Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

A long time has passed in medical history from the trephining of skulls in the stone age to today's miracle surgery: open heart surgery, transplantation of organs, microsurgery, and fetal surgery, to mention but a few.

Until about 40 years ago there had only been two great advances in the history of surgical treatment. One was the development of anesthesia (ether and chloroform) from 1846-1847. The second was the development of aseptic surgical technique in 1865 by Joseph Lister.

I have always felt a sense of pediatrie chauvinistic pride in the latter accomplishment, for the first successful aseptic surgical treatment was on an 11-year-old boy.

Medical history tells us that prior to that time it was believed that oxygen in the atmosphere affected the blood and serum causing infected wounds and sloughing of the tissues. But then Pasteur showed that the septic properties of the atmosphere were not due to oxygen but to minute organisms floating in the air.

Lister decided to test Pasteur's theory. He knew that carbolic acid had proven effective in deodorizing sewage and ridding cows of an infection caused by the sewage. So he waited for a case of a compound fracture, a condition which had always previously led to infection. And then, the previously mentioned 11 -year-old boy was run over by a wagon and sustained a compound fracture of the tibia. Lister applied carbolic acid to the open wound and recovery was rapid and infection-free. In a few years, in spite of resistance, his method of treatment was adopted throughout the civilized world.

To my knowledge pediatrie surgery did not come into its own until 1939 when Robert Gross of Children's Hospital in Boston successfully ligated the patent ductus arteriosus. In the mid-1940s, Gross surgically removed coarctation of the aorta. During that time, he also established a unit for teaching pediatrie surgery.

In 1945, Dr. Helen Taussig and Dr. Alfred Blalock of Johns Hopkins made pediatrie history with the successful surgical treatment of cyanotic congenital heart disease.

Since then, with the rapid advance in surgical technology and diagnostic skills, pediatrie surgery has made rapid, almost miraculous, strides. Diagnostically, the development of angiograms, cardiac catheterization, sonography, and computed tomography have aided greatly, while open heart surgery, organ and tissue transplantation, microsurgery, shunting for relief of hydrocephalus, and fetal surgery are some of the technical advances.

This issue of Pediatrie A nnals presents a symposium on "Frontiers in Pediatrie Surgery" and is under the guest editorship of Dr. Anthony Shaw, Director of the Department of Pediatrie Surgery of the City of Hope National Medical Center in Duarte, California. Dr. Shaw is also Clinical Professor of Surgery at the UCLA School of Medicine.

The symposium presents a fascinating view of some of the most recent exciting advances in pediatrie surgery. Among these are such subjects as ex tracorpo real oxygénation for neonatal respiratory distress, surgery of the human fetus, and microsurgery and replantation of tissues in children.

The first article deals with "Maternal Ultrasound in Neonatal Surgery" and has been written by Dr. Timothy G. Canty and Deborah A. Wolf, R.T., R.D.M.S. of the Department of Pediatrie Surgery and the Division of Diagnostic Ultrasound, University of California Medical Center, San Diego, California.

The advent of ultrasound as a medical diagnostic tool has given physicians the opportunity of safely following fetal development from the 12th week of gestation. The authors of this article point out that not only can most delays in postnatal diagnosis be completely eliminated but in many cases the risks and delays involved in transporting a sick neonate can be eliminated by directing the pregnant…

A long time has passed in medical history from the trephining of skulls in the stone age to today's miracle surgery: open heart surgery, transplantation of organs, microsurgery, and fetal surgery, to mention but a few.

Until about 40 years ago there had only been two great advances in the history of surgical treatment. One was the development of anesthesia (ether and chloroform) from 1846-1847. The second was the development of aseptic surgical technique in 1865 by Joseph Lister.

I have always felt a sense of pediatrie chauvinistic pride in the latter accomplishment, for the first successful aseptic surgical treatment was on an 11-year-old boy.

Medical history tells us that prior to that time it was believed that oxygen in the atmosphere affected the blood and serum causing infected wounds and sloughing of the tissues. But then Pasteur showed that the septic properties of the atmosphere were not due to oxygen but to minute organisms floating in the air.

Lister decided to test Pasteur's theory. He knew that carbolic acid had proven effective in deodorizing sewage and ridding cows of an infection caused by the sewage. So he waited for a case of a compound fracture, a condition which had always previously led to infection. And then, the previously mentioned 11 -year-old boy was run over by a wagon and sustained a compound fracture of the tibia. Lister applied carbolic acid to the open wound and recovery was rapid and infection-free. In a few years, in spite of resistance, his method of treatment was adopted throughout the civilized world.

To my knowledge pediatrie surgery did not come into its own until 1939 when Robert Gross of Children's Hospital in Boston successfully ligated the patent ductus arteriosus. In the mid-1940s, Gross surgically removed coarctation of the aorta. During that time, he also established a unit for teaching pediatrie surgery.

In 1945, Dr. Helen Taussig and Dr. Alfred Blalock of Johns Hopkins made pediatrie history with the successful surgical treatment of cyanotic congenital heart disease.

Since then, with the rapid advance in surgical technology and diagnostic skills, pediatrie surgery has made rapid, almost miraculous, strides. Diagnostically, the development of angiograms, cardiac catheterization, sonography, and computed tomography have aided greatly, while open heart surgery, organ and tissue transplantation, microsurgery, shunting for relief of hydrocephalus, and fetal surgery are some of the technical advances.

This issue of Pediatrie A nnals presents a symposium on "Frontiers in Pediatrie Surgery" and is under the guest editorship of Dr. Anthony Shaw, Director of the Department of Pediatrie Surgery of the City of Hope National Medical Center in Duarte, California. Dr. Shaw is also Clinical Professor of Surgery at the UCLA School of Medicine.

The symposium presents a fascinating view of some of the most recent exciting advances in pediatrie surgery. Among these are such subjects as ex tracorpo real oxygénation for neonatal respiratory distress, surgery of the human fetus, and microsurgery and replantation of tissues in children.

The first article deals with "Maternal Ultrasound in Neonatal Surgery" and has been written by Dr. Timothy G. Canty and Deborah A. Wolf, R.T., R.D.M.S. of the Department of Pediatrie Surgery and the Division of Diagnostic Ultrasound, University of California Medical Center, San Diego, California.

The advent of ultrasound as a medical diagnostic tool has given physicians the opportunity of safely following fetal development from the 12th week of gestation. The authors of this article point out that not only can most delays in postnatal diagnosis be completely eliminated but in many cases the risks and delays involved in transporting a sick neonate can be eliminated by directing the pregnant mother ahead of time to a hospital with full facilities for the surgical care of the infant.

This paper discusses the lesions which may be diagnosed by ultrasound in the fetal neck, thorax and abdomen. It lists 30 fetal abnormalities which can be diagnosed prenatally. Of these, 25 are potentially correctable postnatally - but a few of the conditions may be surgically treated prenatally.

The next contribution to this symposium is "Fetal Surgical Treatment" and is authored by Dr. Michael R. Harrison and his co-workers from the Fetal Treatment Program of the Division of Pediatrie Surgery, Department of Surgery and the Departments of Obstetrics, Gynecology and Reproductive Sciences, and Radiology of the University of California, San Francisco.

Those of us who have followed the literature realize that Dr. Harrison and his associates are foremost in the study of fetal surgery - a field which is still in its infancy.

This paper logically follows the previous article, commencing with the statement that "fetal anatomy, normal and abnormal, can now be accurately delineated by ultrasonography and other imaging techniques."

The authors first present a discussion of prenatal diagnoses that may lead to selective abortion and those that may necessitate early delivery. The main topic of the article is prenatal diagnoses that may lead to intervention before birth. Some of these can be treated by treating the mother, some by injecting nutrients and medications into the amniotic fluid. Others, however, require surgical treatment if the fetus is to survive or not be permanently damaged.

Three examples of successful surgical treatment are presented - congenital hydronephrosis, congenital diaphragmatic hernia, and congenital obstructive hydrocephalus.

Dr. H arrison and his co- workers, who have had considerable experimental experience with sheep, note that success in surgically treating congenital anomalies is much more difficult in treating primates. From an ethical point of view prenatal diagnosis of a fetal malformation may now often lead to treatment rather than abortion.

The third paper presents another exciting advance - "Extracorporeal Membrane Oxygénation in Neonatal Pulmonary Failure." This is contributed by Dr. Thomas H. Krummel and his associates from the Division of Pediatrics and Cardiothoracic Surgery, Department of Pediatrics of the Medical College of Virginia, Richmond, Virginia.

Using a modified heart-lung apparatus, venous blood is brought outside the body, and CO2 removed and O2 added, and then returned into the ascending aorta. This relieves the strain on the lungs and supports the systemic circulation.

It has been used almost entirely on moribund newborns with predictably fatal outcomes. The authors report on nine newborns so treated at the Medical College of Virginia of which seven were moribund and two suffered from refractory hemodynamic inability. Six survived.

They note that in another institution 45 newborns received this extracorporeal treatment (25 survived). The treatment has been continued for as long as two weeks.

This is a clear and full report of an exciting innovation in fetal surgery. It should be available in all large pediatrie units.

The fourth article brings pediatricians up-to-date on the recent advances in organ transplantation. It has been written by Dr. Frank M. Guttman, Professor of Surgery at McGiIl University College of Medicine, and Surgeonin-Chief of the Montreal Children's Hospital.

We all have knowledge of the success of kidney transplants and bone marrow transplants. We know something of the partial success of cardiac transplants and even artificial hearts, but what are the recent advances and prospects of liver, pulmonary, and bowel transplants, and is there any hope of heart-lung, pancreas and even nerve transplants? Dr. Guttman reviews the present successes using Cyclosporin A to prevent rejection and gives us a most interesting look into the future where new surgical techniques may prove effective and where organ freezing may permit the storing of organs in organ banks for months and possibly years. This would relieve the greatest present day handicap - the lack of adequate organ procurement.

The following contribution is on "Microsurgery and Replantation of Tissues in Children" and is written by Dr. Elliott B. Black, III, Clinical Assistant Professor in the Department of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana.

Recently the news, radio and television media have given considerable attention to cases where severed arms or legs have been reattached successfully by microsurgical teams. Dr. Black briefly describes the techniques used and then presents and illustrates a series of cases in children where amputations and avulsion of skin was treated with excellent results. A most important aspect of this paper is the direction for care of a severed part of the body. The part often may be kept viable 24 hours or longer prior to replantation.

The next paper, "Continence Following Colectomy for Ulcerative Colitis," is authored by Dr. Eric W. Fonkalsrud, Chief of Pediatrie Surgery at the UCLA Medical Center.

Those of use who have followed children with ulcerative colitis realize the severity of this condition which includes stunting of growth and development. We have also realized that the only cure is removal of the diseased rectum and colon. Formerly the operation was followed by an abdominal ileostomy, damning a child to a lifetime of this special care with the use of an appliance.

The problem surgeons attempted and finally succeeded in solving was to connect the ileum to the anus, removing the rectal mucosa and leaving the anal sphincter intact. But this wasn't all, for a reservoir had to be made to take the place of the rectum.

This is a fascinating account related by Dr. Fonkalsrud who has been closely associated with the development of this surgical technique. In his own hospital he has successfully treated 19 patients in the past three years.

The following article is on the "Advances in the Repair of Complex Congenital Heart Disease" and has been contributed by Dr. Hillel Laks, Professor and Chief of Thoracic SurgerV at UCLA.

Dr. Laks starti his discussion with a brief history of the palliative methods formerly used in the treatment of cardiac anomalies. The heart-lung machine was then developed, along with hypothermia and cardiac arrest, and a new era in ingenious cardiac surgery was opened. Some of these truly amazing modern corrections are described, including those for pulmonary atresia, truncus arteriosus, transposition of the great vessels with VSD and pulmonary stenosis, and tetralogy of Fallot. Of special interest is the use of the porcine valve. Dr. Laks reports on 56 patients in his hospital who underwent surgery for complex repair in which porcine valves were used. The results were excellent. He notes, however, that for successful results these operative procedures should be confined to specialized centers where skilled teams of surgeons, pediatrie cardiologists, neonatologists and nurses work closely together.

The final article, "Frontiers in the Surgery of Childhood Cancer" is by Dr. Daniel M. Hays, Professor of Surgery, University of Southern California and Attending Surgeon of the Children's Hospital of Los Angeles.

Dr. Hays has limited his discussion to neuroblastomas, rhabdomyosarcomas, and lymphomas. In modern cancer therapy there are three general approaches - chemotherapy, radiotherapy and surgery. In certain conditions such as neuroblastoma, surgery is the primary treatment. In other cancers of infancy and childhood, surgery serves as an adjunct to other forms of treatment. In his article Dr. Hays not only details the effectiveness of surgery, but notes which forms of chemotherapy are most effective in the modern approach to .the treatment of childhood cancer.

10.3928/0090-4481-19821101-05

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