Pattern of poisoning in a developing agricultural country

Four hundred and seventy-two cases of poisoning were seen over a two-year period in Kandy, Ceylon. The overall mortality was 23·7%. The pattern of poisoning was different from that in western countries in that 49·8% of the cases were due to insecticide poisoning and only 10·7% were due to drugs, including barbiturates. Insecticides accounted for 73·2% and drugs for only 4·5% of the 112 fatal cases. Of the fatal cases 51·7% were between the ages of 20 and 40 years and only 6·2% were over 50 years. The wastage of economically useful lives indicates the need for a poison centre.     

Postnatal development of the mucosal plexus in the porcine small and large intestine

Knowledge regarding the foetal and postnatal development of the enteric nervous system is crucial for the understanding of congenital disorders. While lot of information exists regarding the myenteric and submucosal plexuses, the development of the mucosal plexus has not been previously studied. The mucosal innervation seems to play an important role in the local reflex activity of the gut. In this study, we examined the development of enteric mucosal innervation in the pig at various ages of life. Small and large bowel paraffin-embedded specimens were stained with PGP 9.5 and neurofilament protein in three piglets from six age groups (60 and 90 days gestation, newborn, 4 and 12 weeks old, and adult pigs). Small and large bowel demonstrated identical innervation patterns. Myenteric and submucosal plexuses were stained with PGP 9.5 at 60 days gestation. However, the mucosal staining was first noted clearly at the newborn period. By 4 weeks, PGP 9.5 staining was noted in small amounts within the mucosa. Inner proprial and villous fibres were seen ahead in time to the subepithelial fibres. Both inner proprial and villous staining became quiet prominent by 12 weeks of age and remained unchanged into adulthood. However, the subepithelial fibres appear to increase in adulthood. This study demonstrates for the first time that enteric mucosal innervation first appears only at birth. The immaturity of the mucosa generated reflex activity, and secretory functions may have implication in the management of functional intestinal obstruction in the premature infant.     

Experience with aortic grafting during excision of large abdominal neuroblastomas in children

Background

Total or near total resection of high-risk, stage 4 abdominal neuroblastoma has been correlated with improved local control and overall survival but may be complicated by vascular injury. We describe our experience in the management of significant aortic injuries during this procedure.

Methods

With the institutional review board waiver, medical records of children who had major abdominal aortic reconstruction during neuroblastoma resection from 1996 to 2006 were retrospectively reviewed.

Results

There were 5 children with aortic grafting: 3 girls and 2 boys. Mean age at surgery was 7.2 years (range, 16 months to 17 years). Two children were operated on for recurrent retroperitoneal disease. Tumor encasement of the aorta was seen in all children. In 3 children, the injury occurred during dissection of paraaortic and interaortocaval lymph nodes below the level of the renal arteries. In the remaining 2 children, injury occurred early during mobilization of the tumor. Three polytetrafluoroethylene tube grafts and 1 on-lay patch graft were used to repair the 4 distal aortic injuries. One 4-year-old female with aortic and renal arterial injuries was managed with an aortic Dacron tube graft and a polytetrafluoroethylene tube graft for the renal artery. The mean period of follow-up is 28 months after aortic graft (range, 3 months to 10 years). Total colonic ischaemia, transient acute tubular necrosis, and duodenal perforation were seen in one child, who needed subtotal colectomy and ileostomy. Another child with an omental patch over the graft had a transient duodenal obstruction, which was managed conservatively. There were no other complications, and 4 of the 5 children are disease-free to date. One child at 10 years after his distal aortic tube graft remained asymptomatic with normal distal blood flow on magnetic resonance angiogram and with normal growth.

Conclusion

The neuroblastoma surgeon should be prepared to perform aortic and vascular reconstruction. Aortic encasement, preoperative radiation therapy, and reoperative surgery were observed in these patients and may be risk factors.     

Transplantation for type I diabetes: comparison of vascularized whole-organ pancreas with isolated pancreatic islets

OBJECTIVE: We sought to compare the efficacy, risks, and costs of whole-organ pancreas transplantation (WOP) with the costs of isolated islet transplantation (IIT) in the treatment of patients with type I diabetes mellitus. SUMMARY BACKGROUND DATA: A striking improvement has taken place in the results of IIT with regard to attaining normoglycemia and insulin independence of type I diabetic recipients. Theoretically, this minimally invasive therapy should replace WOP because its risks and expense should be less. To date, however, no systematic comparisons of these 2 options have been reported. METHODS: We conducted a retrospective analysis of a consecutive series of WOP and IIT performed at the University of Pennsylvania between September 2001 and February 2004. We compared a variety of parameters, including patient and graft survival, degree and duration of glucose homeostasis, procedural and immunosuppressive complications, and resources utilization. RESULTS: Both WOP and IIT proved highly successful at establishing insulin independence in type I diabetic patients. Whole-organ pancreas recipients experienced longer lengths of stay, more readmissions, and more complications, but they exhibited a more durable state of normoglycemia with greater insulin reserves. Achieving insulin independence by IIT proved surprisingly more expensive, despite shorter initial hospital and readmission stays. CONCLUSION: Despite recent improvement in the success of IIT, WOP provides a more reliable and durable restoration of normoglycemia. Although IIT was associated with less procedure-related morbidity and shorter hospital stays, we unexpectedly found IIT to be more costly than WOP. This was largely due to IIT requiring islets from multiple donors to gain insulin independence. Because donor pancreata that are unsuitable for WOP can often be used successfully for IIT, we suggest that as IIT evolves, it should continue to be evaluated as a complementary alternative to rather than as a replacement for the better-established method of WOP.     

Developmental changes of the adrenergic network in the myenteric plexus of the porcine small bowel

Knowledge about the foetal development of the normal enteric nervous system (ENS) is crucial for the understanding of congenital and acquired functional abnormalities of the gut. The ENS is the largest and most complex division of the peripheral nervous system and consists of intrinsic and extrinsic components. Although previous studies have described sympathetic innervation of the myenteric plexus, little is known regarding its age-related changes. The aim of this study was to investigate the age-related changes in the sympathetic innervation of the myenteric plexus. Whole mount and paraffin sections of the small bowel specimens from six different age groups (60 and 90 days gestation; newborn; 4 and 12 weeks old; and adult) were stained using tyrosine hydroxylase immunohistochemistry. Specimens were then analysed using fluorescence and laser scanning microscopy in detail. The tyrosine hydroxylase positive nerve fibres were first seen within the myenteric plexus at 90 days of gestation (E90). There was a significant increase in nerve fibres and varicosities observed from E90 to 12 weeks of age and stabilisation thereafter. The degree of varicosities around the ganglia, clearly seen on the whole-mount preparations, was also noted to increase up to 12 weeks of age, after which time there was no general variation noted into adulthood. Our findings show, for the first time, that sympathetic innervation of the myenteric plexus starts in the last quarter of gestation and continues till 12 weeks of age. Segmental sympathetic denervation, following bowel resection and anastomosis, during this developmental period may explain the motility dysfunction seen in newborn infants operated for necrotising enterocolitis, bowel atresia and Hirschsprung’s disease.     

Orchidopexy and its impact on fertility

We critically analysed the factors known to influence the fertility potential after orchidopexy in children. A comprehensive literature review of all publications in the English language listed in Medline using the words cryptorchidism, undescended testis, orchidopexy, fertility, semen analysis and surgery from 1970 to 2005. In unilateral ectopic, canalicular and emergent testes, as long as the surgery is carried out in early childhood, fertility outcome is good (>90%). The majority of the bilateral abdominal testes are infertile. While unilateral abdominal testes and unilateral absent or vanishing testes have favourable fertility potential, quantification has proven difficult. Despite multiple studies, fertility in crypt orchid tests is still an uncertain issue. Hormonal treatment in conjunction with early surgical correction has not been fully explored. We recommend orchidopexy soon after 6–7 months of age, corrected for term, to maximise the future fertility potential.     

Enteric nervous system and developmental abnormalities in childhood

ENS consists of a complex network of neurons, organised in several plexuses, which interact by means of numerous neurotransmitters. It is capable of modulating the intestinal motility, exocrine and endocrine secretions, microcirculation and immune and inflammatory responses within the gastrointestinal tract, independent of the central nervous system. Though the embryological development of various plexuses are completed by mid-way of gestation, the maturation of neurons and nerve plexuses appear to continue well after birth. Therefore, any histological or functional abnormalities related to the gastrointestinal function must be investigated with the ongoing maturational processes in mind.     

Timing of pre-emptive tenoxican is important for postoperative analgesia

PURPOSE: In this prospective randomized study, a comparison was made between the efficacy of 20 mg tenoxicam, administered either, 30 min preoperatively or at induction of anesthesia, for the relief of postoperative pain in patients undergoing ambulatory breast biopsy. METHODS: Seventy-three patients were recruited and all received a standard anesthetic consisting of induction with 2 mg x kg(-1) propofol followed by 5 microg x kg(-1) alfentanyl. No premedication was administered and at the end of the procedure the wounds were infiltrated with 10 ml of bupivacaine (0.5%). Patients were randomized to receive 20 mg tenoxicam intraveneously either 30 min before surgery or at induction of anesthesia. RESULTS: Demographic criteria were similar in both groups. There were differences in pain scores at 30, 60, 120 and 240 min postoperatively (VAS at 30 min 3.2 +/- 1.2 vs 5.5 +/- 1.8; P < 0.001: VAS at 60 min 1.8 +/- 1.2 vs 3.7 +/- 1.9; P < 0.001: VAS at 120 min 0.9 +/- 0.9 vs 1.7 +/- 1.0; P = 0.003: VAS at 240 min 0.5 +/- 0.5 vs 1.1 +/- 0.8; P < 0.001: Expressed as mean +/- SD). There was a difference in the number of patients requiring additional analgesia, in the first four hours postoperatively (12 (33%) vs 27 (73%); P = 0.001) and a difference in the time to additional analgesia in these patients (87.5 +/- 32.5 vs 55.0 +/- 26.8 min; P = 0.002). CONCLUSION: Early administration of pre-emptive tenoxicam 30 min before induction of anesthesia improves postoperative analgesia in patients undergoing ambulatory breast biopsy.     

Open tunneled central line insertion in children — External or internal jugular vein?

Background/Purpose

Tunneled central venous catheters (TCVCs) are commonly used to manage pediatric patients with chronic disease. The aim of this study is to compare the outcomes of external jugular vein (EJV) and internal jugular vein (IJV) tunneled catheters inserted using the open technique.

Experience with retroperitoneoscopy in pediatric surgical oncology

Background  

Retroperitoneoscopy (RS) has been successfully introduced in adult oncology for diagnostic procedures, staging, and surgical treatment. Its value for children has rarely been reported. This report describes the authors’ experience using RS in the diagnosis and staging of cancer for children and adolescents.