Journal of Pediatric Surgery

Consensus statement on the adoption of the Committee on Publication Ethics guidelines

2010-07-01

We, the undersigned editors of the member journals of the Surgery Journal Editors Group, in the furtherance of integrity in surgical and scientific publication, agree to adopt the guidelines established by the Committee on Publication Ethics (COPE) . The COPE guidelines represent a means of addressing a variety of ethical concerns, including duplicate publication and authorship misconduct issues, which have, unfortunately, become more prevalent.

National prospective surveillance study of necrotizing enterocolitis in neonatal intensive care units

Clare M. Rees, Simon Eaton, Agostino Pierro — 2010-07-01

Abstract: Purpose: There is scant epidemiological data on necrotizing enterocolitis (NEC), so we conducted a national study to characterize prevalence, surgical management, and mortality.Methods: A prospective cross-sectional survey was performed in the United Kingdom requesting data from 158 level 2 and 3 neonatal intensive care units (NICUs) during 2 winter and 2 summer months in 2005 to 2006; 51% of questionnaires were returned. Results are given as percentage with 95% confidence intervals.Results: (1) Period prevalence: 211 infants were diagnosed with NEC (45% Bell's stage I, 21% stage II, and 33% stage III) from a total of 10,946 NICU admissions, with a period prevalence of 2% (1.7-2.2). In infants less than 1000 g birth weight, the prevalence was 14% (12-16), and in less than 26 weeks of gestation, 14% (11-17). Prevalence decreased significantly with increasing birth weight (P < .0001) and increasing gestation (P < .0001). (2) Surgery: 66 infants received surgical procedures; peritoneal drain in 13 (followed by laparotomy in 8) and in 53, laparotomy alone. (3) Mortality: 27 infants died with NEC of a total 283 deaths, thus, accounting for 9.5% of NICU mortality. Eight (30%) infants with NEC died without surgery.Conclusions: Prevalence of NEC in the United Kingdom is high and comparable to published series in other countries from the 1990s. There may be a hidden mortality in patients who do not receive surgery.

Discordance of the pediatric surgeon's intraoperative assessment of pediatric appendicitis with the pathologists report

2010-07-01

Abstract: Background/Purpose: The nature and duration of postoperative treatment in children with appendicitis is largely defined by the surgeon's intraoperative assessment of the degree of disease. Therefore, misclassification of patients could result in either inadequate or excessive duration of treatment.Materials/Methods: During the execution of an institutional review board–approved multicenter, randomized, prospective, single-blinded trial of laparoscopic versus open appendectomy in children, we tracked the attending pediatric surgeon's determination of the degree of appendicitis and compared it to the pathologists report. Postoperative care was determined, per protocol, by the surgeon's intraoperative classification. “Interval” appendectomies were excluded from the analysis. Statistical significance was analyzed using χ2 analyses.Results: A total of 133 patients were randomized into the open group, whereas 122 randomized to laparoscopy during the first 2 years of the study. The attending pediatric surgeons and pathologists were concordant in the determination of acute appendicitis in 90% of open patients and 93% of laparoscopic patients (P = not significant). When children were classified by the attending surgeon as having complicated appendicitis (gangrenous or ruptured), the concordance rate dropped to 38% and 52%, respectively (P = not significant). When open and laparoscopic patients were combined, the length of postoperative stay (LOS) of concordantly classified acute appendicitis patients was 35 ± 16 hours. Concordantly classified complicated appendicitis LOS was 118 ± 61 hours, and discordantly classified complicated appendicitis (pathology = acute) LOS was 85 ± 41 hours (P = .01). Wound infection rates in the concordant and discordant “complicated” appendicitis groups were 23% and 7%, respectively (P = .05).When the surgeons are grouped as “junior”(n = 2) and “senior” (n = 3), there is a trend toward greater concordance in the latter group (P = .08).Conclusions: In the 2 institutions studied, the 5 pediatric surgeon's intraoperative classification of appendicitis correlated with the pathologist's reading in a high percentage of those patients labeled “acute” but in only approximately one half of those defined as “complicated.” These phenomena are independent of the operative approach but may correlate with surgeon experience. Interventions to improve the timeliness of pathologic diagnosis may improve the accuracy and efficiency of care of pediatric appendicitis.

Pediatric vs adult vascular trauma: a National Trauma Databank review

2010-07-01

Abstract: Introduction: The purpose of this study was to examine nationwide data on vascular injuries in children and to compare pediatric and adult patients with respect to the incidence, injury mechanisms, and outcomes.Methods: This is a National Trauma Databank analysis based on dataset version 7.0 (spanning a 5-year period ending December 2006). Pediatric patients under the age of 16 with at least one reported diagnosis of a vascular injury were compared to the adult cohort aged 16 and greater with a vascular injury.Results: During the study period, of 251,787 injured patients younger than 16 years, 1138 (0.6%) had a vascular injury. The incidence in patients 16 years or older was significantly higher, at 1.6% (P < .01). Compared to the adult vascular patients, pediatric patients had a significantly lower Injury Severity Score (16.8 ± 14.9 vs 26.3 ± 16.7, P < .001) and encountered less frequently penetrating injuries (41.8% vs 51.2%, P < .001). The most commonly injured vessels in the pediatric population were vessels of the upper extremity (424 patients or 37.9%). The overall incidence of thoracic aortic injuries in children was seven-fold lower compared to the incidence in adults (0.03% vs 0.21%). After adjusting for confounding factors, pediatric patients demonstrated improved survival following vascular injuries (adjusted odds ratio, 0.60; 95% CI, 0.45-0.79; P < .001). No significant difference was identified in the rate of amputation between pediatric and adult patients who had sustained upper or lower extremity vascular injuries.Conclusion: Vascular trauma in the pediatric population is uncommon, occurring in only 0.6% of all pediatric trauma patients. Although less frequent than adults, a significant proportion was due to penetrating injury. Vessels of the upper extremity were the most commonly injured and were associated with low mortality. Injuries of the thoracic aorta are rare. Overall, pediatric patients had an improved adjusted mortality when compared to adults.

Prehospital cardiopulmonary resuscitation in the pediatric trauma patient

2010-07-01

Abstract: Purpose: Children requiring prehospital cardiopulmonary resuscitation (CPR) after traumatic injury have been shown to have poor survival. However, outcome of children still receiving CPR on-arrival by emergency medical service to the emergency department (ED) has not been demonstrated in a published clinical series.Methods: An 11-year retrospective analysis from a level I pediatric trauma center of the outcomes of children requiring prehospital CPR after traumatic injury was undertaken. Outcome variables were stratified by survival, death, and CPR on-arrival.Results: Of 169 children requiring prehospital CPR, there were 28 survivors and 141 deaths. Of 69 children requiring CPR on-arrival to the ED, there were no survivors. There were 70 females and 99 males. Mean age of survivors was 3.4 years; nonsurvivors, 8.8 years; and 4.6 years for CPR on-arrival. Thirty-nine percent of all injuries were sustained in motor vehicle collisions; 20%, motor pedestrian collisions; 19%, assaults; 7%, falls; 4%, all terrain vehicle/motorcycle/bicycle; and 4%, gunshot wounds. Forty-two percent of all patients expired in the ED, whereas 34% expired in the intensive care unit. Eighty-seven percent of CPR on-arrival patients expired in the ED. Fifty-five percent of survivors had full neurologic recovery.Conclusion: Although mortality was extremely high for children requiring CPR in the field After traumatic injury, it was absolute for those arriving at the ED still undergoing CPR.

Application of lean methods improves surgical clinic experience

John H.T. Waldhausen, Jeffrey R. Avansino, Arlene Libby, Robert S. Sawin — 2010-07-01

Abstract: Background: A quality visit in high volume surgery clinics is challenging. There is variability in numbers of patients seen and care provider behavior. Documentation, regulatory and compliance issues and computerization of patient care systems may decrease clinic efficiency and throughput. We tried to reduce variability and improve patient experience.Methods: Baseline data included: patients seen, time in exam rooms, and spent with providers, and patient satisfaction surveys. Two Rapid Process Improvement Workshops (RPIWs) were conducted to apply lean methods. 5S techniques helped standardize exam rooms. Similar data were collected at 30 days, 60 days, and 1 year. Satisfaction surveys were followed at 6 months and 1 year.Results: Median pre-RPIW room time was 49 minutes. Post-RPIW times were 33 minutes at 30 days, 41 minutes at 60 days, and 42 minutes at 1 year. Face to face provider-patient time increased 30% to 61% at 30 days, 58% at 60 days, and 59% at 1 year. The median number of patients in a 4-hour clinic increased from 10 to 12. Satisfaction survey Problem Scores improved and were sustained.Conclusions: Lean methodology may be used to improve clinic efficiency as well as patient and staff's experience.

No free ride? The hidden costs of delayed operative management using a spring-loaded silo for gastroschisis

2010-07-01

Abstract: Purpose: The ideal management of gastroschisis (primary vs staged closure) has not yet been established. Despite the ease of silo placement, anecdotal experience shows that silos do not always offer benefit. The aim of this study was to highlight concerns regarding use of spring loaded silos and compare outcomes to primary closure.Methods: Thirty-seven neonates with gastroschisis treated with either primary (n = 10) or staged closure with a spring-loaded silo (n = 27) were reviewed (1998-2007). Variables included ventilator days, daily intravenous fluid, hospital days, and complication rates. SPSS (SPSS Inc, Chicago, Ill) was used to perform t test and χ2 analyses (significance P < .05).Results: Survival for primary closure was 100% (10/10) compared to 89% (24/27) for staged closure (P = .548). Patients managed with silos required prolonged ventilation (16.1 ± 4 days vs 3.6 ± 1 days; P ≤ .05) and greater intravenous fluids on days 3, 4, and 5 of life (132 ± 25 mL/kg per day vs 104 ± 18 mL/kg per day; P ≤ .01). Although there was no difference in the complication rates between the groups, several problems were evident in the silo group: 15% (4/27) required silo replacement, 44% (12/27) required fascial defect enlargement for silo placement, and 19% (5/27) required mesh at closure. No significant differences in recovery of intestinal function were observed. Three silo patients developed ischemic complications because of vascular insufficiency at the level of the abdominal wall, leading to significant intestinal loss, ventilator and total parenteral nutrition dependence, and increased hospital stay.Conclusions: Patients managed with a silo had longer ventilator requirements and greater fluid needs. This Specific technical complications leading to bowel ischemia were notable in the silo group. The silo should be carefully placed to avoid bowel twisting and the funnel effect. Larger prospective studies should be performed to provide decision-making criteria for the use of a silo vs primary closure.

The impact of preoperative ultrasound on correct diagnosis of urachal remnants in children

Eva E. Widni, Michael E. Höllwarth, Emir Q. Haxhija — 2010-07-01

Abstract: Background: Ultrasound is a noninvasive imaging method used widely in urachal diagnostics. This study investigated the effectiveness of ultrasonography in correctly depicting urachal anomalies in children.Methods: Preoperative ultrasound findings of all patients who were operated on for suspected urachal anomalies between 1990 and 2008 were retrospectively compared with the final diagnosis.Results: Fifty-three patients (31 female, 22 male; ∼2.6 years; range, 0-17 years) were reviewed. In 37 patients, the final diagnosis of an urachal anomaly matched the ultrasound findings. In 7 patients, there was a false-positive ultrasound finding, and in 9 patients, there was a false-negative ultrasound finding. Three of 4 patients with urachal cysts, 23 of 29 patients with urachal fistulas, and 8 of 10 patients with urachal sinuses were correctly identified by ultrasonography. In 10 patients, no urachal rests were found intraoperatively: in 7 of these patients, urachal rests were falsely suspected by ultrasound. The positive predictive value for ultrasound is 83%, whereas the negative predictive value is 25%. The sensitivity for this diagnostic method is 79% and the specificity 30%.Conclusions: Ultrasound helps to identify urachal anomalies in case of their presence but is not helpful to rule out a nonexisting urachal anomaly.

Tracheal cartilaginous sleeve in patients with craniosynostosis syndromes: a meta-analysis

Keith Lertsburapa, James W. Schroeder, Christine Sullivan — 2010-07-01

Abstract: Objectives: The purpose of this study is to determine if there is a survival advantage to having a tracheostomy in patients with tracheal cartilaginous sleeve (TCS), to determine if the age of the patient at the time of tracheostomy affects morbidity, and to determine if patients with a true pars membranacea have a survival advantage and less morbidity than those without a pars membranacea.Study Design: Case report and meta-analysis of the literature were conducted.Methods: A review of the world literature from 1979 to 2006 was performed. All reports of patients with craniofacial syndromes found to have TCS by autopsy or endoscopic findings were included. A case report of a new patient with TCS is presented.Results: Patients who undergo tracheostomy have a statistically significant survival advantage (P = .0067). The patient's age at the time of tracheostomy was not associated with survival time (P = .45). There is no association with absence or presence of a pars membranacea and clinical symptoms of respiratory distress (P = .50). There is no overall difference in survival between patients with a pars membranacea and those without (P = .78).Conclusion: Tracheostomy placement in patients with TCS and craniosynostosis can decrease morbidity and increase survival. Interval bronchoscopy is important to treat tracheal stoma granulation tissue. There is no survival advantage to having TCS with a pars membranacea.

Gene expression analysis in hypoplastic lungs in the nitrofen model of congenital diaphragmatic hernia

2010-07-01

Abstract: Background: Pulmonary hypoplasia and persistent pulmonary hypertension are the main causes of mortality and morbidity in newborns with congenital diaphragmatic hernia (CDH). Nitrofen is well known to induce CDH and lung hypoplasia in a rat model, but the mechanism remains unknown. To increase the understanding of the underlying pathogenesis of CDH, we performed a global gene expression analysis using microarray technology.Methods: Pregnant rats were given 100 mg nitrofen on gestational day 9.5 to create CDH. On day 21, fetuses after nitrofen administration and control fetuses were removed; and lungs were harvested. Global gene expression analysis was performed using Affymetrix Platform and the RAE 230 set arrays. For validation of microarray data, we performed real-time polymerase chain reaction and Western blot analysis.Results: Significantly decreased genes after nitrofen administration included several growth factors and growth factors receptors involved in lung development, transcription factors, water and ion channels, and genes involved in angiogenesis and extracellular matrix. These results could be confirmed with real-time polymerase chain reaction and protein expression studies.Conclusions: The pathogenesis of lung hypoplasia and CDH in the nitrofen model includes alteration at a molecular level of several pathways involved in lung development. The complexity of the nitrofen mechanism of action reminds of human CDH; and the picture is consistent with lung hypoplasia and vascular disease, both important contributors to the high mortality and morbidity in CDH. Increased understanding of the molecular mechanisms that control lung growth may be the key to develop novel therapeutic techniques to stimulate pre- and postnatal lung growth.

Structural and biomechanical characteristics of the diaphragmatic tendon in infancy and childhood: an initial analysis

2010-07-01

Abstract: Background: Engineered tendon grafts have been shown, experimentally, to be promising alternatives for partial diaphragmatic replacement. This study was aimed at determining the cellularity, extracellular matrix composition, and biomechanical characteristics of the diaphragmatic tendon in infants and children to be used as a reference for proper diaphragmatic graft engineering.Methods: The left diaphragmatic tendon was procured at autopsy from 13 patients divided into 2 groups. Group I (n = 9) consisted of newborns and infants. Group II (n = 4) consisted of children and adolescents. Samples underwent quantitative assays for total DNA, glycosaminoglycans, collagen, and elastin contents. Biomechanical measurements included modular and ultimate tensile strength analyses. Statistical comparisons were by the 2-sample Student's t test.Results: Group I showed significantly higher levels of total DNA, glycosaminoglycans, collagen, and elastin than group II. Conversely, group II tended to have higher modular and ultimate tensile strengths.Conclusions: In neonates and infants, the diaphragmatic tendon has increased cell density and higher levels of major extracellular matrix components than in older children, in whom the diaphragmatic tendon tends to have higher tensile strength. Engineered diaphragmatic constructs should be tailored to the distinct anatomical, functional, and biomechanical characteristics of the diaphragmatic tendon at different age groups.

Anastomotic stricture after surgical repair of esophageal atresia: frequency, risk factors, and efficacy of esophageal bougie dilatations

2010-07-01

Abstract: Aims: The aim of this study was to evaluate the frequency and risk factors of postoperative anastomotic stricture, and the efficacy and complications of esophageal bougie dilatations for symptomatic anastomotic stricture in a population of children with esophageal atresia.Patients and Methods: The medical records of 62 children operated on for esophageal atresia type III (Ladd and Gross) over a 5-year period were retrospectively reviewed.Results: Anastomotic stricture developed in 23 (37%) of patients. Anastomotic tension during primary repair of esophageal atresia was associated with subsequent stricture formation (P < .05). Patients required esophageal dilation at a mean age of 149 days (range, 30-600 days). Stricture resolution occurred after a mean of 3.2 dilatations per patient (range, 1-7). Dilation was successful in 87% of patients. Three patients continued to present mild (n = 1) to severe (n = 2) dysphagia, mainly related to esophageal dysmotility. No complications were observed during or after the dilatation sessions.Conclusions: Anastomotic stricture, secondary to the surgical treatment of esophageal atresia, remains a frequent complication in patients with esophageal atresia. Esophageal dilation with Savary-Gilliard bougies is a safe and effective procedure in the management of strictures.

Laparoscopic extended cardiomyotomy in children: an effective procedure for the treatment of esophageal achalasia

2010-07-01

Abstract: Purpose: Achalasia of the esophagus is characterized by aperistalsis and incomplete relaxation of the lower esophageal sphincter in response to swallowing. The objective of the present study is to present the experience of a modified Heller myotomy via a laparoscopic approach for the treatment of children who had this condition.Methods: A retrospective review of medical records of all patients who underwent this procedure from 2000 to 2009 was performed. The procedure consisted of an extended esophagomyotomy beginning on the lower part of the lower esophageal sphincter and continuing 5 to 6 cm above on the lower third of the esophagus, and then extended 3 to 4 cm below to the stomach, associated with an anterior 180-degree hemi-fundoplication according to Dor's technique.Results: Fifteen patients were included in the study. There were 8 female and 7 male patients. Mean operating time was 190 minutes with no intraoperative complications and 1 conversion to open surgery because of difficulty in dissecting an inflamed distal esophagus. In a mean follow-up period of 32.3 months, 2 patients had recurrence of mild dysphagia that disappeared spontaneously, and 1 required a single botulinum toxin injection with complete resolution of symptoms.Conclusion: We conclude that the laparoscopic extended Heller myotomy with Dor fundoplication is a safe and effective method for the treatment for achalasia in the pediatric population even in advanced cases.

Influence of Down's syndrome on management and outcome of patients with congenital intrinsic duodenal obstruction

Rangsan Niramis, Maitree Anuntkosol, Achariya Tongsin, Varaporn Mahatharadol — 2010-07-01

Abstract: Purpose: Children with Down's syndrome (DS) have been reported to have a high incidence of congenital heart disease (CHD) and respiratory tract infection. These anomalies and complications lead to poor outcomes, especially after treatment of congenital intrinsic duodenal obstruction (CIDO). The aim of this study was to review and compare the outcome of management of CIDO at a single tertiary institute for children in Thailand.Methods: We reviewed the medical records of patients with CIDO, who were treated at Queen Sirikit National Institute of Child Health (Bangkok, Thailand) from 1997 to 2006. The patients were classified into 2 groups: A = CIDO with DS and B = CIDO with non-DS (NDS). Each group was then divided into 2 subgroups: A1 = DS without CHD, A2 = DS with CHD, B1 = NDS without CHD, and B2 = NDS with CHD. Comparisons of management and outcome between group A and group B, subgroup A1 and subgroup B1, and subgroup A2 and subgroup B2 were performed. Statistical differences were analyzed by the χ2 test at a P < .05.Results: A total of 227 patients (male-female = 108:119) underwent surgical correction of CIDO. Of 227 patients, 86 (37.9%) were shown to have DS (group A), and 141 (62.1%) were NDS patients (group B). Demographic information did not differ between the groups, except for the mothers' age at pregnancy and the operative procedure used for duodenoduodenostomy. Group A had a higher incidence of CHD than group B (66.3% vs 26.2%; P < .05). Early outcome regarding survival rate (SR) was not statistically different between groups (87.2% vs 92.9%; P = .15), but the rate of early postoperative complications in group A was higher than that in group B (45.3% vs 31.1%; P = .03). The overall SR of group A at long-term follow-up was worse than that in group B (68.6% vs 86.7%; P < .05). Late complications and sequelae in group A were also more frequent than in group B (34.6% vs 9.2%; P < .05).When comparing early outcome between DS and NDS patients without CHD, the SR of subgroup A1 was lower than that of subgroup B1 (86.5% vs 96.5%; P = .04), but the rate of early postoperative complications did not differ (41.5% vs 24.1%; P = .05). At long-term follow-up, the overall SR of subgroup A1 was worse than that of subgroup B1 (73% vs 95.6%; P < .05) because of a higher incidence of late death because of recurrent respiratory tract infection in the A1 subgroup. In addition, late complications and sequelae were more common in subgroup A1 than in subgroup B1 (37.5% vs 8.9%; P < .05).In patients with CHD, there was no statistical difference between early and long-term results of SR or complications between subgroup A2 and subgroup B2. The overall SR at long-term follow-up was 63% in subgroup A2 and 56% in subgroup B2 (P = .5).Conclusions: Early outcome of CIDO management revealed minimal differences between DS and NDS patients. However, these differences were clearer in long-term outcomes. The DS patients had lower long-term SR and higher rates of complications and sequelae than NDS patients. It is concluded that DS negatively impacts the management and outcome of patients with CIDO.

Surgical complications after intestinal transplantation in infants and children—UK experience

2010-07-01

Abstract: Surgical complications have a significant impact on morbidity and mortality following intestinal transplantation (ITx). Birmingham Children's Hospital commenced intestinal transplantation in 1993 and the following surgical strategies evolved: (a) pretransplant abdominal tissue expanders, 1998; (b) combined en-bloc reduced liver and intestinal transplantation (CRLITx), 1998; (c) staged abdominal closure, 2001; (d) preservation of graft duodenal artery, 2005.Aim: An internal audit was performed to document the surgical complications after ITx and to evaluate strategies in the management and prevention of complications.Methods: A retrospective analysis of the medical records from January 1993 to June 2007 was conducted to identify surgical complications, evaluate management strategies, and report outcome following ITx.Results: Forty-six children underwent 49 ITx (9 isolated intestinal, 39 combined liver and intestinal [CLITx], and 1 multivisceral transplant). Twenty three children had CRLITx since 1998, although there were none before 1997. The median donor: recipient weight ratio in CLITx was 2.2:1 (range, 0.67:1-6.70:1). Twenty-six children experienced 29 (59%) surgical complications: portacaval shunt thrombosis (n = 2, none alive); graft duodenal stump leakage (n = 3, 2 alive); spontaneous bowel perforation(n = 6, 2 alive); sub-acute bowel obstruction (n = 6, all alive); abdominal compartment syndrome ([ACS], n = 4, 2 alive); pancreatic leak (n = 3, 2 alive); biliary complications (n = 22, 17 alive ) failed staged abdominal closure with wound sepsis requiring skin grafting into the bowel (n = 1, alive), wound dehiscence (n = 1, alive), anastomotic leak (n = 1, alive) and intra-abdominal bleeding (n = 1,alive), primary nonfunction (n = 1, 1 died). Following the complications of ACS in children with primary abdominal closure and graft duodenal stump leaks in 2004, we modified our strategies in 2005 to include staged abdominal closure with recipient to donor weight mismatch, and preservation of the gastroduodenal artery during donor organ procurement in addition to pre transplant abdominal tissue expansion. Fifteen children with recipient and donor weight mismatch subsequently required staged closure of the abdomen and none of them developed ACS. Twelve children had gastroduodenal artery preserved and none developed graft duodenal stump leaks. Twenty-four of the 46 (52%) are alive 6 months to 10 years post transplant.Conclusion: Evolving strategies may avoid or reduce surgical complications commonly seen after intestinal transplantation and thus contribute to an improved outcome.

Vagus nerve stimulation for the management of seizures in children: an 8-year experience

David S. Coykendall, Michael W.L. Gauderer, Randall R. Blouin, Augusto Morales — 2010-07-01

Abstract: Background: Medication-resistant seizure disorder is a challenging, debilitating, and expensive condition. Although multiple interventions are now available, none is universally effective. In 1997, vagus nerve stimulation (VNS) was approved for treatment of refractory seizures in patients older than 12 years. Vagus nerve stimulation has shown some benefit for these individuals, but less is known about its use in patients younger than 12 years. This review analyzes the safety and efficacy of VNS in young children.Methods: From March 2000 to February 2008, patients with medication-resistant seizures were implanted with a neurocybernetic prosthesis. Two weeks later, the device was activated. The children were followed for at least 3 months, and adjustments were made. Retrospective chart review was performed to collect data.Results: Of 28 patients, the mean age at implantation was 8 years and 5 months. Twenty-one (75%) children were younger than 12 years. There were no surgical complications. Two children were reimplanted for lead malfunction, and 4 generators were replaced. Two children had transitory adverse effects (hoarseness and stridor). Mean follow-up was 3 years and 5 months. At 1 year, 52% of children had greater than 50% reduction in seizures.Conclusions: Although the effectiveness of VNS is variable and unpredictable, safety is high even in young children. Because of the potential benefit for these complex patients, the implantation of this nerve stimulation device should be included in the armamentarium of pediatric surgeons.

Ovarian germ cell tumors in children. Management, survival and ovarian prognosis. A report of 75 cases

2010-07-01

Abstract: Background/Purpose: The aims of this study were to evaluate survival and ovarian prognosis in patients treated for ovarian germ cell tumor (OGCT) and to propose a decision-making protocol.Methods: Charts of girls operated on for OGCT from 1976 up to 2009 were reviewed retrospectively. Tumor characteristics were assessed by tumor markers, imaging, and pathology.Results: Charts were available in 71 children presenting 75 OGCT. Tumors were benign in 58 cases and malignant in 17 cases. The average of the largest diameter of benign OGCT was significantly lower than that of malignant OGCT (76.5 ± 49 mm versus 169 ± 54 mm, P < .0001). Ovarian-sparing tumorectomy was carried out in 27 benign OGCT; 23 (85%) preserved ovaries were follicular. Malignant OGCTs were managed according to the protocols of the French Society for Pediatric Oncology. Bilateral oophorectomy had to be performed in 2 children. One patient presented a recurrence and 1 died.Conclusions: In our series, both benign and malignant OGCTs have a good prognosis. A 75-mm cutoff size is proposed as an important criterion to preoperatively differentiate between benign and malignant tumors. In benign OGCT, ovarian-sparing tumorectomy leads to preserve ovaries in approximately 85% of cases, and in malignant OGCT, high survival rate has been obtained.

Retained intravascular fragments after removal of indwelling central venous catheters: a single institution experience

2010-07-01

Abstract: There are few reports regarding the presence of retained fixed fragments after removal of indwelling central venous catheters in children. We conducted a retrospective study of 355 patients who underwent removal of central venous catheter from 1996 to 2008. Six patients (1.6%) had a failed attempt of removal, resulting in a remnant of catheter left in the central venous system. All of them had underlying malignant disorders and received chemotherapy for a prolonged period of time. In 2 patients, a second attempt of retrieval was performed that was partially successful. After an average follow-up of 3.5 ± 1.8 years, 1 patient has developed mild symptoms that could be related to the remaining fragment within the vascular system. Therefore, the incidence of complications caused by retained fixed fragments is low. Patients whose line has been in place for more than 48 months (P = 0.009) and those located in the saphenous vein (P = 0.01) are more prone to experience fragment retention. The decision of retrieval should be balanced according to the presence of symptoms and the length of the fragment retained.

Intussusception after pancreatic surgery in children: a case series

Pablo Laje, Charles A. Stanley, N. Scott Adzick — 2010-07-01

Abstract: Background: Postoperative intussusception (POI) has been described after a wide variety of pediatric surgical procedures, but it has not been reported as a complication after pediatric pancreatic resections.Methods: We performed a retrospective review of 5 cases of pancreatectomy-related POI observed between October 1998 and July 2009 within a series of 234 pancreatic resections in children.Results: The incidence of pancreatectomy-related POI was 2.1%. Postoperative intussusception was observed after either partial or near-total pancreatic resections. There was no sex predisposition. All cases occurred within the first 2 postoperative weeks and involved the small bowel exclusively. The outcome after surgery was uneventful in all cases. The overall clinical course in our cases was similar to that described in the literature for POI associated with other surgical procedures.Conclusions: The incidence of POI after pancreatic resections in children is significantly higher than the general incidence reported in the literature (2.1% vs 0.08%-0.25%).

Laparoscopic-assisted anorectal pull-through for anorectal malformations: a systematic review and the need for standardization of outcome reporting

Omar Al-Hozaim, Jamila Al-Maary, Aayed AlQahtani, Mohammed Zamakhshary — 2010-07-01

Abstract: Introduction: Laparoscopic-assisted anorectal pull-through (LAARP) is becoming an increasingly common procedure to correct high and intermediate anorectal malformations (ARMs). The aim of this review was to evaluate worldwide experiences with LAARP with regard to indications, outcomes, and quality of reporting.Method: A systematic review was conducted. The search was limited to studies reported in English and performed in humans. In addition to Medline and PubMed, a manual search of the Journal of Pediatric Surgery, Pediatric Surgery International, Surgical Endoscopy, and the Journal of Laparoendoscopic & Advanced Surgical Techniques published between June 2000 and April 2008 was conducted.Results: Seventeen studies were included in the final analysis. Of the included studies, none were randomized, 2 were prospective in nature, and 4 compared outcomes of posterior sagittal anorectoplasty and LAARP. The studies included 124 patients (96 males, 28 females) with 80% reported as having high/intermediate malformations. All studies reported short-term outcomes. Reported outcomes included continence, rectal prolapse, the position of the rectum (7 studies using Kelly score), manometry (1 study), contrast enema (1 study), postanal endosonography (3 studies), and postoperative magnetic resonance imaging (3 studies). Outcomes varied widely between reports precluding a meta-analysis.Conclusion: The number of studies dealing with LAARP is low. There is a need for both a standardization and improvement in the quality of reporting in LAARP research. This will ultimately allow for evidence-based surgical decision making.

Anterior or posterior sagittal anorectoplasty without colostomy for low-type anorectal malformation: how to get a better outcome?

Caroline F. Kuijper, Daniel C. Aronson — 2010-07-01

Abstract: Background/Purpose: Usually, anorectal malformations (ARM) are treated in 2 or 3 stages for fear of disturbed wound healing and subsequent damage to the anal sphincter complex. The aim of this study was to assess the feasibility, safety, advantages, and follow-up of an anterior or posterior sagittal anorectoplasty in low-type ARM (rectoperineal or rectovestibular), performed without colostomy.Materials and Methods: Prospective collection of data regarding demographics, VACTERL (Vertebral-, Anal-, Cardiac-, Tracheo-Esophageal-, Renal-, Limb malformations) screening, perioperative measurements, surgeons, and complications.Results: In 35 consecutive children (13 boys, 22 girls), repair of a low-type ARM was performed without colostomy. There were 13 boys and 10 girls with a rectoperineal and 12 girls with a rectovestibular fistula. The median age at operation was 4 months (range, 0-73 months); 34% being performed in the newborn period. Seventeen children had one or more other congenital anomaly. Preoperatively, all patients had rectal washouts with oral and rectal neomycin, and perioperative antibiotics, either 24 h (prophylaxis) or for 2 to 5 days. An anterior or posterior sagittal anorectoplasty was performed.Postoperatively, 9 children had no enteral feeding and total parenteral nutrition (TPN). All children had postoperative anal dilatations according to the Peña scheme. Two children (both with rectoperineal fistula) had a wound abscess; in the first child (with renal insufficiency), a colostomy was performed and in the other child a successful correction of the anoplasty was done. In 7 children (4 rectoperineal, 3 rectovestibular fistulae), the anus eventually healed after minor wound dehiscence. There was 1 anal stricture, after a median follow up of 14 months (range, 1-84 mo). After therapeutic antibiotics (2-5 days), 11% (2/18) had some degree of wound infection, versus 41% (7/17) after either no antibiotics or after prophylactic antibiotics (24 hours). Patients with TPN did not seem to profit with regard to wound healing and one patient experienced a central line related sepsis. At last follow-up, 12 children needed regular laxatives and/or enemas. Anal dilatations were well accepted above 6 months, and a trend was seen towards less need for laxatives when dilatations were continued longer.Conclusion: Repair of a low-type ARM without colostomy, with therapeutic antibiotics, and followed by a long period of postoperative anal dilatations has low morbidity and good outcome, which does not seem to be improved with TPN.

Wound infection after colostomy closure for imperforate anus in children: utility of preoperative oral antibiotics

Francine D. Breckler, Frederick J. Rescorla, Deborah F. Billmire — 2010-07-01

Abstract: Background/Purpose: There is little published data on the efficacy of surgical infection prophylaxis in children. The purpose of this study was to assess wound infection rate in children undergoing colostomy closure for imperforate anus and evaluate the impact of bowel preparation and antibiotics.Methods: Children younger than 18 years with imperforate anus who had a colostomy closure between January 1996 and December 2007 were identified. Data collected included demographics, bowel preparation, antibiotics, operative details, and postoperative infections. Comparison of mechanical bowel preparation and intravenous antibiotics with and without oral antibiotics was compared using χ2 tests. Significance was defined as P < .05.Results: A total of 118 patients were identified. Primary skin closure was done in 97%. Mechanical bowel preparation was used in 93%, intravenous antibiotics in 97%, and oral preoperative antibiotics in 52%. Wound infections occurred in 14% (n = 17). The addition of oral antibiotics to the standard regimen of mechanical bowel preparation with intravenous antibiotics did not alter infection rate (13% versus 17%, P = .64).Conclusion: Wound infection in children undergoing elective colostomy closure for imperforate anus was 14%. Infection rate was not affected by use of oral antibiotics. Future studies may allow specific guideline development for infection prophylaxis in pediatric patients.

Progressive hair coil penile tourniquet syndrome: multicenter experience with 25 cases

Haytham Badawy, Ashraf Soliman, Aly Ouf, Ahmed Hammad, Samir Orabi, Ahmed Hanno — 2010-07-01

Abstract: Objective: Penile hair tourniquet syndrome is an uncommon syndrome characterized by progressive penile strangulation by a hair tie. Complications reported include urethrocutaneous fistula, complete urethral transection, penile gangrene, and penile amputation. Prevention of such major complications depends on awareness of the etiology and presence of a high index of suspicion for early diagnosis.Patients and Methods: Twenty-five children presenting with different degrees of hair coil penile strangulation syndrome have been operated on in the period from 2000 to 2007 in 2 tertiary care centers in the city of Alexandria. Eighteen boys had complete transection of the urethra at the coronal sulcus. Seven boys had partial transection of the ventral wall of the urethra at the coronal sulcus. Repair of the penis was done in all children in a single stage.Results: The mean age of boys is 3 years and 9 months (2-5 years). The mean follow-up is 20.7 (6-48) months. Urethral catheter was left for a mean of 5.5 (4-7) days. In the mean follow-up period, we had 4 complications in the form of 2 tiny urethrocutaneous fistulas and 2 anastomotic urethral strictures. The fistulae were closed surgically after the primary surgery by 1 year in the 2 cases, with no recurrence. Urethral strictures were managed by endoscopic visual urethrotomy, with no recurrence.Conclusion: Penile tourniquet syndrome can cause serious penile complications. Awareness of this rare syndrome can help in preventing such complications. Being familiar with the surgical reconstruction guarantees high success rate.

Wandering spleen in children: multicenter retrospective study

2010-07-01

Abstract: Wandering spleen in children is a rare condition. The diagnosis is difficult, and any delay can cause splenic ischemia. An epidemiologic, semiological, and surgical diagnosis questionnaire on incidence of wandering spleen in children was sent to several French surgical teams. We report the results of this multicenter retrospective study.Fourteen cases (6 girls, 8 boys) were reported between 1984 and 2009; the age range varies between 1-day-old and 15 years; 86% were seen in the emergency department. Ninety-three percent had diffuse abdominal pain. For 57% of the cases, it was their first symptomatic episode of this type. No diagnosis was established based on the clinical results alone. All patients had presurgical imaging diagnosis. Open surgery was performed on 64% cases. Forty-three had splenectomy for splenic ischemia. Thirty-six percent had splenopexy, 14% had laparoscopic gastropexy, and 7% had spleen repositioning and regeneration. Complications were noted in 60% of the cases resulting in postsplenopexy splenic ischemia.Early diagnosis and surgery are the best guarantee for spleen preservation. Even if the choice of one technique, splenopexy or gastropexy, can be argued, gastropexy has the advantage of avoiding splenic manipulation and restoring proper physiologic anatomy. When there is no history of abdominal surgery, laparoscopy surgery seems the best procedure.

Laparoscopic spleen-preserving distal pancreatectomy for solid pseudopapillary tumor with conservation of splenic vessels in a child

2010-07-01

Abstract: Laparoscopic spleen-preserving distal pancreatectomy (LSDP) with conservation of the splenic vessels is gaining acceptance as a reliable treatment for selected patients with low-grade malignant tumors of the pancreas in adults. The operation requires advanced laparoscopic skills to safely divide the fine branches of the splenic vessels. Laparoscopic spleen-preserving distal pancreatectomy with conservation of splenic vessels is rarely reported in children. We describe a 12-year-old girl with solid pseudopapillary tumor in the body of the pancreas that was successfully treated with LSDP, preserving the splenic vessels. The postoperative course was uneventful, and the functional and aesthetic results were satisfactory. Laparoscopic spleen-preserving distal pancreatectomy with conservation of splenic vessels may be a safe and feasible treatment option for children with pancreatic disease.

Use of a massive transfusion protocol with hemostatic resuscitation for severe intraoperative bleeding in a child

2010-07-01

Abstract: Use of a defined massive transfusion (MT) protocol for severe intraoperative bleeding in a pediatric patient has never been described. Herein we present a case whereby use of hemostatic resuscitation delineated in an MT protocol optimally treated hemorrhage resulting from a large tumor during right hepatectomy. The MT protocol principles, benefits, and postoperative course of the patient are described.

Laparoscopic-assisted transhiatal gastric transposition for long gap esophageal atresia in an infant

Ryan M. Juza, Marjorie J. Arca, John C. Densmore, John J. Aiken, Dave R. Lal — 2010-07-01

Abstract: Previous reports describing laparoscopic-assisted transhiatal gastric transposition for long gap esophageal atresia (LGEA) have focused on older infants (median age of 11 months). By performing this operation at an earlier age, patients may avoid esophagostomies or prolonged hospitalizations with nasoesophageal tubes. An additional benefit is the earlier introduction of oral feeds, which is likely to decrease the incidence of oral aversion and feeding difficulties. In this report, we describe our surgical technique for performing a laparoscopic-assisted gastric transposition in a 56-day-old former 36-week premature infant with LGEA.

Ruptured rectal duplication cyst with classical bladder exstrophy

2010-07-01

Abstract: A newborn boy was brought to us, 2 hours after birth, with a mucosal-lined left hemiperineal lesion associated with classical bladder exstrophy and an anterolaterally displaced anus. Perineal anatomy was restored by excising the mucosa lined lesion. The bladder closure for classical bladder exstrophy was done at the same time. Histologically, gastric, respiratory, and small intestinal epithelia were present in the mucosa. A rectal duplication cyst that had ruptured in utero through the hemiperineum could explain the anomaly. The association of classical bladder exstrophy with ruptured rectal duplication cyst has never previously been described in the literature.

Perirectal arteriovenous malformation treated by angioembolization and low anterior resection

2010-07-01

Abstract: We present a case of a child with ongoing lower gastrointestinal bleeding caused by a rectosigmoid arteriovenous malformation. To reduce perioperative bleeding, we performed preoperative angioembolization followed by subsequent resection by low anterior resection. Here we present the case and review the literature regarding neoadjuvent embolization for gastrointestinal and pelvic arteriovenous malformations.

Nonoperative management of a giant omphalocele using a silver impregnated hydrofiber dressing: a case report

Stephen Almond, Roxana Reyna, Natalie Barganski, Mohammad A. Emran — 2010-07-01

Abstract: The surgical management of a giant omphalocele is challenging. Many cannot be closed at birth and must initially be managed nonoperatively with a topical agent to facilitate epithelialization. We report the case of a term, 1-day-old female neonate with a giant omphalocele treated initially with a hydrofiber dressing containing silver (Aquacel Ag; ConvaTec Inc, Skillman, NJ) and then with delayed primary closure.

Anti–N-methyl-d-aspartate receptor encephalitis associated with an ovarian teratoma in an adolescent female

Aaron P. Lesher, Thomas J. Myers, Fred Tecklenburg, Christian J. Streck — 2010-07-01

Abstract: Anti–N-methyl-d-aspartate (NMDA) receptor encephalitis is a recently described paraneoplastic syndrome with prominent neuropsychiatric symptoms. We report a case of NMDA receptor encephalitis in a 15-year-old female related to the development of NMDA receptor autoantibodies triggered by an ovarian teratoma. Removal of the mature teratoma proved curative with eventual resolution of the paraneoplastic disease process and associated psychiatric symptoms. Increasingly, reports of anti-NMDA receptor encephalitis associated with ovarian teratomas in pediatric patients, as well as a novel assay to measure these antibodies, suggest an etiology for this disease process that may be amenable to prompt surgical excision. The clinical presentation, diagnosis, and surgical management of the disease, as well as a review of the literature, are included.

Prenatal diagnosis and postnatal resection of intraabdominal enteric duplications

Pablo Laje, Alan W. Flake, N. Scott Adzick — 2010-07-01

Abstract: Purpose: The high definition provided by modern imaging techniques allows the delineation of fetal anatomy with unprecedented accuracy. The early prenatal detection of enteric duplications is possible and facilitates a prompt postnatal treatment strategy, thereby, decreasing the risk of potential complications.Materials and Methods: We retrospectively reviewed the medical records of all patients treated at our institution with a prenatally diagnosed intraabdominal enteric duplication between 2001 and 2009.Results: Eighteen patients were included in the series. The diagnosis was made as early as 20 weeks of gestational age and included gastric duplications (3 cases), jejunoileal duplications (11 cases), and duodenal duplications (4 cases). None of the patients had prenatal complications. Two patients had associated intestinal malrotation, whereas the remaining 16 had no other malformations. Postnatally, 14 patients had an uneventful clinical course until the time of surgery, 3 patients had complications within the first 2 weeks of life that required emergency surgery, and 1 patient who had been lost to follow-up presented with duodenal obstruction at 3 years of age. Four patients underwent laparoscopic resection.Conclusion: Because intraabdominal enteric duplications can cause complications, we believe that prenatally diagnosed enteric duplications should be resected after birth.

Cystic lymphatic malformation of the pelvis mimicking seminal vesicle cysts

Kun-Shuo Huang, Nien-Lu Wang, Yu-Peng Liu — 2010-07-01

Abstract: A 6-year-old boy presented with fever of 2 days of duration and had blood tests demonstrating leukocytosis and impaired liver function. Abdominal sonogram incidentally revealed 2 cystic lesions within the pelvis. Further contrast-enhanced abdominal computed tomography showed a symmetrically bilobed cystic mass between the urinary bladder and rectum in the location of the seminal vesicles. The boy underwent surgical excision, and the histopathology confirmed the mass as a cystic lymphatic malformation originating from the mesentery of the sigmoid colon.

Minimally invasive technique in treatment of complex, subcutaneous abscesses in children

Alan P. Ladd, Marc S. Levy, Jennifer Quilty — 2010-07-01

Abstract: The rising prevalence of community-acquired, methicillin-resistant Staphylococcus aureus (MRSA) has correlated with an escalating number of complex, subcutaneous abscesses in pediatric patients. The purpose of this study was to present a novel technique and early outcome results for the minimally invasive drainage of complex, subcutaneous abscesses.Methods: Patients' outcomes from the treatment of complex, subcutaneous abscesses were retrospectively reviewed under institutional review board approval from July 2006 to August 2007 at 2 independent, tertiary care pediatric hospitals. Data on patients' demographics, length of hospital stay, and length of treatment were collected, along with analysis of the isolated organisms.The operative technique uses drainage of the abscess through peripheral stab incisions. Cavity debridement and irrigation is followed by placement of a vessel-loop drain through the drainage incisions. Topical wound care without packing is performed twice a day. Drain removal follows resolution of cellulitis and drainage.Results: One hundred twenty-eight patients were treated over a 14-month period. The ratio of females to males was 1.25:1. Average patient age was 51.5 months (median, 21 months) and ranged from 5 weeks to 18 years. The average length of hospital stay was 1.5 days, though 30 patients were treated on an outpatient basis. Methicillin-resistant Staphylococcus aureus was identified in 76% of the cultured specimens. Average length of drain use was 9 days (range, 5-29 days). There were no local recurrences of subcutaneous abscesses. There was no morbidity related to the drainage procedures.Conclusion: We present a successful technique for the drainage and treatment of complex abscesses in children with limited, postoperative wound care and no morbidity or recurrence.

Was the real Sherlock Holmes a pediatric surgeon?

John Raffensperger — 2010-07-01

Abstract: Purpose: This article reviews the pioneering efforts of Joseph Bell, the model for Sherlock Holmes, in the surgical care of children during the antiseptic era.Methods: I reviewed biographies of Sir Arthur Conan Doyle; the biography of Joseph Bell; his surgical textbook, Edinburgh Medical Journals; and the history of the Royal Edinburgh Hospital for Sick Children.Results: Dr Bell was a colleague of Joseph Lister and one of the first surgeons to apply antiseptic methods to operations involving children. He was the surgeon appointed to the first surgical ward of the Royal Edinburgh Hospital for Sick Children; in that role, he cared for many children with surgical diseases.Conclusions: Dr Joseph Bell, by his compassion for children and his surgical skill, was indeed a pioneer pediatric surgeon.

Experimental model of necrotizing enterocolitis

Erdener Özer — 2010-07-01

I read the article by Kumral et al entitled “Activated protein C reduces intestinal injury in an experimental model of necrotizing enterocolitis” recently published in the Journal with great interest. On histopathologic examination of an experimental model of necrotizing enterocolitis, histologic sections from representative samples of injured areas are supposed to be graded in a blinded fashion by a pathologist, as suggested in the cited reference . However, no histopathologists appear in the author list or are acknowledged in the text. In addition, there are no hemorrhagic areas as suggested in the gross findings evident in Fig. 1. Fig. 1 shows neither partial nor full mucosal necrosis for any groups. There is no nuclear fragmentation in Fig. 2. Besides, nuclear fragmentation is not a characteristic for apoptosis as suggested in the legend.

Announcements of Future Meetings

2010-07-01

Minimally invasive innominate artery transection for tracheomalacia using 3-dimensional multidetector-row computed tomographic angiography: report of a case

Tomomi Hasegawa, Azusa Zaima, Chieko Hisamatsu, Eiji Nishijima, Yutaka Okita — 2010-07-01

Abstract: We successfully performed transection of the innominate artery in a patient with a neuromuscular disorder through minimally invasive access after confirming the anatomical relationships of the vessel using 3-dimensional multidetector-row computed tomographic angiography. A 16-year-old girl with spinal muscular atrophy type 1 had been on long-term mechanical ventilation with a tracheostomy. She had scoliosis and tracheomalacia. Bronchoscopy showed a flattened and narrow lower trachea and an anterior pulsatile compression by the innominate artery. She underwent transection of the innominate artery to prevent tracheoinnominate artery fistula formation. Based on preoperative 3-dimensional multidetector-row computed tomographic angiography images, the innominate artery was transected through a small transverse curvilinear skin incision just below the suprasternal notch and an oblique partial manubriotomy from the suprasternal notch to the first left intercostal space.

Myoepithelioma of the parotid gland in a child: a case report

2010-07-01

Abstract: Myoepitheliomas of the parotid glands are very rare in the pediatric population. Only a few cases of myoepitheliomas of the salivary glands have been reported in children. They have some similar features with pleomorphic adenoma. However, they may be malignant and infiltrate locally. Hence, histopathologic examination should be considered to differentiate these tumors. The treatment of myoepitheliomas is complete removal of the tumor. We report a child with myoepithelioma of the parotid gland and review the related literature.

Foveolar cell hyperplasia at the pyloric canal: an unusual cause of gastric outlet obstruction in 3 young children

Lihua Zhao, Xianqing Jin, Jin Zhu, Xiaoqing Li, Rui Liang, Zhenghua Guo — 2010-07-01

Abstract: Foveolar cell hyperplasia (FCH) in the pylorus is rare in children. Between January 1993 and December 2008, 3 children with pyloric canal FCH presented with gastric outlet obstruction and/or anemia and underwent operation because a clear diagnosis could not be established with conservative management. The median age of the children was 18 months. The onset of FCH at the pyloric canal is problematic, and its diagnosis is difficult to make in pediatric patients. Exploratory laparotomy is a reasonable method of establishing the diagnosis and managing the condition.

Sclerosing angiomatoid nodular transformation of the spleen in an adolescent with chronic abdominal pain

Zubin M. Bamboat, Peter T. Masiakos — 2010-07-01

Abstract: Sclerosing angiomatoid nodular transformation (SANT) is a relatively new, benign neoplasm arising within the red pulp of the spleen. The lesion is often identified incidentally on imaging, and the diagnosis is confirmed on pathologic assessment of the resected spleen. Although there have been several reports of SANT in the adult population, data on this lesion in the pediatric population are exceedingly rare. We present a case of SANT in an adolescent male with chronic abdominal pain and discuss the management issues that arise in treating this condition in the pediatric population.

Management of a giant omphalocele with an external skin closure system

Robert Baird, Suad Gholoum, Jean-Martin Laberge, Pramod Puligandla — 2010-07-01

Abstract: Background/Purpose: The management of neonates with giant omphalocele remains challenging and multiple strategies have been described. We present the case of a 34-week-old neonate with isolated giant omphalocele managed with an external surgical skin closure system as a component of a staged closure strategy.Case Presentation: An Inuit boy of 34 weeks gestation was born by urgent Caesarean delivery at an affiliated obstetrical hospital with a giant ruptured omphalocele and loss of abdominal domain. He was transferred to our institution and a silastic silo was fashioned and placed in the operating room. He returned to the operating room several times and was treated by placement of a combined Gore-Tex (WL Gore and Associates, Flagstaff, Ariz)/silastic inlay mesh. An eschar formed over this temporary closure, and we elected to place a dynamic skin closure device to continue gradual bedside reduction. The initial abdominal wall defect was 8.5 cm in transverse diameter and was reduced to 4.5 cm over 3 weeks. Complete closure was subsequently achieved without the need for skin grafting.Discussion: The use of a dynamic reduction skin closure device has not been documented previously in the pediatric population or in the context of a congenital defect. We describe the use of an external surgical skin closure device in the context of the staged closure of a giant neonatal omphalocele and postulate that such a device may prove useful in the treatment of other congenital tissue defects.

2010-07-01

Journal of Pediatric Surgery

Consensus statement on the adoption of the Committee on Publication Ethics guidelines

National prospective surveillance study of necrotizing enterocolitis in neonatal intensive care units

Discordance of the pediatric surgeon's intraoperative assessment of pediatric appendicitis with the pathologists report

Pediatric vs adult vascular trauma: a National Trauma Databank review

Prehospital cardiopulmonary resuscitation in the pediatric trauma patient

Application of lean methods improves surgical clinic experience

No free ride? The hidden costs of delayed operative management using a spring-loaded silo for gastroschisis

The impact of preoperative ultrasound on correct diagnosis of urachal remnants in children

Tracheal cartilaginous sleeve in patients with craniosynostosis syndromes: a meta-analysis

Gene expression analysis in hypoplastic lungs in the nitrofen model of congenital diaphragmatic hernia

Structural and biomechanical characteristics of the diaphragmatic tendon in infancy and childhood: an initial analysis

Anastomotic stricture after surgical repair of esophageal atresia: frequency, risk factors, and efficacy of esophageal bougie dilatations

Laparoscopic extended cardiomyotomy in children: an effective procedure for the treatment of esophageal achalasia

Influence of Down's syndrome on management and outcome of patients with congenital intrinsic duodenal obstruction

Surgical complications after intestinal transplantation in infants and children—UK experience

Vagus nerve stimulation for the management of seizures in children: an 8-year experience

Ovarian germ cell tumors in children. Management, survival and ovarian prognosis. A report of 75 cases

Retained intravascular fragments after removal of indwelling central venous catheters: a single institution experience

Intussusception after pancreatic surgery in children: a case series

Laparoscopic-assisted anorectal pull-through for anorectal malformations: a systematic review and the need for standardization of outcome reporting

Anterior or posterior sagittal anorectoplasty without colostomy for low-type anorectal malformation: how to get a better outcome?

Wound infection after colostomy closure for imperforate anus in children: utility of preoperative oral antibiotics

Progressive hair coil penile tourniquet syndrome: multicenter experience with 25 cases

Wandering spleen in children: multicenter retrospective study

Laparoscopic spleen-preserving distal pancreatectomy for solid pseudopapillary tumor with conservation of splenic vessels in a child

Use of a massive transfusion protocol with hemostatic resuscitation for severe intraoperative bleeding in a child

Laparoscopic-assisted transhiatal gastric transposition for long gap esophageal atresia in an infant

Ruptured rectal duplication cyst with classical bladder exstrophy

Perirectal arteriovenous malformation treated by angioembolization and low anterior resection

Nonoperative management of a giant omphalocele using a silver impregnated hydrofiber dressing: a case report

Anti–N-methyl-d-aspartate receptor encephalitis associated with an ovarian teratoma in an adolescent female

Prenatal diagnosis and postnatal resection of intraabdominal enteric duplications

Cystic lymphatic malformation of the pelvis mimicking seminal vesicle cysts

Minimally invasive technique in treatment of complex, subcutaneous abscesses in children

Was the real Sherlock Holmes a pediatric surgeon?

Experimental model of necrotizing enterocolitis

Announcements of Future Meetings

Minimally invasive innominate artery transection for tracheomalacia using 3-dimensional multidetector-row computed tomographic angiography: report of a case

Myoepithelioma of the parotid gland in a child: a case report

Foveolar cell hyperplasia at the pyloric canal: an unusual cause of gastric outlet obstruction in 3 young children

Sclerosing angiomatoid nodular transformation of the spleen in an adolescent with chronic abdominal pain

Management of a giant omphalocele with an external skin closure system

Table of Contents