an appropriate time as the patient goes through puberty. The commonest erectile deformity found in epispadias in adult life is tight dorsal chordee. Surgical correction is required. In some patients, adequate correction will be achieved by clearance of superficial pericorporeal scar tissue, possibly aided by Nesbit's procedure. For the remainder, formal correction of the chordee is required. This is best done by the insertion of a gusset of dura or other material to lengthen the concave side of the curve.

Can a single kidney survive for a normal life span? This is the type of question frequently asked by patients and especially by parents of children who lose one kidney in early childhood. Based on our wide experience with single-kidney rats, we will try to give an answer to this question. After the removal of its counterpart, the single remaining kidney will rapidly adapt to the new situation by a compensatory increase in the glomerular filtration rate (GFR) and renal mass. This is true not only for intact kidneys but also for damaged ones. The GFR level obtained by damaged kidneys will be less than that of intact single kidneys, however, depending on the degree of initial damage. The GFR is stable for a certain period of time, which is longer for intact single kidneys than for damaged kidneys and also depends on the daily protein intake; after that renal function will deteriorate. This decline in GFR is preceded by a marked increase in urinary protein excretion. Although the follow-up period is not completed yet, the survival time of single intact kidneys in rats on a normal diet is expected to be 15%-20% less than the normal rat life span. In rats on a lifelong high protein intake the kidney survival time drops to 40% below the normal rat life span. In rats on a moderately reduced protein intake, however, single intact kidneys may survive for a normal life span. The situation is worse for single damaged kidneys. Depending on the severity of the initial damage, kidney survival time will be much less than a normal life span. We studied rats with an initial recovery to 75% of renal function. Despite this initial recovery, the animals died of renal failure within 50% of the expected life span. A low-protein diet prolonged the renal survival by about 12%, a high-protein diet shortened it by the same percentage.

This is a report on the follow-up data of 18 patients with posterior urethral valves diagnosed during the first year of life. One infant died of progressive renal failure; a slight elevation of serum creatinine levels in three children aged 4-6 years indicated a doubtful prognosis. On initial examination, ten patients showed severe unilateral or bilateral reflux. Seven of 14 refluxing units remained non-functioning and had to be removed. Following transurethral fulguration of the valves, five infants developed unilateral or bilateral reflux which was not evident on initial preoperative voiding cystograms. In contrast to those in other series, none of these refluxes ceased spontaneously. Ureteral reimplantations were done on 11 ureters of eight patients, but regression of ureteral dilatation postoperatively remained unsatisfactory in six instances, none of whom had a true mechanical obstruction. We conclude that many of these megaloureters encountered in infants with posterior urethral valves are concomitant with profound and often irreversible damage of the ureter wall. Surgery of such ureters, therefore, should be avoided whenever feasible.

In the period between 1980 and 1985 101 one-stage repairs for distal hypospadias were carried out. Fifty-five patients were operated on using the Magpi technique as originally described by Duckett (1981). The hypospadias of the remaining 46 patients were corrected using a modification of this technique incorporating reconstruction of the foreskin. The technique of the modified, prepuce-preserving operation is described. Despite complications such as moderate meatal stenosis, fistulae and glandular-meatal as well as foreskin dehiscence, the overall functional and cosmetic results were very good.

Depending on the underlying disease, children with solitary kidneys who have to undergo urological operations have the same good or poor prognosis as children with two kidneys (Whiting et al. 1983; Redman and Birsada 1976; Stackl et al. 1983). However, the problem of long-term prognosis persists. It is similar to that for children who have undergone surgery for reflux: a certain number of them will develop renal insufficiency in 20-30 years. Nephrologists estimate that 20% of adults who suffer from renal insufficiency and become dialysis dependent formerly had reflux nephropathy. The influence of reimplantation, performed with good results during the past few years, cannot be assessed so far. Large prospective studies are needed.

Within a 10-year period reconstructive urinary tract surgery has been carried out in eight children with solitary kidneys. The children were 0-5 years old. Six had unilateral renal agenesis and two had unilateral multicystic kidney. In five children ureteroneocystostomy was performed, in two of them because of reflux. In two children pyeloureteroplasty was performed, and in one both ureteroneocystostomy and pyeloureteroplasty. The multicystic kidneys were removed. The renal function was poor preoperatively in five children; two of these also had urosepsis. These children were all under 15 months of age. Postoperatively, the renal function was subnormal (although improved) in two children; in six it was normal. The most important prognostic factors in solitary kidneys with urinary tract obstruction are infection and developmental injury.