A Technique for Tunneling Central Venous Catheters

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141663/1/jpen0521.pd

New surgical approaches to ulcerative colitis in children and adults

Ulcerative colitis continues to be a devastating disease for the child and the young adult. In spite of intensive medical therapy with sulfasalazine and corticosteroids, the majority of patients with universal ulcerative colitis will ultimately require a total colectomy. The standard operation of a total proctocolectomy and a permanent end ileostomy is probably still the best procedure for the definitive management of this disease because all diseased tissue is removed with this operation; however, the resultant abdominal stoma can create significant psychological trauma in many of these patients. For that reason, sphincter-saving operations were introduced in 1933 but were only marginally successful until 1977, when renewed interest in the endorectal pull-through occurred. Since that time, several centers around the world have gained significant experience with the endorectal procedure, with or without the use of an ileal reservoir. Although the ileal reservoir appears to have certain advantages over the straight endorectal pull-through, the procedure also is associated with a significant number of complications and is a far more complicated technical exercise . The experience at the University of Michigan with the straight endorectal pullthrough procedure in patients with ulcerative colitis and familial polyposis during the period from 1977 to 1984 is herein reported. All of the patients in our series are continent and experience a median stool frequency of 6 per 24 hours 1 year after the procedure. Patient satisfaction has been excellent with the majority of patients preferring their lifestyle without an ileostomy to that experienced with an ileostomy. At the present time, we can strongly recommend the endorectal pullthrough procedure to all patients with ulcerative colitis . La colite ulcéreuse reste une affection redoutable chez l'enfant et le jeune adulte. Malgré un traitement médical intense par la sulfasalazine et les corticoïdes la majorité des malades atteints de colite ulcéreuse diffuse devront subir une colectomie totale. L'opération standard, la coloprotectomie avec iléostomie terminale permanente reste probablement la meilleure méthode de traitement de cette affection car elle permet l'exérèse totale des lésions; cependant l'iléostomie peut être à l'origine d'un sévère traumatisme psychologique. Pour l'éviter les opérations respectant l'appareil sphinctérien ont été tentées dès 1933 mais avec un succès relatif jusqu'en 1977 moment ou se manifeste un nouvel intérêt pour l'abaissement endorectal de l'iléon. Depuis cette époque de multiples centres dans le monde lui ont donné la préférence que l'abaissement transanal s'accompagne ou non de la constitution d'un réservoir iléal. Bien que le réservoir iléal présente certains avantages sa constitution délicate s'accompagne de nombreuses complications. L'expérience de l'Université de Michigan concernant l'abaissement iléal transanal appliqué au traitement de la colite ulcéreuse et de la polypose familiale pendant la période s'étendant de 1977 à 1984 est rapportée par les auteurs. Tous les malades ainsi traités sont continents, le nombre moyen des selles par 24 heures s'élevant à 6. La satisfaction éprouvée par la majorité des opérés est supérieure à celle des malades qui ont subi une coloprotectomie totale avec iléostomie classique. A partir de ces faits, il est possible d'affirmer que l'exérèse globale du rectum et du colon avec abaissement transanal de l'iléon est l'opération de choix. La colitis ulcerativa sigue siendo una enfermedad devastadora para el niño y el adulto joven. A pesar de terapia médica intensa con sulfasalazina y corticosteroides, la mayoría de los pacientes con colitis ulcerativa universal, a la larga, requieren colectomía total. La operación estandar de proctocolectomía total e ileostomía permanente todavía es, probablemente, el mejor procedimiento para el manejo definitivo de esta enfermedad en virtud de que la totalidad del tejido enfermo puede ser removido mediante la operación; sinembargo, el estoma abdominal resultante puede crear un trauma psicológico significativo en muchos de estos pacientes. Para resolver este problema, en 1933 fueron introducidos los procedimientos de conservación de esfínter, los cuales apenas fueron marginalmente exitosos hasta 1977, cuando se desarrolló un renovado interés en los procedimientos endorrectales de “pullthrough.” Desde tal época algunos centros de diversos lugares del mundo han llegado a tener suficiente experiencia con el procedimiento endorrectal, con o sin el uso de reservorio ileal. Aun cuando el reservorio ileal parece poseer ciertas ventajas sobre el simple procedimiento de “pullthrough,” la operación también se halla asociada con un número importante de complicaciones y significa un ejercicio quirúrgico técnicamente bastante más complicado.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41317/1/268_2005_Article_BF01656313.pd

Hirschsprung's disease

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47144/1/383_2004_Article_BF00166864.pd

Pediatric trauma

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47184/1/383_2004_Article_BF00177094.pd

Circumcision in the United States: medical and nonmedical attitudes

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47182/1/383_2004_Article_BF00177486.pd

Commentary

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47179/1/383_2004_Article_BF00182790.pd

Pediatric TPN: Efficacy and Toxicity of a New Fat Emulsion

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141693/1/jpen0384.pd

Surgery for ulcerative colitis in children

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47165/1/383_2004_Article_1230.pd

Pericardial flap interposition for the definitive management of recurrent tracheoesophageal fistula

From 1974 to 1988, six children with fistula recurrence following primary tracheoesophageal fistula (TEF) repair have been managed at our hospital. Reclosure of the fistula with pleural flap interposition was used as the initial corrective procedure in five patients, with an 80% incidence of second TEF recurrences. Due to these discouraging results, we have abandoned this technique and instead favor fistula reclosure with interposition of a pedicle of vascularized pericardium between the esophageal and tracheal suture lines. The pericardial pedicle is easy to mobilize, effectively isolates the tracheal and esophageal suture lines, and eliminates the often difficult task of finding sufficient pleural tissue for fistula interposition in small infants. Furthermore, the vascularized pedicle serves as a template for the ingrowth of neomucosa from the existing esophageal mucosa should an anastomotic leak occur. Since adopting this approach, we have used this technique on four children, three of whom had second recurrences after pleural interposition, and have had no evidence of recurrent fistula formation at follow-up ranging from 2 to 6 years. With at least a 20% incidence of second recurrences reported following conventional management with fistula closure and pleural interposition, we believe use of a pericardial flap in the management of the recurrent TEF is the most appropriate surgical procedure.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/30367/1/0000769.pd

Intestinal vaginoplasty for congenital absence of the vagina

Congenital absence of the vagina is rare and occurs as a result of aplasia of the Mullerian ducts (46,XX) or complete androgen insensitivity syndrome (AIS--46,XY). Both syndromes are associated with normal female external genitalia and these patients are raised as females. These children are usually treated during adolescence with chronic dilatation of the shallow vaginal introitus (pressure tube technique) or by skin graft vaginoplasty (Mcindoe procedure). Neither of these procedures is entirely satisfactory, as both may lead to neovaginal stenosis, inadequate length, poor lubrication, or all three. We have recently modified the operation first described by Baldwin in which a loop of sigmoid colon or small bowel is isolated, closed at one end, and brought down on its vascular pedicle as a neovagina and anastomosed to the hymenal ring. We have performed this operation on four adolescents (mean age, 15 years) and two infants (aged 4 days and 14 months) with excellent results (mean follow-up, 7.5 years for the adolescents and 1.8 years for the infants). The advantages of a bowel segment in contrast to a skin graft are: (1) minimal likelihood of "poor take" or later contraction because a vascularized epithelial-lined tube is used; (2) patency and depth can be maintained without a mold and with minimal dilatation; (3) spontaneous mucus production matches that of the normal vagina and facilitates sexual intercourse; (4) dysparenunia frequently seen with skin grafts is avoided by the ability of the intestinal segment to withstand local trauma; and (5) the use of an intestinal segment offers the option of performing a bowel interposition vaginoplasty during infancy at the time of surgical correction of more complex associated caudal anomalies. The sigmoid colon is the best choice for interposition vaginoplasty because of size, location, and ease of preserving blood supply.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29974/1/0000337.pd