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26 - Innovation in medical care: examples from surgery
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- By Randi Zlotnik Shaul, Bioethicist University of Toronto, Canada, Jacob C. Langer, Professor University of Toronto, Canada, Martin F. Mckneally, Professor University of Toronto, Canada
- Edited by Peter A. Singer, University of Toronto, A. M. Viens, University of Oxford
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- Book:
- The Cambridge Textbook of Bioethics
- Published online:
- 30 October 2009
- Print publication:
- 31 January 2008, pp 194-200
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- Chapter
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Summary
C, a newborn infant, develops persistent vomiting on the second day of life. X-rays show midgut volvulus, a condition in which the intestines have twisted around their blood supply. Surgical exploration reveals necrosis of all but 15 cm of his small bowel. The necrotic bowel is removed and total parenteral nutrition (TPN) is initiated. At one year of age, he is taking half of his nutritional needs through his intestinal tract; the other half is given intravenously. Blood chemistry tests show that he is starting to develop significant liver damage from the TPN. C's remaining small bowel has become dilated and dysfunctional. You have recently read about a new operation called the serial tapering enteroplasty (STEP), an innovative technique, which may be able to lengthen the remaining intestine and permit it to function more effectively. A surgical stapler in common use is deployed to segment the dilated bowel into a tapered, lengthened tube more closely resembling the shape of the small intestine (Kim et al., 2003). This operation, first developed in dogs, has been undertaken in a small number of infants with short bowel syndrome. It is considered a non-validated innovation by most pediatric surgeons and is not yet accepted as part of standard surgical practice. You would like to offer the procedure to your patient, but you do not think that there is time to go through the full Research Ethics Board approval process at your hospital. Your intention is to try to help, and perhaps other patients like him.[…]
24 - Small bowel disorders
- from Part IV - Abdomen
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- By Julie R. Fuchs, Department of Pediatric Surgery, J. W. Riley Hospital for Children, Indianapolis, IN, USA,, Jacob C. Langer, Department of Surgery, University of Toronto and Department of Pediatric General Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
- Edited by Mark D. Stringer, Keith T. Oldham, Pierre D. E. Mouriquand
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- Book:
- Pediatric Surgery and Urology
- Published online:
- 08 January 2010
- Print publication:
- 09 November 2006, pp 305-314
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Summary
There is a wide variety of conditions which affect the small bowel in children, from the newborn period to adolescence. Many of these, including abdominal wall defects, meconium ileus, Crohn's disease, and the general topic of short bowel syndrome, are discussed elsewhere in this text. This chapter will review the long-term outcomes associated with congenital duodenal obstruction (i.e., atresia and webs), jejunoileal atresia and webs, Meckel's diverticulum, intussusception, malrotation, and intestinal duplication. Most children recover from these problems and go on to live a normal healthy life. For this reason, relatively few studies exist documenting long-term outcomes. In this chapter the authors have used a combination of the existing literature, and their own institutional experience, to document outcome in an objective way.
Long-term problems associated with small bowel disorders can be classified into several categories:
those specific to the disorder itself (e.g., motility disturbances associated with atresia or malrotation);
those that are a result of surgical intervention (e.g., short bowel syndrome following massive resection, or peritoneal adhesions following laparotomy);
those related to underlying disease processes or associated anomalies.
Complications and survival can also be divided into early and late time periods. Since both may influence long-term outcomes, some disease processes require a discussion of both early and late morbidity and mortality.
Congenital duodenal obstruction
Although infants with complete duodenal atresia present in the neonatal period, duodenal web or stenosis may present later during the first years of life. The obstruction is postampullary in approximately 80% of patients and preampullary in 20%.