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During the last two years eight children aged 3 months to 7 years were treated successfully for contaminated small bowel syndrome (CSBS). All patients had a history of a laparotomy in the neonatal period and showed bile stained vomiting and diarrhoea. On examination, a painful distended abdomen with hyperactive bowel sounds was found. Plain abdominal x-rays showed signs of mechanical intestinal obstruction. The diagnosis of CSBS was made by positive gram stain and cultures of samples taken via a nasogastric tube. After antibiotic treatment the symptoms disappeared within a few days. We therefore believe that CSBS should always be considered in the differential diagnosis of abdominal emergencies. Our views agree with those of other authors in so far as we feel that antibiotic therapy may help to avoid unnecessary laparotomies in such cases.

Intestinal obstruction is always accompanied by intestinal hypersecretion. This phenomenon explains the initial symptoms like bilious vomiting and abdominal distension as well as the later clinical signs of hypovolaemia and shock. The proximal hypersecretion in intestinal obstruction is incompletely understood and in the surgical literature on ileus only little attention has been paid to this crucial observation. In analogy to secretory diarrhea and because of own clinical observations we conclude that bowel contamination caused by intestinal stasis is mainly responsible for the increased intestinal secretion in bowel obstruction.

Our series of 17 children with laryngotracheal clefts is reported. In three of four cases with a complicated postoperative course, gastroesophageal reflux (GER) has been found. Three breakdowns of the surgical repair opposed to be due to GER. Only one child with a cleft type III died, although a mortality rate of 93% is reported in the literature. GER has to be excluded before tracheoesophageal cleft surgery is undertaken.

Pulled elbow is a common injury in infancy and childhood. The history and clinical findings are usually classical, but one should never forget that the classical history can always be easily reconstructed by the examining physician. It can be estimated that in 93% of all cases a dramatic response to therapy can be observed. In the remaining 7% the most common cause for failure to treatment is an incomplete or recurrent subluxation of the radial head and distortions or fractures of the elbow. But in approx. 1% the examining physician must suspect a hidden osteomyelitis or osteoarthritis of the elbow. With adequate antibiotic therapy the prognosis is generally good. To avoid this diagnostic pitfall, it is essential to re-examine carefully all cases which do not respond to therapy in order to exclude an osteomyelitis.

Between 1982 and 1987 27 Nissen's fundoplications were carried out in our institution. Postoperatively 7 infants showed a typical dumping syndrome. The symptoms were irritability, pallor, sweating, tachycardia, lethargy, diarrhoea and vomiting. In all cases an absolute refusal of feeding was observed. The diagnosis was confirmed by a typical early postprandial hyperglycaemia with hyperinsulinaemia leading to a reactive hypoglycaemia. Additionally, we were able to demonstrate an increased HbA1c as an expression of recurrent hyperglycaemias in 3 infants. In 6 infants the dumping syndrome was of short duration and the symptoms disappeared after application of a so-called dumping diet. In this diet the easily resorbable carbohydrates are replaced by uncooked starch. But in one case we were forced to use continuous enteral nutrition because of persistence of the symptoms 1 year after the Nissen fundoplication. Complete refusal of feeding is an early symptom of the dumping syndrome. If this symptom is observed after a Nissen's fundoplication, a dumping syndrome must be excluded.

A method of parallel model identification, which allows the analysis and simulation of a large group of complex behavioural processes by means of a phenomenalistic model, is described. In order to give a general view of the possibilities and limits of the proposed method, the results of an investigation in social psychology, i. e. the simulation and analysis of human conformity behaviour, is summarized.

Pulled elbow is a common injury in infancy and childhood. The history and clinical findings are usually classical, but one should never forget that the classical history can always be easily reconstructed by the examining physician. It can be estimated that in 93% of all cases a dramatic response to therapy can be observed. In the remaining 7% the most common cause for failure to treatment is an incomplete or recurrent subluxation of the radial head and distortions or fractures of the elbow. But in approx. 1% the examining physician must suspect a hidden osteomyelitis or osteoarthritis of the elbow. With adequate antibiotic therapy the prognosis is generally good. To avoid this diagnostic pitfall, it is essential to re-examine carefully all cases which do not respond to therapy in order to exclude an osteomyelitis.

The main function of the colon is fluid and sodium conservation. In ileostomy patients these colonic functions are lacking. The consequence is excessive loss of fluid and sodium, failure to thrive, and skin excoriation around the ileostomy. Patients with ileostomies require 6-10 mmol/kg sodium per day. With ordinary feeds, infants receive 2-4 mmol/kg sodium; therefore the sodium deficit may be estimated at 4-6 mmol/kg per day. Monitoring of adequate sodium substitution is best carried out by measuring the concentration of sodium in spot urine. Levels higher than 10 mmol/1 sodium signify an adequate oral sodium intake. During the initial period of oral feeding, glucose excretion in the ileostomy fluid must be monitored, as glucose-positive ileostomy effluence necessitates additional sodium substitution in order to activate the sodium and glucose cotransport. Thirty neonates with ileostomies were followed-up retrospectively. All patients received a sodium substitution of at least 4-6 mmol/kg orally per day. The 30 patients had a total of 4769 ileostomy-days. All patients were successfully fed orally and most of them nursed at homeuntil closure of the ileostomy.

Die Entwicklung eines dynamischen Prozessmodells basiert auf einer speziell fur diesen Zweck ausgelegten Versuchsreihe, womit sich die “Allgemeingultigkeit” des Modells auf die im Versuchskonzept vorgesehenen Aenderungen der Einflussgrossen beschrankt. Es kann somit nicht von einem Modell des Konformitatsverhaltens gemeinhin gesprochen werden, sondern nur von einem in Bezug auf eine Versuchsanordnung umfassenden Prozessmodell. Eine exakte Beschreibung der Versuchskonzeption verfolgt damit zwei Ziele: 1. Die Kenntnis der Versuchsbedingungen erlaubt eine richtige Einschatzung der Versuchsergebnisse und einen objektiven Vergleich mit den Erkenntnissen fruherer Untersuchungen zum Anpassungsverhalten. 2 Die Versuchsreihe kann jederzeit unter gleichen Bedingungen wiederholt oder erweitert werden. In diesem Kapitel werden alle verwendeten Hilfsmittel wie auch der Versuchsablauf ausfuhrlich beschrieben und die im Experiment beobachteten Daten schematisch dargestellt und diskutiert werden.

We describe a boy with asymmetrical hydrocephalus in whom a marked hemiparesis of recent origin resolved completely following insertion of a shunt. In 2 children with shunted obstructive hydrocephalus due to a midline tumour a newly developed hemiparesis improved markedly in one and resolved in the other case subsequent to revision of a blocked shunt. A hemiparesis should therefore not necessarily be attributed to assumed progression of an underlying disease. Other unusual symptoms of hydrocephalus or shunt dysfunction reported in childhood as well as possible causes of hemiparesis in shunted patients are listed.

Aus den im Experiment beobachteten Versuchsdaten wird in diesem Kapitel das dynamische Prozessmodell zur Nachahmung des Konformitatsverhaltens empirisch ermittelt. An Hand dieses Modelles konnen sowohl die Zeitabhangigkeit des Anpassungsprozesses nachgewiesen als auch einige Resultate der fruheren Untersuchungen von S.E. Asch, B. P. Cohen und H. D. Schmidt verifiziert resp. widerlegt werden.

Mit der vorliegenden Arbeit zur ‘Exemplarischen Untersuchung des Konformitatsverhaltens anhand eines systemtheoretischen Ansatzes’ wurden zwei Ziele verfolgt: 1. Aus verschiedenen Ansatzen der Systemtheorie war eine Untersuchungsmethode zu entwickeln, die sich auf Probleme der Verhaltensforschung ubertragen liess. Als konkretes Beispiel wurde das ‘Konformitatsverhalten’ analy siert. 2. Von einer umfassenden Untersuchung des Anpassungsverhaltens mit einem dynamischen, nichtlinearen Prozessmodell erhoffte man sich sowohl die Klarung der in der Literatur umstrittenen Fragen als auch einige grundsatzliche Erkenntnisse uber die Dynamik und die Einflussgrossen des Konformitatsprozesses.

We present 4 cases in which atraumatic reduction of an intussusception was achieved only after intraoperative intravenous administration of Glucagon. Because of this observation all our cases of the past 10 years with intussusceptions where bowel resection was necessary, were reviewed. Intraoperative macroscopic and histological findings revealed that bowel resections were not only necessary because of necrosis but also because of bowel wall lesions caused by traumatic reduction or the impossibility to reduce the intussusception. This aspect and the successful use of Glucagon during operation demonstrate that Glucagon should be administered wherever atraumatic surgical reduction of intussusception is not possible. This procedure may contribute to avoid unnecessary bowel resections.

Altered motility of the intestine after laparotomy, adynamic bowel segments, blind bowel loops following bypass operations, or diverticula may cause pathological growth of intestinal microflora and thus lead to contaminated small bowel syndrome (CSBS). As a result of malabsorption in the jejunum and ileum, loss of weight, growth arrest, diarrhea, steatorrhea, megaloblastic anemia, and hypoproteinemia may occur. In addition to these, the acute symptoms of small bowel contamination, intestinal obstruction and secretory diarrhea, are less well known.

Altered motility of the intestine after laparotomy, adynamic bowel segments, blind bowel loops following bypass operations, or diverticula may cause pathological growth of intestinal microflora and thus lead to contaminated small bowel syndrome (CSBS). As a result of malabsorption in the jejunum and ileum, loss of weight, growth arrest, diarrhea, steatorrhea, megaloblastic anemia, and hypoproteinemia may occur. In addition to these, the acute symptoms of small bowel contamination, intestinal obstruction and secretory diarrhea, are less well known. A stenosis in the terminal ileum was experimentally created in Göttingen minipigs and the bacterial flora of the small bowel assessed by quantitative cultures. After 3 months the number of aerobic and anaerobic bacteria in the pre- and poststenotic region had increased by a factor of 10(2)-10(5). The acute form of CSBS was diagnosed by microbiological examination of gastric samples in 14 children. After the children were treated with orally and intravenously administered antibiotics, the symptoms disappeared within 12-36 h. Reoperations for small bowel obstruction can be avoided by conservative treatment of CSBS with antibiotics.

In a previous series of 36 small intestinal transplants in young minipigs, a monitoring system, based on a special transplantation model, clinical and histologic criteria has been worked out. The spontaneous evolution was observed and no attempt was made to save the animal when complications on the graft occurred. Most of the animals died. In the present series of 32 small intestinal transplants the monitoring system and explantation criteria are now tested. Twenty-three primarily successfully transplanted animals had complications of the graft, i.e., hemorrhagic infarction, deficient arterial circulation, or rejection. Only 1 of the 23 died before explantation could be done. Twenty-two were explanted according to the previously established criteria. Two died of complications notdirectly related to the graft, the other 20 animals survived for 1–5 mo. All 22 explanted grafts showed irreversible damages both macroscopically and on histologic examination. The present series confirms that early recognition of complications of the graft and timely removal with survival of the recipient animal is possible. This could be an important step forward to the clinical application of small intestinal transplantation in man.

The present study represents the continuation of past research on the driver's eye movement behavior. Previous experiments yield to describe the driver's eye movement behavior in terms of time discrete process models. The established models were not perfectly accurate in predicting the driver's future fixations of the eye. The current goal was, first, to study whether any previous presupposition was not fulfilled, or whether, secondly, there exists some upper limit regarding the causal relationship between the successive fixations of the eye. The conducted experiments empirically support the validity of the prepositions. The results also yield that a driver's visual search depended on his long-term variables. The observed eye movement behavior represented a visual adaptation to the environmental conditions. The degree of adaptation depended, however, on the individual's capabilities.

Ein zeitdiskreter dynamischer Prozess wird formal definiert und eine Moglichkeit aufgezeigt, wie das Anpassungsverhalten in dieser umfassenden Beschreibungsform dargestellt werden kann.

The main function of the colon is fluid and sodium conservation. In ileostomy patients these colonic functions are lacking. The consequence is excessive loss of fluid and sodium, failure to thrive, and skin excoriation around the ileostomy. Patients with ileostomies require 6-10 mmol/kg sodium per day. With ordinary feeds, infants receive 2-4 mmol/kg sodium; therefore the sodium deficit may be estimated at 4-6 mmol/kg per day. Monitoring of adequate sodium substitution is best carried out by measuring the concentration of sodium in spot urine. Levels higher than 10 mmol/l sodium signify an adequate oral sodium intake. During the initial period of oral feeding, glucose excretion in the ileostomy fluid must be monitored, as glucose-positive ileostomy effluence necessitates additional sodium substitution in order to activate the sodium and glucose cotransport. Thirty neonates with ileostomies were followed-up retrospectively. All patients received a sodium substitution of at least 4-6 mmol/kg orally per day. The 30 patients had a total of 4769 ileostomy-days. All patients were successfully fed orally and most of them nursed at home until closure of the ileostomy.

Two infants with dumping syndrome after Nissen's fundoplication were bolus-fed with regular cows' milk formula and with test meals containing either cooked or uncooked starch. Cows' milk formula and test meals made with cooked starch provoded dumping symptoms, hyperglycaemia and hyperinsulinaemia. Dumping symptoms vanished and normoglycaemia was established when meals contained uncooked starch as the sole carbohydrate. The findings suggest that uncooked starch has a place in the dietary control of dumping syndrome in infants and possibly in adults.

Discussion of an investigation in Social psychology shows that system-identification and control analysis are useful tools for analysing dynamic behavioral systems. The theoretical background is provided by the theories of adaptive and learning systems.

Neuronal intestinal dysplasia (NID) is a disturbance of the innervation of the gut. Its symptoms resemble the ones seen in Hirschsprung's Disease. Contrary to aganglionosis, however, there is hyperplasia of the ganglia. Our study revealed isolated NID (4/49 cases) to be eight times rarer than aganglionosis (33/49 patients). Combination of both diseases has been reported to occur in 20% of NID cases; we did however find it in 75% (12/16) of our patients. NID was located proximal to the aganglionic segment and reached the stomach in 1 case. Combination of both diseases resulted in superposition of symptoms, thus rendering impossible to differentiate between NID group A (with hypoplasia of sympathetic innervation and acute early onset) and group B (with normal sympathetic innervation and chronic, late onset) on clinical grounds only. Major malformations were present in 5/16 patients with NID; 2 of them had trisomy 21.

During the last two years eight children aged 3 months to 7 years were treated successfully for contaminated small bowel syndrome (CSBS). All patients had a history of a laparotomy in the neonatal period and showed bile stained vomiting and diarrhoea. On examination, a painful distended abdomen with hyperactive bowel sounds was found. Plain abdominal x-rays showed signs of mechanical intestinal obstruction. The diagnosis of CSBS was made by positive gram stain and cultures of samples taken via a nasogastric tube. After antibiotic treatment the symptoms disappeared within a few days. We therefore believe that CSBS should always be considered in the differential diagnosis of abdominal emergencies. Our views agree with those of other authors in so far as we feel that antibiotic therapy may help to avoid unnecessary laparotomies in such cases.

Intestinal obstruction is always accompanied by intestinal hypersecretion. This phenomenon explains the initial symptoms like bilious vomiting and abdominal distension as well as the later clinical signs of hypovolaemia and shock. The proximal hypersecretion in intestinal obstruction is incompletely understood and in the surgical literature on ileus only little attention has been paid to this crucial observation. In analogy to secretory diarrhea and because of own clinical observations we conclude that bowel contamination caused by intestinal stasis is mainly responsible for the increased intestinal secretion in bowel obstruction.

More and more refined laboratory investigations for differential diagnosis of neonatal direct hyperbilirubinaemia have been developed, but not one of them is absolutely diagnostic. All of them take time and by the time the infant is referred to the surgeon it is often too late, as the prognosis for successful surgical correction becomes rapidly worse with increasing age. Most authorities have now agreed that in cases of extrahepatic biliary atresia cirrhosis has already well developed after the second month of life. The only virtually certain methods of diagnosis are direct inspection of the gall bladder, cholangiogram, and a sizeable liver biopsy. Our clinical experience has convinced us that laparoscopy with liver biopsy and simultaneous cholangiography by transhepatic puncture of the gall bladder is the simplest, fastest and most certain method for diagnosis. It allows for early differentiation of direct hyperbilirubinemia in the neonatal age and should be carried out if the hyperbilirubinemia has persisted during the first month of life and before laboratory investigations are instituted.

In diesem Kapitel werden drei Arbeiten zur Untersuchung des Konformitatsverhaltens besprochen, die fur die vorliegende Arbeit von Bedeutung sein werden.

It is believed that partial destruction of the hepatic lymph drainage during the operation of hepato-portoenterostomy is probably the cause of postoperative attacks of cholangitis. Experimental evidence is described that appears to show that omentopexy to the porta hepatis will aid hepatic lymph drainage and may thus prevent postoperative cholangitis.

The severe consequences of prolonged impaction in the oesophagus of a fairly radiolucent foreign object (aluminium can top) in 2 children are reported. The value of endoscopy in cases of unexplained dysphagia, even in the presence of normal radiographic examination, is stressed.

In childhood perianal fistulas are frequent. The origin of the fistula is the anorectal line, especially from the Morgagni crypts. Local recurrence of abscesses are observed. Due to two observations we conclude that the fistulas caused a sepsis with E. coli. In one case meningitis and a consecutive empyema occurred, in a second case pyelonephritis. In the following we describe the patient with meningitis and subdural empyema.

The indications and technique for laparoscopy in childhood are discussed. During the last 5 years 59 laparoscopies were carried out in the Surgical Department of the University Children's Hospital, Zurich, Switzerland. These cases are described in some detail. No complications were encountered.

ISBN:3-260-03507-9

There is much scientific interest in the connection between the emergence of gender based inequalities and key biographical transition points of couples in long term relationships. Little empirical research is available comparing the evolution of a couple’s respective professional careers over space and time. This article contributes to filling this gap by addressing the following questions: (a) What are the critical biographical moments when gender (in)equalities within a relationship begin to arise and consolidate? (b) Which biographical decisions precede and follow such critical moments? (c) How does decision making at critical moments impact the opportunities of both relationship partners in gaining equal access to paid employment? These questions are addressed from the perspectives of intersectionality and economic citizenship. Biographical interviewing is used to collect the personal and professional narratives of Swiss bi national and migrant couples. The case study of a Swiss Norwegian couple illustrates typical processes by which many skilled migrant women end up absently or precariously employed. Analysis reveals that the Norwegian woman's migration to Switzerland is a primary and critical moment for emerging inequality which is then reinforced by relocation (to a small town characterized by conservative gender values) and the subsequent births of their children. It is concluded that factors of traditional gender roles ethnicity and age intersect to create a hierarchical situation which affords the male Swiss partner more weight in terms of decision making and career advancement. The paper's findings are highly relevant to the formulation of policies regarding gender inequalities and the implementation of preventive programmes within this context.