PELVIURETERIC OBSTRUCTION IN CHILDREN: CONVENTIONAL PYELOPLASTY IS SUPERIOR TO ENDO-UROLOGY

Background : Hydronephrosis secondary to periureteric junction (PUJ) obstruction is common in infancy and childhood. Pyeloplasty has until recently been the accepted method of management, but alternative endo-urological techniques have evolved in the last decade. Methods : Published results of conventional pyeloplasty for primary PUJ obstruction in children were compared with published results of endo-urological procedures. Results : Sixty-six pyeloplasties were performed in 61 children in a 6-year period. During a similar period, 63 primary endo-urological procedures were reported in the literature. The success rate after pyeloplasty was 95.5% compared with 65% after endo-urology. Conclusions : Conventional pyeloplasty is superior to endo-urology and should remain the gold standard for the treatment of primary PUJ obstruction in children.     

VESICO-URETERIC REFLUX AND SURGICALLY TREATED PELVI-URETERIC JUNCTION OBSTRUCTION IN INFANTS UNDER THE AGE OF 12 MONTHS

Background : Pelvi-ureteric junction obstruction has been increasingly diagnosed in infants, mostly as a consequence of antenatal ultrasound examinations. Methods : Of 55 infants below the age of 12 months who underwent dismembered pyeloplasty over a 7-year period, we aimed to determine the patterns and outcome of associated vesico-ureteric reflux that was present in 15 (28%) of the 53 infants in whom follow-up was available. Results : A total of eight infants had resolution of their reflux with conservative management and the median time to resolution was 15 months. Five infants proceeded to ureteroneocystotomy. Conclusions : Given the association of vesico-ureteric reflux and pelvi-ureteric junction obstruction, routine cystography is recommended when the diagnosis of pelvi-ureteric junction obstruction is made.     

Intraoperative vascular localization to facilitate endopyelotomy after renal transplantation

Background : Pelviureteric junction (PUJ) obstruction after renal transplantation is uncommon. Surgical correction can be technically challenging due to dense perinephric adhesions and variable hilar vascular anatomy. Endopyelotomy is well established in the treatment of PUJ obstruction in native kidneys. Methods : The present paper reports the first experience of antegrade visual cold‐knife endopyelotmy performed in a renal allograft. In orientating the incision at the PUJ, preoperative imaging was supplemented by intrarenal Doppler ultrasound, using a probe designed for transoesophageal cardiac monitoring. To the authors’ knowledge this approach has not previously been reported. Results : Renal vascular relationships were readily indentified by identifying arterial and venous waveforms. Conclusions : For this uncommon procedure the use of intrarenal Doppler ultrasound provides greater security in avoiding inadvertent vascular injury.     

SURGERY OF THE HORSESHOE KIDNEY—AN EXPERIENCE OF 24 PATIENTS

A decade (1973–83) of surgical experience in the management of the diseases of horseshoe kidney is presented. Calculus disease was the major pathological entity (80%) followed by ureteropelvic junction obstruction, nephrocarcinoma and polycystic disease, respectively. Three patients with calculi had, in addition, pyonephrosis and squamous cell carcinoma. Aortography offers maximum information about abnormal vasculature and other anatomical details in proper planning of surgical intervention. It is felt that a symphysiotomy and nephropexy may be considered when the horseshoe kidneys are being operated for calculus disease.     

免疫抑制对大鼠肠梗阻早期肠菌移位的影响

为探讨肠源性感染的发生机理，将６０只ＳＤ大鼠随机均分成肠梗阻组、环磷酰胺＋肠梗阻组、环磷酰胺组和假手术组４组。回肠机械性肠梗阻２４小时后取各组鼠腹腔液、门静脉血、心脏血、肠系膜淋巴结（ＭＬＮ）和回肠末段内容物作细菌定量分析，同时测定门静脉血内毒素含量。结果显示：肠梗阻２４小时即导致门静脉内毒素血症，肠内Ｇ－杆菌大量繁殖，肠菌移位于ＭＬＮ中。免疫抑制剂环磷酰胺不仅增加肠梗阻时肠菌移位的发生率（１００％∶８０％），且使更多的肠菌存活于ＭＬＮ中并向体循环内播散。由此表明，在免疫抑制状态下肠菌经淋巴途径侵入肠外组织，在肠源性感染的发生中起着重要作用     

经皮肝穿胆道置管引流治疗恶性梗阻性黄疸

目的 了解介入治疗恶性梗阻性黄疸的疗效。方法 采用经皮肤穿刺放置内支架或外引流对32例恶性梗阻性黄疸患者进行治疗。结果 中下段胆管梗阻疗效好，治疗一周后多数患者血清胆红素下降超过50％，15天后有16例患者血清胆红素降至正常。结论 胆道介入治疗确实有良好的缓解或消除黄疸的效果，特别是中下段胆道梗阻，黄疸可完全消退，但对上段胆道梗阻的患者，仅能部分缓解黄疸，疗效不如中下段胆道梗阻患者。     

A STUDY OF THE RISK OF STRANGULATION AND OBSTRUCTION IN GROIN HERNIAS

Background : Complications that develop in groin hernias, such as irreducibility and obstruction, with or without strangulation may make an easily treatable condition a life-threatening one. Identification of risk factors that may predict development would help place the patient in a high-risk group. Priority admission and early elective surgery for such a patient would avoid significant mortality and morbidity. Methods : This is a 10-year combined prospective and retrospective study of children and adults. Records of complicated groin hernias were identified from July 1985 to July 1995 from the outpatient department and available inpatient medical records. The same number of controls of simple uncomplicated hernias were then chosen using random number tables from among the large number belonging to the same time period. These two groups were then compared and analysed using statistical methods for age, sex, side of hernia, site of hernia (inguinal/femoral), duration of hernia, length of the waiting list for elective surgery, and contents of the hernial sac along with some other parameters to identify patients with high–risk factors. Results : Age was found to be a significant risk factor and predicted complications in both elderly adults and very young children. Sex of the patient (male) and side of hernia (right) were significant risk factors in children only. Site of hernia was an important risk factor and adults with femoral hernia were most likely to experience complications. Duration of hernia for less than a year proved to be the most important risk factor for both children and adults. The majority of patients with complicated hernias had not presented earlier in the outpatient department, which implies that most hernias that become complicated do so within a very short time before patient referral. Mortality was high in patients with coexisting diseases, while morbidity was affected by viability of contents of the hernial sac which in turn was directly affected by duration of irreducibility or delay in presentation. Conclusions : The risk factors useful in predicting complications in an adult patient with groin hernia were age (older age group), duration of hernia (short duration), type of hernia (femoral more than inguinal) and coexisting medical illness. In children, the risk factors were age (very young), gender (male), short duration of hernia and side (right side).     

螺旋CT及补充B超显像在急性肠梗阻病因诊断中的价值

目的 探讨螺旋ＣＴ、补充Ｂ型超声显像在急性肠梗阻病因诊断中的作用。方法 对３０例急性肠梗阻患者术前的螺旋ＣＴ及Ｂ超显像检查资料进行综合分析。结果 螺旋ＣＴ对急性肠梗阻的病因诊断符合率为８６．７％（２６／３０）,加用Ｂ超显像弥补ＣＴ动态观察不足后,诊断正确率提高至９３．３％（２８／３０）;对耐受性差的中、老年患者优势明显,尤其对肿瘤引起的肠梗阻、肠套叠等正确率高;对肠间脓肿、肠结石症所致肠梗阻可提出     

NASOGASTROINTESTINAL INTRALUMINAL TUBE STENTING IN THE PREVENTION OF RECURRENT SMALL BOWEL OBSTRUCTION

Nasogastrointestinal intraluminal tube stenting using a Dennis tube (Sherwood Medical St Louis, Missouri, USA) was performed on 25 patients. Two intubations were for midgut volvulus, 13 for small intestinal obstruction after extensive adhesolysis, and 10 as an adjunct to the operative management of enterocutaneous fistulae following extensive adhesolysis, resection and anastomosis. No patient developed recurrent small bowel obstruction for periods up to three years after operation. Use of an intraluminal tube stent in preventing recurrent small bowel obstruction due to adhesions is safe and effective when used on appropriately selected patients. Its effectiveness should be more widely recognized.     

经内镜胆管内支架置入术对良恶性胆管梗阻的临床应用

目的探讨经内镜胆管内支架置入术对各种良恶性胆管梗阻的治疗效果。方法95例良恶性胆管梗阻病人先行内镜逆行胰胆管造影（ERCP）检查,确定胆管梗阻病变部位和性质后,再决定使用内镜下塑料胆道支架引流（ERBD）和内镜下金属胆道支架引流（EMBE）。结果95例患者中92例插管成功,成功率96.84%（92/95）。针对良性胆管梗阻行ERBD 28例,主要见于胆总管结石;针对恶性胆管梗阻行ERBD 44例,行EMBE 20例,主要见于胰头癌、胆管癌、壶腹癌、原发性肝癌及肝门、肝内转移压迫胆管,所有病例均在引流后总胆红素及直接胆红素明显下降。结论：经内镜下胆管内支架引流术的应用愈来愈广泛,其操作安全而有效,特别是对各种良恶性病变引起的胆管梗阻起了关键性的治疗作用。     

胆管恶性梗阻内镜引流术的疗效观察

目的 比较塑料内置管及金属内支架在胆管恶性梗阻引流中的疗铲。方法 全组患者１０５例,行鼻胆管或塑料内置管引流８７例次,放置金属内置管３１例次。结果 鼻胆管或塑料内置管引流组,引流有效率８２．８％,３０天死亡率１０．３％,平均通畅时间２．４月,平均生存期２．５月;金属内支架组,引流有效率９０．３％,３０天死亡率６．５％,平均通畅时间６．８月,平均生存期７．２月。结论对于胆管恶性梗阻,内镜引流术是一种     

小儿急性肾功能衰竭100例临床分析

介绍１００例小儿急性肾功能衰竭（ＡＲＦ）的病因、临床表现、实验室检查、病理及预后。肾前性１３例（１３％），肾性８６例（８６％），其中肾小球疾病６６例（６６％），肾后性１例（１％）。３１例肾活检，病理为９种类型，毛细血管内增生性肾小球肾炎（ＥｎＰＧＮ）８例（２５．８１％），系膜增殖性肾小球肾炎（ＭｓＰＧＮ）４例（１２．９０％），膜增殖性肾小球肾炎（ＭＰＧＮ）Ｉ型５例（１６．１３％），局灶节段性肾小球     

IN SITU PERFUSION BY RETROGRADE CANNULATION OF A TUMOR ARTERY FOR NEPHRON-SPARING SURGERY

Background:
Although ice slush cooling or ex situ perfusion with bench surgery is most widely used for protecting ischemic renal damage which possibly accompanies complicated nephron-sparing surgery, each has its own disadvantages. The former does not allow excessively long ischemia and the laller requires complicated procedures as autotransplantation. In order to mitigate against these problems, we devised a novel method of in situ renal perfusion with intracellular hyperosmolar solution.
Methods:
One renal segmental artery mainly supplying a tumor was isolated and cannulated with a small feeding tube. The tube was introduced through a small arteriotomy incision directed towards the proximal side, advanced until its tip remained in the main or first branch of the renal artery, and then it was anchored to that artery. After the main renal artery and vein were clamped, the kidney was perfused with cold Euro-Collins' solution through the tube, while the venous blood and perfusate were drained from the left gonadal vein or small venotomy incision of the right renal vein. Results: In one case of renal cell carcinoma and three cases of angiomyolipoma, two of which ruptured, nephron-sparing surgery was carried out under in situ hyperosmolar perfusion. Ischemic time of these four cases was an average of 96 minutes, varying from 45 to 145 minutes. All the kidneys functioned well postoperatively,
Conclusions:
The method presented here is very simple, requires no unusual dexterity and safely allows for a long period of renal ischemia. This method is best indicated in cases where simple clamping of the renal pedicle with ice-slush cooling appears insufficient, yet ex situ surgery with autotransplantation seems excessive.     

EGF IMPROVES RECOVERY FOLLOWING RELIEF OF UNILATERAL URETERAL OBSTRUCTION IN THE NEONATAL RAT

PURPOSE: Renal epidermal growth factor (EGF) is suppressed by unilateral ureteral obstruction (UUO), and we reported previously that exogenous EGF attenuates renal injury due to UUO in the neonatal rat. In this study, we wished to determine whether administration of epidermal growth factor (EGF) improves long-term renal cellular recovery after relief of obstruction. MATERIALS AND METHODS: One ureter of 1 day-old rats was occluded or sham-operated, and rats received daily injections of EGF, 0.1 mg./kg., or saline for the following 7 days. Five days following UUO, the obstruction was removed. Kidneys were removed 28 days following release of UUO or sham operation, and processed for histomorphometry and immunohistochemistry. RESULTS: Kidney weight and the number of glomeruli were reduced in the postobstructed kidney regardless of administration of EGF. However, EGF reduced tubular vimentin by 36% and clusterin expression by 70% (markers of tubular injury), and decreased tubular atrophy by 50% in the postobstructed kidney compared with saline-treated rats. EGF also reduced interstitial alpha-smooth muscle actin and interstitial collagen deposition by 50% in the postobstructed kidney. CONCLUSIONS: Short-term administration of EGF markedly attenuates both tubular and interstitial injury one month following the release of UUO in the neonatal rat. This suggests therapeutic potential for targeted delivery of growth factors to optimize recovery after release of urinary tract obstruction.     

RENAL ALLOGRAFT SURVIVAL IN PATIENTS WITH CONGENITAL OBSTRUCTION OF THE POSTERIOR URETHRA

In an attempt to clarify the influence of dysfunctional bladders on renal allograft outcome, graft survival was studied retrospectively in patients with congenital posterior urethral obstruction (posterior urethral valves). Using the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), 25 index patients were compared to all other transplant recipients of the same age range. Three instances of abnormal bladder function leading to graft function deterioration were found, therefore we would recommend investigation of bladder function in all boys with congenital urethral obstruction prior to renal transplant, and as part of the work-up of graft failure, where the cause is otherwise not obvious.     

A PROSPECTIVE STUDY ON THE USE OF WATER-SOLUBLE CONTRAST FOLLOW-THROUGH RADIOLOGY IN THE MANAGEMENT OF SMALL BOWEL OBSTRUCTION

Background: The purpose of this prospective study was to determine the value of water-soluble contrast follow-through radiology in predicting the outcome in patients with small bowel obstruction. Methods: Patients with clinical and radiological evidence of small bowel obstruction were selected according to pre-set criteria. A water-soluble contrast follow-through examination using 76% urografin was carried out within 24 h of hospital admission. The result was interpreted as ‘significant obstruction’ if the contrast failed to reach the caecum in 4 h or if there was a clear cut-off in the gastrointestinal tract. The result was interpreted as ‘insignificant obstruction’ if the contrast reached the caecum within 4 h. The surgeon was blinded to the result of the contrast examination in the patient management, and the decision to operate was based entirely on conventional clinical grounds. Results: Fifty-one patients in an 18 month period underwent the contrast examinations. Thirty-four patients (67%) had had previous abdominal operations. The results showed that significantly more patients who had ‘significant obstruction’ on contrast radiology required surgery to relieve the intestinal obstruction (17/19) than those who had ‘insignificant obstruction’ (1/32; Fisher's exact test, P < 0.0001). This difference was found to be significant in both patient subgroups: patients with or without previous abdominal operation. There was no major morbidity or mortality related to the contrast radiology procedure. Conclusions: Urografin follow-through examination is a safe procedure; using 4 h as the cut-off it is highly predictive of the outcome in small bowel obstruction in patients with or without previous abdominal operation.     

THE COST OF ELECTIVE AND EMERGENCY REPAIR OF AAA IN PATIENTS UNDER AND OVER THE AGE OF 80

Background : As Australia’s population ages, the number of elderly patients presenting for surgery of abdominal aortic aneurysms (AAA), both elective and ruptured, will increase. The aim of the present study was to compare the costs of treatment of patients with AAA, under and over the age of 80, in the elective and emergency settings in a hospital with a divisional structure in which the true costs can be accurately obtained. Methods : A total of 40 patients were selected at random from a series of 267 patients treated with open surgery for AAA between January 1987 and December 1994, 10 in each of four groups: group A, elective repair in patients aged < 80 (171/267); group B, elective AAA repair in patients aged > 80 (25/267); group C, emergency AAA repair in patients aged < 80 (50/267); and group D, emergency AAA repair in patients aged > 80 (11/267). A retrospective analysis of the hospital costs of treatment of these patients at St George Hospital was conducted. These true costs were then compared to Australian National Diagnostic Related Group (AN-DRG) costs. Results : Group A and B had no mortality. In Group C and D the mortality was 20 and 60%, respectively. The emergency treatment groups also had longer lengths of stay. A statistically significant difference in cost of AAA repair between elective and emergency groups in both age groups was seen; that is, group A cost less than group C and group B cost less than group D. Costs per survivor, however, showed a dramatic difference between the cost of group C patients ($30 000) and group D patients ($60 000). In comparison with AN-DRG calculated costs, the true costs of groups A and B were equivalent to AN-DRG costs. In the emergency groups, how- ever, there were marked discrepancies between the true cost ($61 000) and that calculated by the DRG ($25 000) in group D, with similar differences seen in group C to a lesser extent. Conclusion : Emergency repair of AAA is significantly more expensive and has a high mortality in the over-80 age group. Also, there is a substantial shortfall between the true costs of treating these patients and the funds allocated for treatment in this group.     

RECOVERY PERIOD FROM URETERAL OBSTRUCTIONS OF DIFFERENT DURATION AND SEVERITY IN THE RAT KIDNEY

The relationship between the period for recovery from hydronephrosis and the characteristics of the obstruction still needs to be clarified. In rat kidney the left ureter was completely obstructed for 3, 7, 14 and 21 d and the renal function was measured by renal scintigraphy using ^99mTC-dimercaptosuccinic acid 3, 7 and 14 d after the obstruction was removed. In addition, recovery from unilateral partial obstruction (PO) of different degrees of severity for 7 d was examined. The kidneys with very mild PO recovered within 3 d and those with a very long period of complete obstruction (CO) did not exhibit any significant recovery. However, most of the kidneys with CO of various durations and those with 7 days' PO of various degrees of severity exhibited maximum recovery 7 d after the release of the obstruction. This study suggests that the period required for maximum recovery from hydronephrosis is usually constant, unless the obstruction is too mild to cause any damage or too long to permit any recovery.