Bench surgery and renal autotransplantation in the pediatric patient.

A new operative procedure in renal surgery has evolved from the extensive recent experience in kidney transplantation. Bench surgery and autotransplantation have not been, as yet, fully exploited by surgeons caring for children. This approach to reconstruction of renal substance and renal vessels has as its greatest dividend conservation of kidney tissue. The operation has specific applicability for selected cases of: (1) renovascular hypertension; (2) congenital obstructive uropathy; (3) bilateral Wilms' tumor, and; (4) renal trauma in children.     

Das stumpfe Nierentrauma — operative oder konservative Therapie? Ein Beitrag zur Klassifikation

There is consensus concerning the management of minor (Grade I) and critical (Grade III) renal trauma, while the management of Grade II-lesions is contradictory. 48 consecutive cases of renal trauma were evaluated in order to define more exactly the indications of operative and non-operative therapy. As a diagnostic approach sonography and computerized tomography were added to urine examinations and intravenous pyelography, while angiography is only used when surgical intervention is expected. As therapeutic regimen for the intermediate group of Grade II b-lesions we recommend expectant management with “delayed urgency”. This concept is based on a more differentiated classification particularily of major injuries (modified from Hodges and Lutzeyer). The importance of short-time clinical, sonographic and CT-control is underlined. Deterioration of clinical condition, associated injuries or preexistant renal anomalies are indicating delayed operation. Emphasizing the intermediate group within major injuries between expectant conservative and operative management (about 5–10%) the main controversial issues are presented.     

Acute diaphragmatic injuries

A 5-year experience with 43 patients with acute diaphragmatic injuries is reviewed. Thirty-three of the patients had penetrating trauma, and 10 suffered blunt trauma. All but 1 of the patients had associated intraabdominal trauma. Fifteen had traumatic diaphragmatic hernia at the time of operation. The operative approach was uniformly through the abdomen. Mortality and morbidity were directly related to the number of associated organs injured.Chest roentgenograms in 26 of the 43 patients were interpreted as suspicious or diagnostic of diaphragmatic injury when presented as unknowns to fully trained radiologists, but only 7 of these were originally so interpreted.Delay in operation was a significant contributing factor to morbidity, particularly in patients with thoracic stab wounds. Guidelines suggested to prevent delay include: (1) increased awareness of the possibility of acute diaphragmatic injury, (2) careful evaluation of the plain chest roentgenogram and liberal use of appropriate contrast studies when indicated, (3) prompt repair of recognized diaphragmatic injuries, (4) laparotomy as the operative approach in the acute injury, and (5) appropriate contrast studies after recovery from massive thoracoabdominal trauma and prior to hospital discharge.     

Renal injuries caused by external blunt trauma. Moderate approach to serious injuries

The records of 65 patients with renal injuries caused by external force were reviewed. Careful clinical observation and serial radiologic examinations permitted the separation of patients into two groups, major and minor renal injuries; the former were usually treated surgically and the latter, conservatively. Purposeful delayed operation for serious renal trauma caused by blunt external force possesses many of the advantages of immediate surgical intervention, but does not require preliminary pedicle control or emergency arteriography. Immediate surgical repair, delayed purposeful secondary operation, and conservatism all may be employed to advantage depending on individual circumstances.     

Transposition of the ureter as a technique for permitting reversible external ureteral obstruction

A model for reversible external ureteral obstruction has been developed in the dog by transposing the ureter into a pedicle skin flap. Advantages of this model include: (1) the facility for repetitive, reversible obstruction to the ureter by external means not requiring anesthesia or operation, (2) the potential for partial obstruction, and (3) the absence of any restriction to the animals activities or the need for special protection of the pedicle skin flap.     

Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center

PURPOSE: In the last 20 years the management of high grade, blunt renal trauma at our institution has evolved from primarily an operative approach to an expectant nonoperative approach. To evaluate our experience with the expectant nonoperative management of high grade, blunt renal trauma in children, we reviewed our 20-year experience regarding evaluation, management and outcomes in patients treated at our institution. MATERIALS AND METHODS: We retrospectively studied all patients sustaining renal trauma between 1983 and 2003. Medical records were reviewed for mechanism of injury, assigned grade of renal injury, patient treatment, indications for and timing of surgery, and outcome. Injuries were categorized as either low grade (I to III) or high grade (IV to V). RESULTS: We reviewed the medical records of 164 consecutive children who sustained blunt renal trauma between 1983 and 2003. A total of 38 patients were excluded for inadequate information. Of the remaining 126 children 60% had low grade and 40% had high grade renal injuries. A total of 11 patients (8.7%) required surgical or endoscopic intervention for renal causes, including 2 for congenital renal abnormalities and 1 for clot retention. Eight patients (6.3%) required surgical intervention for isolated renal trauma, of whom 2 (1.6%) required immediate surgical intervention for hemodynamic instability and 6 (4.8%) were treated with a delayed retroperitoneal approach. Only 4 patients (3.2%) required nephrectomy. All patients receiving operative intervention had high grade renal injury. CONCLUSIONS: Initial nonsurgical management of high grade blunt renal trauma in children is effective and is recommended for the hemodynamically stable child. When a child has persistent symptomatic urinary extravasation delayed retroperitoneal drainage may become necessary to reduce morbidity. Minimally invasive techniques should be considered before open operative intervention. Early operative management is rarely indicated for an isolated renal injury, except in the child who is hemodynamically unstable.     

Ultrastructural integrity of human ventricular myocardium following cardioplegic arrest.

The appearance of the ventricular myocardium in 6 patients electing coronary bypass operation was evaluated by electron microscope before and after aortic cross-clamping. Bypassing protocol included the induction of hypothermic cardioplegia by intermittent aortic root perfusion, with potassium chloride added to cold blood serving as the cardioplegic agent. Cross-clamp intervals ranged from 66 to 125 minutes. Ultrastructural alterations following bypass manipulations, and distinct from those observed before cross-clamping, were limited to the presence of extensive myocardiocytic pooling of glycogen. Scrutiny of the intramyocardial capillary bed following perfusion with the cardioplegic solution revealed no abnormalities attributable to, or intensified by, the bypass maneuver. These findings indicate that hypothermic potassium cardioplegia, as specified, is not injurious to human myocardial ultrastructure.     

Mesenteric venous thrombosis in two women taking oral contraceptives

2 cases of mesenteric venous thrombosis in women taking oral contraceptives (48-year old gravida 5 taking norethindrone with mestranol for 10 years, a 33-year old gravida 2 taking Enovid and C-Quens since 1962 followed by norethindrone with mestranol 1 month prior to admission) were treated at the Jewish Hospital of St. Louis. Both patients had acute abdominal pain, vomiting, and bloody and diarrheal stools. In order to remove nonviable portions of the bowel which are viable at initail operation, 2 operations are necessary in the treatment of mesenteric venous thrombosis. Both of these patients underwent 2 operations and both had extensive segments of bowel removed. The post-operative courses of both patients were long (85 and 40 days respectively) and difficult. No predisposing or etiologic factor could be determined in either patient. A relationship of mesenteric venous thrombosis to oral contraceptives is suggested, but no definite causal relationship can be established.     

Grade 4 renal injury: current trend of management and future directions

The management of blunt renal trauma has been evolving. The past management largely based on American Association for Surgery of Trauma (AAST) grading system, i.e. necessitated a computed tomography (CT)scan. Although the CT scan use is increasing and becomes the standardized mode of investigation, AAST grading no longer plays the sole role in the decision of surgical interventions. Two case reports of blunt renal trauma managed successfully by conservative methods are presented.Case one was an 18 year-old boy who had a fall when riding a motorbike at 20 km/h with a helmet and full protective equipments. He was landed by his left flank onto a rock.Contrast abdominal CT revealed a 4 em, grade Ⅲ splenic tear and a grade Ⅳ left kidney injury with large perirenal haematoma. His international severity score (ISS) was 34.He was managed conservatively with bed rest and frequent serum haemoglobin monitoring. Subsequent CT with delayed contrast revealed stable perirenal haematoma with urine extravasation which was consistent with a grade Ⅳ renal injury. Case two was a 40 year-old male who had a motor bike accident on a racetrack when he was driving at 80 to 100 km/h, wearing a helmet. He lost control and hit onto the sidewall of the racetrack. Contrast abdominal CT revealed a grade Ⅳ left renal injury with a large urine extravasation. His renal injury was managed conservatively with interval delayed phase CT of the abdomen. A repeat CT on abdomen was performed five months after the initial injury which revealed no residual urinoma.In this study, moreover, a review of the literature to the management of blunt renal trauma was conducted to demonstrate the trend of increasing conservative management of such traumas. Extra radiological parameters may guide future decision making. However, the applicability of data may be limited until randomized trials are available.     

Late Patency of the Internal Mammary Artery as a Coronary Bypass Conduit

From January, 1972, through August, 1977, 472 patients had internal mammary artery (IMA) coronary bypass, of which 100 were double-IMA bypasses. We selected those patients having a widely patent IMA one year postoperatively who then had a second catheterization 49 to 105 (mean, 64) months following operation. None of the 93 patients who met these criteria was specifically recalled for this study; they all had follow-up catheterizations for multiple other reasons. All of the 91 left IMA and 22 right IMA bypasses (total, 113) were patent at late catheterization, but 1 right IMA was diffusely narrowed. One left IMA had acute angulation with 50% stenosis proximal to the distal anastomosis, which was unchanged over the follow-up interval. There were 100 patent saphenous vein bypasses at one year and 87 at late catheterization.Late closure of coronary bypass grafts is secondary to progression of coronary disease, atherosclerosis of the bypass conduit, or intimal proliferation. Because we have not encountered the latter two causes of conduit closure, IMA grafts remain our graft of choice for nonemergent operations in patients under 60 years of age having revascularization of the left anterior descending coronary artery system.     

Intraoperative myocardial protection: a comparison of blood and asanguineous cardioplegia

Cardiac arrest was achieved in 84 patients using asanguineous cardioplegia and in 97 patients using cold blood potassium cardioplegia. The patient groups were similar in age, sex ratio, and preoperative risk factors. Other than the cardioplegic solution used, the conduct of each operation was identical. There were no differences in mean total pump time (118 minutes for the asanguineous cardioplegia group versus 117 minutes for the cold blood cardioplegia group) or cross-clamp time (73.5 versus 70 minutes, respectively). However, the blood cardioplegia group had a greater number of distal anastomoses per patient (3.9 versus 3.7; p less than 0.05). Myocardial protection was assessed clinically and by serial electrocardiograms. Cellular integrity was determined by release of the myocardial isoenzyme of serum creatine kinase (CK-MB). Cellular morphology was studied in 6 randomly selected patients in each group by electron microscopic examination of left ventricular myocardial samples obtained before and after bypass. Three patients given blood cardioplegia and 5 given asanguineous cardioplegia required intraaortic balloon counterpulsation at termination of bypass. There were no ultrastructural changes in either group. Electrocardiographic changes (Minnesota code) occurred in 12 of 84 patients receiving asanguineous cardioplegia versus 12 of 97 patients receiving cold blood potassium cardioplegia. To maintain a satisfactory cardiac index (greater than 2.0 L/min/m2), 38 of 84 patients given asanguineous cardioplegia versus 25 of 97 patients given blood cardioplegia required inotropic support up to 24 hours postoperatively (p less than 0.05). Infarct size determined from CK-MB release was significantly greater (p less than 0.05) in patients given asanguineous cardioplegia (36.27 gm-equivalents) than in those given blood cardioplegia (26.7 gm-equivalents).(ABSTRACT TRUNCATED AT 250 WORDS)     

Considerations in extrathoracic reconstruction for disease of the branches of the aortic arch

The effectiveness and decreased morbidity and mortality of extrathoracic reconstruction for disease of branches of the aortic arch has been reported by several workers; however, there has been relatively little discussion in the literature in regard to designing the operation to correct the pathophysiologic process of the disease (embolism versus flow reduction). The technique of reconstruction should be selected with regard to a patient's symptoms and arteriographic findings, with embolic phenomena more likely in patients with cerebral hemispheric symptoms and arteriographic stenosis rather than total occlusion. Simple bypass for suspected proximal embolic disease is inadequate.     

Isolated renal vein thrombosis after blunt trauma

Renal vein thrombosis typically occurs in the setting of nephrotic syndrome, tumor thrombus, primary retroperitoneal processes with vein compression, oral contraceptive use, steroid therapy, transplanted kidney, or trauma. Trauma-induced renal vein thrombosis usually presents in combination with renal arterial or parenchymal injury. We report a case of isolated renal vein thrombosis secondary to blunt abdominal and flank trauma. The diagnosis was made with computed tomography, which revealed a filling defect in the affected renal vein and persistent nephrogram on delayed images. In general, conservative management is the preferred treatment approach with anticoagulation.     

Changes in alpha-adrenergic receptors in dog livers during endotoxic shock

The effects of endotoxin administration on alpha-adrenergic receptors in dog liver plasma membranes were studied using [3H]dihydroergocryptine as a radioactive ligand. The Scatchard analysis revealed a two-component binding characteristic both in control and endotoxin-injected dogs. The Kd (dissociation constant) of the high-affinity component was increased by 32.5% (0.4 +/- 0.04 nM for control vs 0.53 +/- 0.06 nM for endotoxic; P less than 0.05) with no significant change in the Kd for the low-affinity component (3.0 +/- 0.44 nM for control vs 3.4 +/- 0.44 nM for endotoxic) 2 hr following endotoxin administration. The maximum binding capacity of the high-affinity component was decreased by 38.1% (460 +/- 19.3 and 285 +/- 14.8 fmole/mg protein for control and endotoxic, respectively; P less than 0.01) and that of the low-affinity component was decreased by 34.2% (1050 +/- 66.4 and 690 +/- 44.6 fmole/mg protein for control and endotoxic, respectively; P less than 0.05) 2 hr after endotoxin injection. The competitive inhibition studies show that the apparent Kd values for (-)-epinephrine, (-)-norepinephrine, and prazosin were increased 15, 13, and 25 times, respectively, with no significant change in the apparent Kd values for yohimbine or phentolamine 2 hr postendotoxin. These data demonstrate that the binding affinity of the high-affinity component and the number of alpha-adrenergic receptor binding sites were decreased in endotoxic shock. A modification of the alpha-adrenergic receptors in dog livers induced by endotoxin administration may play an important role in the development of hepatic glucose dyshomeostasis during shock.     

Reconstructive valve surgery.

Despite continued refinement of heart valve prostheses, valve replacement carries risks of thromboembolic, mechanical, and infectious complications, and long-term success is further limited by the eventual wear of prosthetic parts. In many patients with congenital or acquired valve diseases, valve function may be improved, if not restored, by reconstructive techniques, prosthetic replacement being thereby avoided or delayed. This review examines the current status of reconstructive procedures for management of diseased valves, with emphasis on long-term results and post-operative hemodynamic studies. In many instances the choice between reconstruction and replacement of a diseased valve remains controversial. The documented success of selectively applied reconstructive techniques, however, weighs against expedient decisions for prosthetic replacement and supports a continuing search for new techniques.     

An experimental evaluation of nucleotide enhancement techniques for kidney transplantation

The effect of various nucleotide-enhancing agents on renal function and intracellular nucleotide levels was evaluated in a canine autotransplant model. Thirty-five dogs (18-28 kg) underwent left nephrectomy and 30 min of warm ischemia followed by Collins C-4 flush and 24 hr of cold-storage preservation. Heterotopic autotransplantation and immediate contralateral nephrectomy was then performed. Seven equal groups were evaluated: group A--controls, group B--adenosine pretreatment (1.0 g), group C--dipyridamole pretreatment (10 mg), group D--adenosine (1.0 g), and dipyridamole (10 mg) pretreatment, group E--adenosine (200 mg) and EHNA (2.5 mg/kg) pretreatment, group F--adenosine (200 mg) and EHNA (2.5 mg/kg) in the Collins C-4 flush, and group G--adenosine (200 mg) and EHNA (2.5 mg/kg) at the time of autotransplantation. All kidneys underwent cortical biopsies at the end of preservation and 1 hr after restoration of blood flow for determinations of AMP, ADP, and ATP. In the pretreatment groups (groups B through E) there was 60% graft survival whereas the controls (group A) and the groups treated after ischemia (groups F and G) had 0, 0, and 20% graft survival, respectively. In groups B and E, ATP levels were greater than controls after preservation and 1 hr after restoration of blood flow. Group C AMP and ADP levels and group D energy charge were greater than controls in the post-transplantation biopsies. Administration of adenosine and EHNA after ischemia was not associated with increased intracellular nucleotide levels. One hour post-transplantation biopsies demonstrated greater ability to regenerate cortical nucleotides in the surviving animals but no absolute value could be identified as a predictor of viability. In conclusion, pretreatment with adenosine, dipyridamole, and EHNA alone and in combination is beneficial in ischemically injured kidneys undergoing cold-storage preservation.     

Renal trauma in the multiple injured patient.

Immediate radiological evaluation of renal injuries by a large dose or infusion excretory urogram resulted in a definitive diagnosis in 87% of the cases. Further radiological evaluation or exploration was required to make a definitive diagnosis in the remaining 13%. Blunt external trauma was responsible for 94% of the renal injuries. Less morbidity and a sharp reduction in delayed renal operation followed the introduction of immediate surgical management with the more severe types of renal injury. Clamping of the renal vessels prior to opening Gerota's fascia prevents reactivation of hemorrhage and allows for a deliverate operation with conservation of undamaged renal tissue. Associated injuries were present in 73% of the patients, including intra-abdominal injuries in 42%. The over-all nephrectomy rate of 5% in this study compares favorably to the nephrectomy rate in studies reporting the expectant management of renal injuries.     

Intestinal perforation due to blunt trauma in children in an era of increased nonoperative treatment

Over the past decade, nonoperative management of most pediatric blunt abdominal trauma has emerged as accepted practice. It is possible that treatment of associated hollow visceral disruption might be missed or delayed because of this nonoperative approach. In a review of all cases of intestinal perforation from blunt trauma seen over the past 6 years, we found 12 cases of intestinal disruption in more than 600 cases of significant blunt trauma. Child abuse caused eight cases and four were motor vehicle related (MVR). Seven of eight battered children had a delay of more than 48 hours from injury to hospital presentation. Three of four MVR patients had an 18-hour delay from injury to operation. Ten of 12 patients survived. The two children who succumbed were both battered and were moribund and unstable when first seen and failed to respond to aggressive stabilization and surgery. Serial physical examinations, contrast radiographic studies, and peritoneal lavage were the most helpful diagnostic modalities. There were no significant complications and no patient required more than one operation (except for ostomy closure). All surviving patients are well at followup and seven of ten have been followed for more than 3 years; two are not yet 1 year from surgery and one is lost to followup. Several principles have emerged from this review: 1) motor vehicle trauma and child abuse are the major etiologic factors in childhood blunt trauma; 2) accurate and rapid diagnosis of intestinal perforation in children is difficult; 3) recovery in the presence of stable vital signs can be expected, even with the long delays; and 4) abused children must be carefully evaluated for abdominal trauma.     

Cimetidine inhibits burn edema formation

Large doses of cimetidine significantly inhibit edema formation in thermally injured rat skeletal muscle. Tissue sodium influx and potassium efflux is also sharply restricted. These effects were obtained even if the administration of cimetidine was delayed for up to 4 hours after injury, but no beneficial effect occurred if drug administration was delayed for 14 hours, when most of the edema had already accumulated. The minimal effective dose is between 0.1 to 0.2 mg/gm.     

Major renal injuries in children: the real incidence of kidney loss

Background: The prognosis of major renal injuries appears to have improved since a conservative approach has been promoted. The overall prognosis might be less optimistic if all cases are pooled, whatever the type of initial injury (parenchymal or vascular) or the type of treatment (operative or conservative). Methods: The records of 32 children were reviewed. Six patients had a vascular injury, and 26 had a parenchymal injury. Ten were operated on within one month after trauma, and 3 (including one previously operated) underwent delayed surgery for sequelae. Parenchymal loss from atrophy was estimated on echography, computerized tomography, or radionuclide scintigraphy. Results: Fourteen patients (44%) recovered a functioning kidney. Nine (28%: all 6 patients with vascular injury and 3 with parenchymal trauma) lost their kidney from nephrectomy (n = 3) or atrophy (n = 6). Seven patients had severe or moderate sequelae from either partial nephrectomy or partial atrophy. Two had a minimal loss from polar hypotrophy. The incidence of kidney loss or sequelae was 56% (18 of 32 patients). Conclusion: In keeping with the literature data provided all cases are analyzed, at least one out of 4 kidneys will be lost or severely damaged after major kidney trauma in children. J Pediatr Surg 37:1446-1450.