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PATENT OMPHALOMESENTERIC DUCT

REVIEW OF THE LITERATURE AND CASE REPORT

J. E. MORGAN, M.D.
CLEVELAND,OHIO

C
ONGENITAL patency of the omphsuI- duct consists of a f%tuIous tract compIeteIy
omesenteric duct is a rare deveIop- Iined with intestinaI-Iike mucosa joining
menta1 anomaIy eventuating in a the termina1 iIeum to the naveI. This, of
feca1 fistuIa at the naveI. Arey’ has de- course, results in the discharge of feces at
scribed the embryoIogy invoIved as foIIows : the umbiIicus. The duct may degenerate
“The yoIk sac of an earIy human embryo into a fibrous, cord Iike structure and per-
consists potentiaIIy of two regions. Its roof sist as such. In these cases there is no feca1
is destined to foId off as a tube which f%tuIa and the anomaIy is onIy found at
becomes the primitive gut. The remainder autopsy or when a Ioop of bowe1 becomes
is the yoIk-sac proper, which has no nutri- entangIed in the cord causing intestinal
tive function but continues to grow into a obstruction.2v3
vesicIe somewhat the size of a pea. It may Persistence of the duct is usuaIIy found
persist throughout pregnancy and appear as a singIe deveIopmenta1 defect and as
among the deciduae. The isthmus of yolk- such it is amenabIe to surgica1 correction.
sac tissue connecting gut with yolk-sac It may, however, be associated with other
proper normaIIy grows at a much sIower anomaIies which wouId in themseIves be
rate and becomes drawn out into a thread- incompatibIe with Iife. The cIinician is
Iike duct, the yoIk-staIk. This stalk is primariIy interested in the cases which
incorporated into the umbiIica1 cord during occur as singIe defects suitabIe for correc-
the sixth week, but at the same time it tion. Instances of the condition are rare and
usuaIIy is aIso losing connection with the are usuaIIy reported as singIe cases. We
gut. Rapid degeneration and disappearance have found no coIIective review in EngIish
is the fina fate of the norma yoIk staIk. since CuIIen’s work in 1916.~ We have,
“NevertheIess, in about two per cent of therefore, reviewed the cases indexed in
a11 aduIts there is some evidence of the medica Iiterature and report another
persistence of that end of the yoIk staIk singIe case.
which originaIIy attached to the intestine. In aI1, one hundred five cases of persist-
The site is about two feet above the iIeo- ent patent omphaIomesenteric duct have
coIic vaIve. Such pouches are named been reported. WhiIe a few of these had
(MeckeI’s) diverticuIa of the iIeum. Com- concomitant congenita1 defects, such as
monIy they range in size from a slight umbiIica1 herniae, none is incIuded in
eIevation on the intestina1 waII to finger- which the conditions present precIuded the
Iike, bIind tubes severa centimeters Iong. possibiIity of continued existence. A few
Much more rareIy the origina staIk is which were found at autopsy on premature
retained in its entirety between iIeum and infants are incIuded. The sum of TabIes I,
umbiIicus. If patent, it aIIows intestina1 II, III and IV gives a compIete bibIiography.
contents to pass outward, whence they may The composite cIinica1 history was briefly
escape through its fistuIous mouth. Such as foIIows: The babies were usuaIIy fuI1
retention and patency constitutes an um- term, heaIthy infants. At the time of birth
biIica1 fIstuIa.” it was often, though not invariabIy, noticed
Many variants of the condition have that the umbiIica1 cord near the nave1 was
been seen. A truIy persistent and patent abnormaIIy Iarge. When the umbiIica1 cord
267
268 American Journal of Surgery Morgan-Patent Duct NOVEMBER,19.w

sIoughed off, a smaI1, cherry-red tumor’ tract. This occurred twenty-six times or in
about 44 cm. in Iength was Ieft at the navel. approximateIy one-fourth of the coIIected
This was frequentIy thought to be granula- cases. These are Iisted in TabIe I. In tweIve
tion tissue. However, at the apex of the of these cases operative treatment was
tumor there was a smaI1 opening into which attempted. Three are reported as surviving
a probe could b e passed severa centi- the operation. In one of these (CrymbIe,
meters. FecaI materia1 soon began to dis- P. T.,) there was onIy partia1 proIapse of
TABLE I
CASES IN WHICH PROLAPSUS OCCURRED
- T

No. of
Author Reference Treatment Outcome
Case

Amdt. C.. . Arch. f. Gynck., 52: 71, 1896 Case 1 Operation Death
Barth, A.. Deutscbe Ztscbr. j. Cbir., 26: 193, 1887 Case I Operation Death
Basevi, Settimio.. Jabtb. J. Kindetbeilk., 12: 275, 1878 Case 1 No operation Death
Bhn.................. Mhm. de la Sot. de biol., Paris, 55: 131, 1853 Case 1 No operation Death
Clamann.............. Deulscbe med. Wcbnscbt., 28: 416, Igo Case 1 No operation Death
Cooper, Percy R.. Clin. J., 47: 78, 1918 Case 1 Operation Death
Crymble, P. T.. Btit. J. Sutg., g: 304, 1921 Case I Operation Death
Cutler, George David. Boston M. @ S. J., 190: 782. 1924 Case I Operation Recovery?
Gesenius. . . . . . . . J. f. Kindetktankd., 25: i6, ;8;8 Case I No operation Death
Golding-Bird, C. H Clin. Sot. Tt., 29: 32, 1896 Case 1 No operation Death
Guthrie, L. G.. Pediatrics, 2: I, 1896 Case 1 No operation Death
Helweg, Kr. . Hospitals tid., 2: 705, 1884 Case 1 Operation Death
HoImes, T.. Surgical Treatment of the Diseases of Infancy Case 1 No operation Death
and ChiIdhood. London, 1868
Hue, Francois.. La Normandie mbd., 21: 162, 1906 Case 1 No operation Death
Hiittenbrenner, A. . A&. Wien. med. Zeitung, 23: 225-235, 1878 Case I Operation Death
King, T. W.. . Guy’s Hosp. Rep., 2: 467, 1843 Case I No operation Spontaneous
reduction;
recovery
KGIbing, A. Neue Zeitscbt. j. gebursk., 14: 443, 1843 Case 1 Operation Death
LGwenstein, L.. Langenbeck’s Atcb. j. k&n. Cbit., 44: 541, Case 1 Operation Death
1894-95
OphiiIs, W.. Inaug. Diss., Giittingen, 1895 Case 1 Operation Death
oql................ . . Ri_fotma med., 45: 615, 1929 Case I Operation Death
Rosenbaum, L. . Altona, 1891 Case 1 No operation Death
Siebold. Quoted by ‘ii
Schrader Inaug. Diss., Augsburg, 1854 Case I No operation Death
Thiremin, E. . . Rev. mens. d. mal. de l’enj,, 558, 1885 Case I No operation Death
ThCremin, E. Lot. cit. Rev. mens. d. mal. de I’enf., 558, 1885 Case 1 No operation Spontaneous
reduction;
recovery
VioIbing. Quoted by Bureau 1 Th&se de Paris, 1898. No. 257 Case 1 No operation Death
Weinlechner. Jabtb. f. Kindetb., 8: 55, 1874 Case I op eration Death
-

charge through this opening. The amount the duct and not true eversion of the iIeum.
of drainage varied from an occasiona In another, (CutIer, G. D.), the chiId is
soiling, occurring onIy when the boweIs were reported as surviving the operation but it
Ioose, to a continuous discharge of feces. died of erysipeIas and pneumonia before
Most of the chiIdren ate we11and deveIoped Ieaving the hospita1. In the fourteen cases
normaIIy unIess some unfortunate circum- of proIapse in which no operation was
stance intervened. attempted, spontaneous reduction occurred
The most common and most dangerous twice and the chiIdren survived. AI1 the
compIication reported was eversion or rest died of intestina1 obstruction. The
proIapse of the iIeum through the fktuIous mortaiity rate for the entire group was,
NEW SERIES VOL. LVIII, No. zz Morgan-Patent Duct American Journd of Surgery 269

therefore, about 80 per cent. In fairness it the sIough occurred, drained Iarge quan-
should be said that many of these cases tities of feca1 materia1 from the nave1 and
were reported before the advent of modern the symptoms of obstruction disappeared.
surgica1 technic. The compIication is, how- Treatment of patent omphaIomesenteric
ever, extremely dangerous. Eversion or duct, as with most surgica1 conditions, has
proIapse occurred any time from four hours varied through the years. In 1873, Mac-
after birth to two years of age but was Swiney of DubIin answered a caI1 to see a
most frequent at about five months. It boy seven years of age and found an ascaris
occurred most often during a fit of cough- Iumbricoides emerging from an opening
ing or crying. The proIapse appeared as a at the naveI. He responded to the emer-

TABLE II
CASES FOUND AT AUTOPSY OR IN WHICH NO MENTION IS MADE OF TREATMENT
-
No. of
Author Reference DetaiIs
Case
~_
Garratt, J. R. ........... Brit. M. J., I: 645, 1918 Case I Occurred in identical twins;
Case 2 no treatment mentioned
Hickman. ............... Tr., Patb. Sot. London, 20: 418, 1869 Case 1 No treatment mentioned
HoImes, T., ............. SurgicaI Treatment of Diseases of ChiIdren. Case 1 No treatment mentioned
London, I 868
MacSwiney, S. M. ....... Proc. Path. Sot., Dublin, 6: 251, 1873-75 Case 1 No treatment mentioned
Parker, C. H. ............ Am. J. Roentgenol., IO: 607, 1923 Case 1 No treatment mentioned
Poussin. ................ J. de med., 40: 81, 1817 Case 1 No treatment mentioned
Auslander, MiIton M. am i
McClure, Laura ........ Am. J. Dis. Child., 40: 1276, 1930 Case 1 Autopsy specimen
Auvard. ................ Trau. d’obstur., I : 331, 1889 Case 1 Autopsy specimen
Bridgeman, M. L. am i
Menne, Frank R., ..... Am. J. Dis. Cbild., 42: 602, 1931 Case 1 Autopsy specimen
Brindeau, ............... Fhier, 25: 45, 1895 Case 1 Autopsy specimen
Broadbent ............... Med. Times Ed Gaz., 2: 45, 1866 Case 1 Autopsy specimen
Fitz, R. ................. Am. J. Med. SC., 88: 30, 1884 Case 1 Autopsy specimen
Leisrink and AIsberg...... Arch. f. klin. Cbir., 28: 768, 1882 Case 1 Autopsy specimen
Prestat. (Quoted by Ledde r-
hose) ................. Deutscbe Cbir., Iief. 45 b., 1890 Case 1 Autopsy specimen
Roth, M ................ Vircbows Arch., 86: 371, 1881 Case 1 Autopsy specimen
Schroeder, G. ............ Inaug. Diss. (Erlangen), Augsburg, 1854 Case 1 Autopsy specimen
Wilks, SamueI. .......... Tr. Patb. SOL, London, 16: 126, 1865 Case I Autopsy specimen
-

red, sausage-Iike tumor Iying across the gency as foIIows, “I at once proceeded to
abdomen and attached by its middIe to the deIiver it in an artistic way, and I had to
navel. Symptoms of intestina1 obstruction exercise some caution in the operation Iest
rapidIy appeared and unIess the condition it should break as there was considerable
was reIieved, death folIowed. tension on the creature, and it was evident
The onIy other condition causing a feca1 that its body was tightIy compressed in a
fistuIa at the nave1 was the appIication of tract or sinus through which it was sIowIy
the cord tie to a Ioop of bowe1 present in making its way out.” The “delivery” suc-
an umbiIica1 hernia. When the cord tie cessfuIIy accompIished, the doctor men-
sIoughed through, a direct communication tioned no further treatment. Table II Iists
was Ieft between bowe1 and the outside. eighteen such cases in which no specific
Such cases were easiIy differentiated by tieatment was mentioned or which were
their cIinica1 course. Symptoms of intes- found at autopsy. During the nineteenth
tina obstruction appeared soon after the century, efforts were made to close the
tie was appIied. Those who Iived unti1 fi.stuIous tract by appIying caustics, cur-
270 American Journal of Surgery Morgan-Patent Duct NOVEMBER,1942

retting it or Iigating the umbiIica1 tumor. The report of a case of patent omphaIo-
Reports of nineteen such cases are Iisted mesenteric duct observed from birth
in TabIe III. These earIy surgica1 methods through successfu1 operation foIIows :
met with a fair measure of success in at
CASE REPORT
Ieast stopping the feca1 discharge. With the
advent of modern surgery, reports of the On February 14, 1937, I delivered the
radica1 remova of the entire sinus tract patient at EvangeIicaI Deaconess HospitaI. It

TABLE III
CASES TREATED CONSERVATIVELY OR BY LIGATURE, CAUSTICS, CURETTAGE OF THE TRACT
OR OCCLUSION APPARATUS
-
No. of Treatment Outcome
Author Reference Case
--
BilIroth. ......... Cbir. Klin., 294, 186g Case 1 Ligature Healed
Brun, L. A ....... These de Paris, No. 238, 1834 Case I Ligature Healed
Case 2 Ligature HeaIed
Case 3 No details
Eves, A. . Lancet, I: IOI, 1845 Case 1 Ligature HeaIed
Gampert . . . Rev. mkd. de la Suisse Rom., 13: 356, 1893 Case 1 Cautery and Iiga- HeaIed
ture
Hansen, J. A. ... Inaug. Diss., KieI, 1885 Case I Tumor removed HeaIed
and skin closed
Jacobi, A. . New Yorker med. Monatscbr., 14: 273, Igo Case I OccIusion appa- HeaIed
ratus
Kuierovb, D tosop. ltk. Eesk., 74: 547, 1935 Case 1 Conservative Spontaneous
CIosure
MarshalI. . . Med. Times u Gaz., 2: 640, 1868 Case I Dissected mucous HeaIed
membrane and
closed wound
Pernice, L. . . . Die NabeIges-chwiilste, HaIIe, I 892 Case 1 Tract curetted HeaIed
Pratt, J. W. . . .. Lancet, 2: 1142, 1884 Case 1 Ligature HeaIed
Quaet-FasIem . Inaug. Diss., KieI, 1899 Case I Removal of tumor HeaIed
and suture
Case 2 RemovaI of tumor Healed
and suture
Case 3 RemovaI of tumor HeaIed
and suture
Railton, T. C.. .. . . &it. M. J., I: 795, 1893 Case I Tumor removed HeaIed
and wound su-
tured
S&nchez, Santiago. ...... Arch. de med. inf., 5: 275, 1936 Case I Conservative Death
Weiss, Eduard. ......... [naug. Diss., Giessen, 1868 Case 1 Repeated appIica- HeaIed
tions of caustic
Wernher. Cited by Weiss
Eduard. ............. [naug. Diss., Giessen, 1868 Case I Zaustics No heaIing
-

began to appear in about the year r8go. was the mother’s fourth pregnancy. Labor came
Forty-two such cases are Iisted in TabIe III on at term and was quite rapid. A maIe baby
with five deaths. At present the only ques- weighing seven and one-half pounds was born
tion of treatment is when to operate. Some spontaneousIy. He appeared norma and cried
prefer to wait unti1 the chiId is about one immediateIy. Nothing unusua1 was noted about
the umbiIica1 cord which was tied with the tape
year of age. Others beIieve that the danger in use at that time
of eversion of the ileum through the fistuIa
__ _ _ The mother’s hospita1 course was uneventfu1.
outweighs the danger of’ operating on an She did not have siffrcient breast milk and the
infant onIy a few weeks of age. baby was given an evaporated milk and Karo
NEW SERIES VOL. LVIII, No. z Morgan-Patent Duct American Journal of Surgery 271

syrup formuIa which it took readily. When the At that time the baby seemed to be in exceIIent
cord sloughed off on the ninth day there was a genera1 condition and showed no evidence of
smaI1 bud of what was thought to be granuIa- distress. He was taking his formuIa well and

TABLE IV
CASES HAVING RADICAL RESECTION

No. of
Author Reference rreatment Outcome
Case

AIsberg ........................ Deutscbe med. Wcbnscbr., 18: 1040, 1892 Case 1 Resection Recovery
Ardouin, P. .................... Arch. prov. de cbir., 17: I, 1908 Case 1 Resection Recovery
Broca ......................... Rev. d’ortbop., 6: 47, 1895 Case I Recovery
Broca (Quoted by Bureau, J.) .... Thbe de Paris, No. 257, 32, 1898 Case 1 Recovery
Caldbick, S. L .................. Surg. Clin. Nortb America, 8: 1341, 1928 Case 1 Resection Recovery
Cavazzani, T. .................. Gazz. d. asp., 21: 472, 1900 Case I Resection Recovery
DeLucia, A. E. ................. Ann. di. med. nav. e colon., 2: 315, 1916 Case I Resection Recovery
Eid, F. L Canad. M. A. J., 23: 676, 1930 Case I Resection Recovery’
FroeIich, k.‘.‘.‘.‘.:: :::::::::::::: Rev. mens. d. mal. de l’enj., 20: 5 17, 1902 Case I Resection Recovery
Gevaert, G ..................... Ann. de m&d. et de cbir., 4: I, 1892 Case I Resection Recovery
Kehr,H ....................... Deutscbe med. Wcbnscbr., 18: I 166, 1892 Case I Resection Recovery
Kern .......................... Beitr. 2. klin. Cbir., 19: 353, 1897 Case 1 Resection Recovery
Kirmisson, E. .................. Rev. d’ortbop., 12: 321, 1901 Case 1 Resection Recovery
Konig, P. ...................... Tberap. Rundscbau, 2: 679, 1908 Case I Resection Recovery
Karte ......................... Deutscbe med. Wcbnscbr., 24: 321, 1898 Case I Resection Recovery
Lamare, J. P., Courtois, J. and
Isidor, P ..................... Gynkcologie, 37: 193, 1938 Case 1 Resection Recovery
J. Leveuf, R. Leroux, and A. Perrol Ann. d’anat. path., 12: 1915, 1935 Case I Resection Recovery
Case 2 Resection Recovery
Case 3 Resection Recovery
J. G. Montgomery, H. M. GiIkey,
F. B. Kyger and W. L. Jennings. J. Missouri M. A., 35: 244, 1938 Case I Resection Recovery
Morian ........................ Langenbeck’s Arch. j. klin. Cbir., 58: 306, 1899 Case I Resection Recovery
Muresanu, E ................... Cluj. med., 9: 158, 1928 Case 1 Resection Recovery
Neurath, Rudolf., .............. Wien. klin. Wcbnscbr., 9: 1158, 1896 Case 1 Resection Recovery
O’NeiI, W. E. .................. SUrg. C&I., Chicago, 3: 541, 1919 Case I Resect on Recovery
Park, RosweII .................. M. Fortnigbtly, 9: 9, 1896 Case I Resection Recovery
Pautienis, I(. ................... Medicina, Kaunas., 18: 1002, 1937 Case 1 Resection Recovery
de Planque, P. M ............... Nedrl. ttjdscbr. u. geneesk., I : 3177, 1928 Case 1 Resection Recovery
Quaet-FasIem .................. Inaug. Diss., KieI, 1899 Case 4 Resection Recovery
Ratnayeke, May ................ Brit. J. Surg., 24: 402, 1936 Case I Resection Recovery
Robinson, H. B. ................ Lancet, I : 302, 1902 Case 1 Resection Recovery
Rupp, A. ...................... Miincben. med. Wcbnscbr., 58: 85, 191 I Case 1 Resection Recovery
Ryadnov, S. M ................ SOVet. Klin., 20: 143, 1934 Case I Resection Recovery
Salzer, H. ..................... Wien. klin. Wcbnscbr., 17: 614, 1904 Case I Resection Recovery
Semb, 0 ....................... Norsk mag. F. legevdensk., 83: 778, 1922 Case 1 Resection Recovery
Shepherd, F .................... Arch. Pediat., 9: 55, 1892 Case I Resection Recovery
StierIin, R. ................... Deutscbe med. Wcbnscbr., 23: 188, 1897 Case I Resection Recovery
Strater, M .................... Deutscbe Ztscbr. j. Cbir., 74: 143, 1904 Case I Resection Recovery
BattIe, W. H. ................. Clin. sot. Tr., London, 26: 237, 1893 Case I Resection Death
Deschin. ...................... Centralbl. j. Cbir., 22: 1154, 1895 Case I Resection Death
Most, A. ..................... Beitr. z. klin. Cbir., 144: 236, 1928 Case I Resection Death
RosenbIum, L. ................ Altona, 1891 Case I Resection Death
Sauer, Felix. .................. Deutscbe Ztscbr. j. Cbir., 44: 316, 1896 Case 1 Resection Death

tion tissue present at the navel. No discharge was gaining weight. His boweIs had been mov-
was noted from this area whiIe at the hospita1. ing per rectum. There was a smaI1 red bud of
ShortIy after going home on the tenth post- tissue about 34 cm. in Iength protruding from
partum day, the mother noticed that there was the naveI. At the apex of this bud there was a
a discharge from the navel which Iooked like minute opening from.which a smaI1 amount of
bowe1 content. We were notified immediateIy. Iiquid was occasionaIIy ejected. This discharge
272 American Journal of Surgery Morgan-Patent Duct

appeared to be bowe1 content. The skin around PhysicaI examination at this time showed the
the nave1 was norma and there was no evidence patient to be an unusuaIIy we11 deveIoped and
of infection. The condition was considered due. robust IittIe boy. His weight was twenty-three
pounds. He was in good physica condition and
was mentaIIy active. The abdomen was round-
ed and of norma contour for an infant one year
oId. It was everywhere soft and flaccid. There
was no evidence of tenderness. There was no
rigidity and there was no paIpabIe masses.
There was a smaI1, moist, rounded, cherry-red
bud protruding about 36 cm. from the naveI.
(Fig. I.) This smaI1 mass was covered with what
appeared to be intestinal mucosa which was
continuous with the skin of the abdomen a11
around its edge. The skin about the nave1 was
normaI, cIean and in a healthy condition. At the
apex of the bud there was a smaI1 opening into
which a probe couId be introduced and passed
FIG. I. Patient’s abdomen showing bud pro- downward and to the right for about 3fd cm.
truding from the navel.
One especiaIIy interesting fact was noted: If
most probabIy, to a persistent patent omphalo- one watched the abdomen for some time,
mesenteric duct. This was expIained to the changes occurred in the contour of the bud at
parents and deveIopments were awaited. A the naveI. At times it wouId stand up, become
bIand ointment dressing was kept over the tense, and protrude for a distance of aImost
navel and the skin about it was kept cIean. I cm. At other times it would sIowIy draw
The chiId was next seen when he was six inward unti1 it aImost disappeared from view.
weeks of age. He was in exceIIent heaIth and The nave1 dimpIe wouId then appear aImost
was gaining weight rapidIy. He was having normaI. This change in contour took pIace
normal bowel movements per rectum. The sIowIy and graduaIIy. It was interpreted as
nave1 appeared about the same as it had before. being due to peristaIsis. Whether there was
The smaI1 red tumor was covered with mucosa- actuaIIy smooth muscIe out at the nave1 or
Iike tissue. It did not bIeed easiIy on manipuIa- whether the phenomenon was due to a puI1 on
tion as one wouId expect if it were simply the nave1 from the norma peristaIsis in the gut
granuIation tissue. There was no evidence of couId not be determined.
discharge at the time I saw it. The mother Examination of the bIood showed hemo-
stated, however, that both feces and gas came gIobin and ceIIuIar content to be normaI.
out through the opening. She had noted that FIuoroscopic and x-ray examination was per-
the occurrence of the discharge was dependent formed at our ofice. A blunt cannula was
upon the condition of the baby’s boweIs. If the introduced about I cm. into the opening at
chiId was kept rather constipated, there might the nave1 and a smaI1 quantity of thick barium
be no discharge for severa days. If the boweIs soIution injected. The barium couId be seen to
were Ioose, the discharge occurred aImost con- traverse a smaI1 tract running downward,
tinuousIy. Since deveIopment proceeded nor- inward and to the right. This tract appeared to
maIIy, a conservative course was foIIowed unti1 be about 3 or 6 cm. in length. From it, the
he was about one year of age. When seen in the barium couId be seen to enter coils of smaII
offIce at that time his deveIopment had been intestine. Just where the fistuIous tract joined
exceIIent except for deIayed dentition. He was the gut couId not be definiteIy determined.
now on an aImost genera1 diet, stiI1 avoiding However, the juncture was affected in the right
foods which had a Iaxative effect. There was Iower quadrant of the abdomen, an area usuaIIy
stiI1 intermittent discharge of bowel content occupied by loops of terminal ileum. Also, when
and gas from the naveI. The family history was the barium, which had just entered the smaI1
entireIy negative for cancer, tubercuIosis or intestine through the fistula, was observed
diabetes. There was no history of any other ffuroscopicaIIy at five minute intervaIs, it couId
congenita1 defects or abnormaIities. be seen to enter the cecum within a few
NEW SERIESVOL. LVIII, No. 2 Morgan-Patent Duct American Journal of Surgery 273

minutes. This would also indicate that the The tract had no mesentery but lay free in the
tract joined the smaI1 intestine in the Iower peritoneal cavity. It received its bIood supply
part of the ileum. X-ray pIates taken in from one large vesse1 from the mesentery of the

FIG. z. Lateral x-ray showing fistulous tract.

anteroposterior and IateraI positions confirmed bowe1 which extended completely across the
the fIuroscopic findings. (Fig. 2.) A diagnosis of bowe1 and out the fistuIous tract. This vessel
fistuIous tract from the nave1 to the smaI1 was Iigated and the fIstuIous tract was ampu-
intestine due to persistent patent omphaIo- tated with the cautery beyond a clamp.
mesenteric duct was made and surgical closure
was advised.
The patient was operated upon at Evan-
geIica1 Deaconess Hospital, February 21, 1938.
A transverse eIIiptica1 incision was made about
the navel and carried down to the peritoneum.
The peritonea1 cavity was entered just above
the naveI. This incision was carried around the
naveI, compIeteIy freeing it. When the nave1
was Iifted up, there was a rather thin, fibrous
cord attached to its peritonea1 side. As this cord
was foIIowed downward it became Iarger in FIG. 3. Resected fistulous tract with probe pro-
diameter and assumed the appearance of truding from naveI.
bowel. After extending downward and to the
right for about 8 cm. it joined at right angles (Fig. 3.) The defect in the bowe1 was closed
the antimesenteric border of a Ioop of smaI1 transversely with a running Lembert suture.
bowe1 which Iay in the right Iower quadrant of Care was taken not to impinge upon the Iumen
the abdomen. By the time the fistuIous ract of the bowe1. The abdominal waI1 was cIosed in
joined the bowe1 it had become aImost as Iarge Iayers much as one wouId repair an umbiIica1
as the gut itseIf and identica1 in appearance. hernia. No drainage of the peritonea1 cavity
274 American Journal of Surgery Morgan-Patent Duct NOVEMBER,
194~.

was instituted. The patient’s postoperative smooth muscIe was demonstrated micro-
course was uneventfu1 except for the eruption scopicaIIy a11 the way out the tract, this
of two upper incisors. He Ieft the hospita1 on changing contour was probabIy due to
the fifteenth day. peristaIsis in the tract and nave1 bud itself.
Microscopic description of the excised speci-
We have never found this sign mentioned
men by Dr. Francis Bayless was as foIIows:
in the Iiterature on the subject. It shouId be
“Sections of the Meckel’s diverticulum show a
mucosa1 surface typica of the ileum. No
a heIpfu1 diagnostic point in differentiating
heterotopic gastric mucosa is seen and there between a bud of simpIe granuIation tissue
are no other abnormalities. Sections from and the tumor of a patent omphaIomesen-
different portions of the passage leading to the teric duct.
umbiIicus show that there is we11 deveIoped and
intact muscuIaris, submucosa and mucosa CONCLUSION

throughout, and that there is an abrupt


The Iiterature pertaining to patent
transition from mucosa to stratified squamous
epithelium at the umbiIica1 orifice.”
omphalomesenteric duct is reviewed and a
case* is reported.
COMMENT

WhiIe our case cIoseIy foIIowed the com- REFERENCES

posite picture of the condition, there was I. L. B. AREY. Persona1 communications.


one point which we considered of specia1 2. GUY S. VAN ALSTYNE. Ann. Surg., gz: 1109, 1930.
3. F. DIESSL. Patancy of Ductus Omphalomesentericus.
interest. As noted in the history, proIonged Deutscbe Ztscbr. f. Cbir., 201: 266, 1927.
observation of the bud at the nave1 showed 4. THOMAS CULLEN. Embryology, Anatomy and
that it changed shape. At times it seemed Diseases of the UmbiIicus. Philadelphia, 1916.
W. B. Saunders Co.
to erect and protrude for aImost a centi-
meter. Again it drew down into the ab- *This case was studied in the of&e of Dr. S. J.
domen and aImost disappeared. Since Webster.