Late results of treatment of megaesophagus

Heller's operation remains the best operation but pneumatic dilatation, which has replaced other methods, gives equivalent results. Our report may be completed by better assessment of the physiopathology, new methods of exploration and more precise knowledge of the complications and failures of myotomy. Finally, the chapter, cancer and megaoesophagus, is the most important to be added.     

Coarctation of the aorta in children. Late results after surgery

From 1960 to 1970, 110 patients underwent operation for coarctation of the aorta. The overall mortality was 23%. However, in infants operated on at less than 6 months of age, the mortality was 63%, whereas there was only a 4% mortality in those operated on after 6 months of age. Late follow-up was available in 87 patients from five to 15 years postoperatively. There was a 14% frequency of recoarctation in the group of long-term survivors. Systemic hypertension, defined as an upper extremity blood pressure greater than 140/90 mm Hg, was found in 23% of the survivors. This study has demonstrated a significant frequency of postcoarctectomy hypertension and residual hemodynamic and angiographic abnormalities in patients without clinical evidence of recoarctation. This indicates the need for continued long-term follow-up of these patients.     

Late sequelae of oncologic treatment in children

The risk of late effects of cancer treatment in children is higher than that after treatment during adulthood. The late effects of chemotherapy are proportional to the dosage and those of irradiation to the size of the radiation field, fractionation and dose. Irradiation may lead to impaired growth of bone and soft tissues, cranial irradiation to pituitary deficiencies, alopecia and impaired cognitive function, irradiation of the neck to altered thyroid function, thoracic irradiation to diminished pulmonary function and cardiovascular morbidity, radiation therapy of the abdomen to infertility in females, impaired renal function and chronic enteritis. Chemotherapy-induced damage is more organ-specific. Well-known cardiotoxic agents are the anthracycline derivatives. Restricted pulmonary function is seen after treatment with bleomycin and nitrourea derivatives. Several antineoplastic agents are gonadotoxic in men. Nephrotoxic agents are cisplatin and ifosfamide. The cumulative relative risk of developing a second primary neoplasm is 3,8-6,9 after a follow-up period of 25 years. Alkylating agents and the topoisomerase inhibitors are known to increase the risk of haematologic malignancy, while radiation therapy is associated with bone, soft tissue, thyroid, breast, brain and gastrointestinal malignancies.     

Secretory otitis media. Late results of treatment with grommets

In 108 children (184 ears) with chronic secretory otitis treated with grommets, the condition at one-to-five years follow-up was compared with that at five-to-eight years follow-up. At the latter time, hearing was extremely good, 97.5% of the ears having a speech reception threshold (SRT) of 20 dB or less. However, only 67% of patients could be classified as cured by normal tympanometry. The remaining ears showed a negative middle-ear pressure of 100 to 300 mm H2O (25%), recurrent accumulation of secretion (1.6%), adhesive otitis (3.3%), perforation (1.7%), or cholesteatoma (1%). The eardrum was normal in 44% of patients, while in 25% it was diffusely atrophic, lax, or retracted.     

Follow-up results of modified Glenn-Andersen operation in children with primary vesicoureteral reflux

A questionnaire survey covered 11 females with temporal arteritis (CA) and 20 healthy controls. Gastrointestinal, joint and spinal complaints were significantly more frequent in CA patients. Clinical characteristics of joint and spinal disorders in CA patients are close to those of chronic reactive arthritis. It is suggested that Horton's disease may be lacking as a stage of the infectious process in elderly patients (chronic intestinal and/or urinary infection-reactive arthritis-CA). A case is reported where CA developed after intestinal and urinary infection. Administration of antibiotics for treatment of the recurrence induced a continuous remission under reduced doses of glucocorticoids. In another case biseptol + glucocorticoids brought about a persistent remission allowing glucocorticoid discontinuation.     

Urethral duplication in children: surgical treatment and results

PURPOSE: Urethral duplication is a rare congenital anomaly. We report the clinical presentation, imaging findings and surgical treatment in 7 boys with incomplete sagittal duplication of the urethra. MATERIALS AND METHODS: Duplication involved hypospadias in 5 cases (group 1) and a bifid urethra with an accessory preanal tract (Y duplication) in 2 (group 2). Group 1 was treated with 1-stage urethroplasty, including marsupialization of the dorsal orthotopic urethra, ventral-to-dorsal urethrourethrostomy and penile island flap onlay repair to cover the open dorsal urethra. In contrast, group 2 was treated with 2-stage urethral reconstruction with detachment and mobilization of the accessory preanal branch in association with a scrotal tubed neourethra followed by urethroplasty, as in group 1. In all cases the dorsal penile urethra was located between the corpora cavernosa and surrounded by the tunica albuginea. RESULTS: A urethrocutaneous fistula developed in 1 of the 5 group 1 patients. In group 2, 1 patient had recurrent penoscrotal meatal stenosis after the 1-stage procedure and 1 had a urethral diverticulum with calculi at the scrotal tubed neourethra 7 years after urethral reconstruction. Six of the 7 patients now void spontaneously through a meatus located normally at the tip of the glans. The remaining patient with a neurogenic bladder is on intermittent catheterization via appendicovesicostomy due to difficult catheterization of the irregular and sensitive neourethra. CONCLUSIONS: While the ideal surgical management of urethral duplication anomalies remains uncertain, we used a combination of surgical techniques to correct this severe malformation.     

Long-term results of non-filtering surgery for the treatment of primary angle-closure glaucoma

BACKGROUND: We previously reported the effectiveness of goniosynechialysis and trabeculotomy ab externo for adult-onset glaucoma. In this study, we performed non-filtering surgery on patients with primary angle-closure glaucoma and studied the long-term outcome of this treatment. METHODS: Included in this study were 35 eyes of 25 patients with primary angle-closure glaucoma, each of which had an intraocular pressure greater than 20 mmHg with maximal tolerated antiglaucoma medication, even after laser iridotomy or surgical iridectomy. Of these 35 eyes, 22 underwent trabeculotomy and 13 underwent goniosynechialysis. All patients were followed up for at least 18 months. RESULTS: In 21 (95%) of 22 eyes after trabeculotomy, and in 12 (92%) of 13 eyes after goniosynechialysis, intraocular pressures were well controlled at or below 21 mmHg at the final examination. However, in two of the 21 eyes in which trabeculotomy was a success, and in four of the 12 eyes in which goniosynechialysis was successful, the procedure had to be repeated before adequate control of pressure was achieved. CONCLUSION: Our results show that intraocular pressure in most cases of primary angle-closure glaucoma can be controlled by restructuring of the physiologic aqueous outflow route by means of goniosynechialysis or trabeculotomy, and that filtering surgery is not necessary.     

Endoscopic treatment of urinary incontinence in children with primary epispadias

OBJECTIVE: To evaluate the efficacy of the endoscopic insertion of polydimethylsiloxane particles (Macroplastique, Uroplasty Inc) (MPQ) into the posterior urethral region of boys with urinary incontinence and primary epispadias. PATIENTS AND METHODS: Between 1991 and 1995, 12 boys aged 3-7 years (mean 4.8) received an endoscopic submucosal injection with MPQ into the posterior urethra to correct urinary incontinence; the 12 boys were wet day and night. All patients had undergone a modified Cantwell epispadias repair before injection. The procedure was performed 24 times with a total volume of 83 mL of material injected into 59 sites in the posterior urethra (mean volume per injection 1.4 mL). The mean follow-up after injection was 10.8 months (range 3-22). RESULTS: Three patients became completely dry, the degree of incontinence was improved in six and there was no change in three. CONCLUSION: The preliminary results of this relatively non-invasive treatment are encouraging.     

The late results of the surgical treatment of patients with a pathologically mobile kidney

Long-term (1-10 years) results of wandering kidney surgery were followed-up for 118 patients. The outcomes were found dependent on the duration of the disease, variety and severity of the lesion, age of the patients. The response appeared better in younger patients, in those with shorter duration of the disease and with unessential changes in the kidney. Recommendations are provided on the regimens, jobs, outpatient and inpatient follow-up for the subjects treated surgically for wandering kidney to reinforce the correction results achieved.     

Long-term results of percutaneous endopyelotomy in the treatment of children with failed open pyeloplasty

PURPOSE: We reviewed our experience with the safety and long-term efficacy of percutaneous endopyelotomy in children with secondary ureteropelvic junction obstruction who previously underwent open pyeloplasty. MATERIALS AND METHODS: Nine patients a median of 7 years old underwent endopyelotomy between June 1985 and July 1995. Anderson-Hynes pyeloplasty had previously been performed in all children. Antegrade endopyelotomy was done with a cold knife in conjunction with balloon dilation in some cases. Postoperative stenting lasted 6 weeks. RESULTS: The median interval between pyeloplasty and endopyelotomy was 7.5 months. Mean operative time was 240 minutes. Percutaneous endopyelotomy was successful in 8 of the 9 patients. One patient who required repeat endopyelotomy after 4 years is presently well at 5 years of followup. Average followup was 5.6 years (range 2 to 10). There was a low morbidity rate, including 1 case of urinary tract infection, 1 of pneumonia and 1 that required blood transfusion. CONCLUSIONS: Percutaneous antegrade endopyelotomy is a safe, effective and durable alternative for children who previously underwent unsuccessful pyeloplasty.     

Late effects of radiotherapy in children

PURPOSE: To examine benzoporphyrin derivative angiography as a modality for studying photosensitizer biodistribution in experimental choroidal melanomas. METHODS: A liposomal preparation of benzoporphyrin derivative was used in this study. Digital benzoporphyrin derivative angiograms were performed in 10 rabbits (six for experimental choroidal melanomas, two for normal choroids, and two for irides) using a Topcon ImageNet H1024 digital imaging system, a Kodak Megaplus video camera, and a Topcon TRC-50-VT fundus camera. Only one eye from each rabbit was used. Filters specifically designed for benzoporphyrin derivative (peak absorption at 580 nm and peak emission at 695 nm) were used. Benzoporphyrin derivative (1 mg/kg) was injected into an ear vein while images of tumor, normal choroid, or iris were being obtained. Follow-up images were obtained during the first 3 hours and at 24 hours after injection. Fluorescence microscopy was performed in all 10 rabbits using 1 mg/kg of benzoporphyrin derivative. Tumor-bearing eyes were enucleated at the same time points that angiograms were performed, and the two sets of results were compared for maximum dye accumulation. RESULTS: Digital angiography demonstrated that maximal benzoporphyrin derivative fluorescence occurred in tumors 15 to 45 minutes after injection. Fluorescence photometry corroborated these results. CONCLUSION: Photosensitizer angiography is a valid modality for determining the optimum treatment time for photodynamic therapy.     

Long-term results in the treatment of femoral-shaft fractures in young children by immediate spica immobilization

Manual traction reduction without anesthesia and immediate immobilization in a spica cast were used to treat eighty-five children ranging in age from birth to ten years old who had closed femoral-shaft fractures and no associated injuries. Up to two centimeters of overriding, 30 degrees of anterior angulation, and 15 degrees of medial angulation were accepted. Any angulation in excess of these amounts, or lateral or posterior angulation, was corrected by wedging the cast at the fracture site. Further telescoping of the fracture fragments in the case was attributed to the child pressing the foot against the bottom of the cast and was prevented by removing the sole of the cast. Of the seventy-five children examined two to eighteen years after fracture, none had any residual skeletal deformity or joint stiffness. The length discrepancies of the fractured limbs ranged from 1.7 centimeters of shortening to 0.9 centimeter of overgrowth.     

Late results of cervical disc surgery

Late results of cervical disc surgery have been reported and statistically studied in 383 cases: 83% were lateral discs, 13% were central spondylosis discs, and 4% central soft discs. Central spondylosis occured at a higher spinal level, and caused cord compression with or without weakness of the hands, but no pain. A posterior approach was used in all lateral discs, and either an anterior or a posterior approach, with or without fusion, for central discs. Preoperative myelography was always done and is recommended postoperatively in central disc surgery to evaluate the results. Our results were good to excellent in 95% of lateral discs, in 64% of central spondylosis discs, and in an unexpected 91% of 11 cases of central soft discs. There were no recurrences and no serious complications, although 20% developed other cervical or lumbar disc herniations.