תוצאת חיפוש

יגאל אפרתי, גד לוטן, ברוך קלין, לב זלוטקביץ

המח' לכירורגיית ילדים, מרכז רפואי אסף-הרופא, צריפין, הפקולטה לרפואה סאקלר, אוניברסיטת תל-אביב

בעבודה זו מדווח על ניסיוננו במהלך 8 השנים האחרונות בטיפול באשך שלא מושש (אש"מ) בשיטה לאפרוסקופית.

מאה-שלושים-ושלושה ילדים שגילם נע מ-8 חודשים עד לאפרוסקופיה איבחונית. המשולבת לעתים בכריתת אשך, בוצעה ב-59 ילדים עם ניוון אשכים. בשבעים-וארבעה ילדים אובחן אשך תוך-בטני (55.6%). מימצא דו-צדדי אובחן ב-10 ילדים (7.5%). בעשרים-ואחד ילדים (15.7%) היה האשך ממוקם בסמוך לטבעת הפנימית, ובהם בוצעה אורכידופקסיה מיידית בסיוע לאפרוסקופיה, ביתר 53 הילדים (39.8%) בוצע תיקון בשני שלבים לפי פאולר-סטיפנס.

במעקב אחר קבוצה זאת ניצפה ניוון של האשך ב-4 ילדים בלבד.

התוצאות הטובות המדווחות במירב הסדרות שפורסמו בדומה למימצאינו המדווחים במאמר זה, מציבות את השיטה הלאפרוסקופית לטיפול באש"מ כשיטה המועדפת מבחינת הדיוק המוחלט באיבחון, שיעור הסיבוכים והתחלואה הנמוכים והצלחת הטיפול.

Aortopexy for Tracheomalacia in Infants and Children

I. Vinograd, B. Klin, A. Silbiger, G. Eshel

Depts. of Pediatric Surgery, and Anesthesia, Dana Children's Hospital, Sourasky-Tel Aviv Medical Center;  Dept. of Pediatric Surgery and Intensive Care Unit, Assaf Harofeh Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

During the past 12 years (1985-1998), 28 infants and children were operated on here for tracheomalacia. The diagnosis was made in all using rigid bronchoscopy. During the examination the infants breathed spontaneously, but the trachea collapsed on forced expiration.

Indications for surgery were repeated cyanotic spells ("dying spells") in 22, recurrent pneumonia, and inability to extubate (in 8). In 11 there were more than 1 indications. Age at surgery was from 7 days to 3 years (average 11.7 months).

All 28 children underwent bronchoscopy and guided aortopexy via a left-third intercostal approach. The ascending aorta and aortic arch (and in 6 the proximal innominate artery as well) were lifted anteriorly, using 3-5 non-absorbable sutures (5.0). The sutures were placed through the adventitia of the great vessels and then passed through the sternum.

Respiratory distress was significantly improved in 21. Another 2 required external tracheal stenting with autologous rib grafts, and in 1 other an internal Palmaz stent was introduced for tracheal stability. In 4 aortopexy failed, 1 of whom had tracheobronchomalacia throughout, and another 3 had laryngomalacia which required tracheostomy to relieve the respiratory symptoms.

Postoperative complications were minor: pericardial effusion in 1 and relaxation of the left diaphragm in another. 1 infant subsequently died, of unknown cause 10 days after operation, after having been extubated on the 1st postoperative day. On long-term follow-up (6 months to 12 years) 25 were found free of residual respiratory symptoms and 3 remained with a tracheostomy.

Thus, infants and children with severe tracheomalacia associated with severe respiratory symptoms, can be relieved by bronchoscopic guided suspension of the aortic arch to the sternum.

Atypical Mycobacterial Cervical Lymphadenitis in Children

B. Klin, I. Boldur, J. Sandbank, Z. Schpirer, I. Vinograd

Depts. of Pediatric Surgery, Microbiology and Pathology, Assaf Harofeh Medical Center, Zerifin, and Sackler Faculty of Medicine, Tel Aviv University

Scrofula (mycobacterial cervical lymphadenitis) has been well-known for thousands of years. Atypical mycobacteria were first categorized by Timpe and Runyon in 1954. Treatment has varied over the centuries, from exclusion therapy in ancient Greece, through digitalis, iodide, chemotherapy, and surgical excision. The varied differential diagnosis and consequent diagnostic and therapeutic challenges make reassessment of this almost forgotten disease necessary.

21 patients with typical mycobacterial cervical lymphaden„itis seen in over the past 5 years were reviewed. Age distribution ranged from 1-14 years, with peak incidence at 4 years; 9 were boys and 12 girls. Most presented with nontender, palpable neck masses and minimal constitutional complaints. Adenopathy was unilateral in all cases but 2. Mycobacterium avium-intracellulare and M. fortuitum were the main causative organisms. All underwent excision of the affected nodes. Long-term follow-up has been uneventful, except for 1 case of local recurrence requiring re-excision.

This study emphasizes the marked variability in the clinical presentation of scrofula in children, stressing the importance of the differential diagnosis between tuberculous and atypical mycobacterial cervical lymphadenitis. The treatment of choice for the latter is complete excision of the affected nodes. Other treatment is followed by recurrence and unnecessary complications and should be avoided.

One-Stage Surgery for Hirschsprung's Disease in Children

Mark Weinberg, Baruch Klin, Itzhak Vinograd

Dept. of Pediatric Surgery, Assaf Harofeh Medical Center, Zerifin, and Sackler School of Medicine, Tel Aviv University

Traditionally Hirschsprung's disease has been treated by 2-or 3-stage procedures. During the past 6 years a 1-stage Duhamel procedure without stoma has become our treatment of choice for Hirschsprung's disease in neonates and young infants. Over a 6-year period, 15 infants and children with colonic Hirschsprung's disease were treated with the 1-stage Duhamel retro-rectal pull-through procedure without a stoma, with the Lester-Martin modification. All patients had the usual short segment aganglionosis, but 1 had a long segment which included the splenic flexure.

Early complications included wound infection in 1 and minor rectal bleeding in 3. Late complications included constipation in 1 and enterocolitis in 4. Long-term functional results were very good in all those operated except for 1 with rectal achalasia.

We conclude that Hirschsprung's disease can be successfully treated with a 1-stage pull-through operation, the child usually benefitting from the shorter hospital stay and the avoidance of a colostomy.