Journal of Pediatric Surgery

Murine model of Hirschsprung-associated enterocolitis. I: Phenotypic characterization with development of a histopathologic grading system

2010-03-01

Abstract: Purpose: The aim of the study was to characterize enterocolitis in the Ednrb-null (Ednrb−/−) mouse with aganglionosis of the colon and to develop and validate a semiquantitative histopathologic grading system to assess enterocolitis.Methods: We isolated colon and ileal specimens of Ednrb−/− and control mice (Ednrb+/+) and performed histochemical staining (H&E) on tissue sections. After establishing inflammation grading criteria, 2 blinded pathologists independently assessed the severity and depth of inflammation of proximal colon segments on 2 separate occasions. Interclass correlations (ICCs) and coefficient of variation (CV) were calculated to determine interrater and intrarater agreement. We then prospectively applied the enterocolitis grading system to Ednrb−/− mice that became clinically ill. A cohort of Ednrb−/− mice were observed until they developed clinical illness, at which time they were euthanized and had multiple organ homogenates cultured for bacteria, and colon and small bowel were histopathologically graded for enterocolitis. Spearman's rank correlations comparing enterocolitis scores with level of bacteremia were performed.Results: Intra- and interrater ICCs of the histologic scoring system were satisfactory (0.61 and 0.94, respectively), as were intra- and interrater CVs (18% and 9%, respectively). Of the Ednrb−/− mice, 65% developed bacteremia. Those with bacteremia had significantly higher enterocolitis scores than those without bacteremia (P < .01). Ednrb−/− mice that developed bacteremia showed a strong positive correlation between total enterocolitis scores and number of bacterial colony forming units in peritoneal lavage, liver, kidney, and aerobic spleen.Conclusions: The Ednrb−/− mouse with aganglionosis develops enterocolitis and has features similar to Hirschsprung-associated enterocolitis in humans. Our grading system is a reliable way to assess enterocolitis. By performing microsurgical pull-through, we can now perform controlled, hypothesis-driven, mechanistic studies to evaluate etiologic factors affecting enterocolitis in the Ednrb−/− mouse.

Activated protein C reduces intestinal injury in an experimental model of necrotizing enterocolitis

2010-03-01

Abstract: Background: Necrotizing enterocolitis is a devastating intestinal disease of premature infants. Although activated protein C (APC) is well defined as a physiologic anticoagulant, emerging data suggest that it also has cytoprotective, antiinflammatory, and antiapoptotic properties. There is no study on active protein C administration for necrotizing enterocolitis in animal models.Methods: Twenty-one Wistar albino rat pups were divided into 3 groups: group 1 = control; group 2 = hypoxia-reoxygenation and saline; group 3 = hypoxia-reoxygenation and APC (0.2 mg/kg per day) treatment. On the 15th day, hypoxia was induced by placing the pups in a 100% carbon dioxide chamber for 5 minutes. After the hypoxia period, the pups were reoxygenated for 10 minutes with 100% oxygen and returned to their mothers. All pups were killed 4 hours after the hypoxia-reoxygenation period was over. The abdomen was opened, and representative samples of injured areas were taken for histopathologic examination, nitrite levels, apoptosis, and cytokine levels.Results: On histopathologic examination, injury scores in group 2 animals were found to be significantly higher than in group 3 animals (P = .002). Significantly increased intestinal nitric oxide levels were found in group 2 rats compared with the rats of groups 1 and 3 (P = .001 and P = .001, respectively). The APC treatment was significantly reduced “apoptotic cell death” in the bowel, when compared with vehicle-treated group. The proinflammatory cytokine levels (interleukin [IL]-1β, tumor necrosis factor [TNF]-α, and IL-6) were significantly increased in hypoxia group as compared with control group. The concentration of cytokines, IL-1β, IL-6, and TNF-α was reduced in the APC treatment group.Conclusion: The APC treatment attenuates hypoxia-reoxygenation induced with intestinal injury and decreased apoptotic cell index in this animal model. The protective effect of APC is associated with its ability to reduce the expression of inflammatory cytokines and nitric oxide.

Interdisciplinary management of infantile short bowel syndrome: resource consumption, growth, and nutrition

2010-03-01

Abstract: Background/Purpose: To date, there are hardly any data on the treatment costs of infantile short bowel syndrome (SBS), despite growing interest in evidence-based and cost-effective medicine. Therefore, the aim of the study was to evaluate resource consumption and costs, next to studying nutritional and growth outcomes, in children with SBS who were treated by an interdisciplinary short bowel team.Methods: Data were collected for 10 children with infantile SBS (≤1 year of age) born between 2002 and 2007. Data included demographic and medical data of the first admission and data on resource consumption, growth, and type of nutrition for the total follow-up period. Real economic costs were calculated in Euro (€) and US dollar ($).Results: Seven of the 10 patients were discharged with home parenteral nutrition. Total follow-up varied between 9 months and 5.5 years (median, 1.5 years). Six patients could be weaned off parenteral nutrition and 5 patients off enteral tube feeding, resulting in full oral intake. Seven patients had normal growth. Median duration of initial hospital admission was 174 days, and average costs of initial admission amounted to €166,045 ($218,681). Average total costs were €269,700 ($355,195), reaching to a maximum of €455,400 ($599,762). These costs mainly comprised hospital admissions (82%), followed by nutrition (12%), surgical interventions (5%), and outpatient visits (1%).Conclusions: This study is among the first to describe resource consumption and costs in infants with SBS, examining real economic costs and extending beyond the initial hospitalization. Treatment of SBS requires considerable resource consumption, especially when patients depend on parenteral nutrition. Because the costs mainly comprise those of hospital admissions, early home parenteral nutrition could contribute to costs reduction. Interdisciplinary teams have the potential to facilitate early home parenteral nutrition and thus may reduce health care costs.

A new rat model of prenatal bowel obstruction: development and early assessment

2010-03-01

Abstract: Purpose: Although intestinal motility disorders often complicate the postoperative surgical management of newborns with congenital intestinal atresia, their pathogenesis remains unclear. Animal models of prenatal intestinal obstruction have been mainly developed in the lamb and the chicken. Despite new insights brought by these models, they have one or more limitations, such as high fetal mortality rates, high costs, long gestation periods, and an insufficient number of fetuses per litter. Moreover, some species are phylogenetically distant from mammals.Methods: We developed a reproducible model of prenatal intestinal obstruction in the rat to study the histologic changes induced by the obstruction. We report, the technical devices and the first assessment of this atresia model in a didactic way to allow other researchers to easily reproduce the model.Results: Prenatal intestinal obstructions in this study fulfilled all the macroscopic and histologic criteria usually listed by other models of prenatal intestinal obstruction that have been developed in other species. Furthermore with our model, we obtained a high success rate at a low cost.Conclusions: We presented in this study a reproducible model of prenatal intestinal obstruction in the rat with the macroscopical and histologic features of prenatal intestinal obstruction.

Incidence of septicemia immediately after elective gastrointestinal contrast procedures in infants: a cohort study

Ziad Abu-Sharar, Ashley Robinson, Pascal M. Lavoie — 2010-03-01

Abstract: Background: Sepsis is a documented complication of gastrointestinal contrast procedures in neonates. However, the identification of preventive measures is hampered by a lack of data on its incidence and risk factors.Methods: The study used a retrospective cohort analysis of infants with selected surgical gastrointestinal conditions admitted to a tertiary neonatal center. Risk factors were identified by logistic regression and matched case-control analyses. Contrast procedure-related bacteremia or sepsis were defined by clinical signs with or without a positive blood culture, respectively, within 48 hours after an intervention.Results: The apparent incidence of contrast procedure-related sepsis was 2.7 per 100 infant procedures. Infants with contrast procedure-related sepsis were also generally of lower gestational age and birth weight and generally sicker (ie, higher incidence of hepatic cholestatic disease, and poorer weight gain). Notably, all infants with contrast procedure-related sepsis previously had necrotizing enterocolitis. Although the number of cases of sepsis directly attributable to the procedures may be lower, as suggested by a comparison with the baseline time prevalence of bacteremia in this cohort, significant associated morbidities and mortality were observed.Conclusions: This is the first study reporting the incidence of contrast procedure-related sepsis in high-risk infants with surgical gastrointestinal conditions. Based on our observations, the routine use of prophylactic antibiotics to prevent this complication in this population does not seem warranted.

Transrectal ultrasound and fluoroscopy-guided drainage of deep pelvic collections in children

2010-03-01

Abstract: Purpose: Pediatric deep pelvic abscesses generally occur as a complication of perforated appendicitis or after laparoscopic appendectomy. We describe our technique and experience in imaging-guided transrectal drainage (TRD) of deep pelvic abscesses in children.Methods: From January 2005 to November 2008, imaging-guided TRD was attempted in 29 children. The procedure records and medical records were reviewed retrospectively.Results: Twenty-nine TRD procedures were performed in 17 males and 12 female patients. The mean age was 11.8 years (range, 3.8-15.9 years). Fourteen patients required TRD after an abdominal operative procedure: laparoscopic appendectomy (n = 9), open appendectomy (n = 3), exploratory celiotomy for gunshot wound (n = 1), and exploratory celiotomy with intestinal resection for adhesive bowel obstruction (n = 1). Fifteen patients were referred for TRD as initial therapy for deep pelvic fluid collections: perforated appendicitis (n = 14) and Crohn perforation (n = 1). Twenty-seven (93.1%) procedures were successful, described as either placement of a TRD catheter or aspiration of the deep pelvic fluid using transrectal approach. There were no procedure-related complications.Conclusions: Imaging-guided TRD in children is a safe and easy procedure that allows drainage of deep pelvic abscesses that are otherwise not easily accessible.

Rectovestibular fistula with normal anus: a simple resection or an extensive perineal dissection?

Le Li, Ting-chong Zhang, Chong-bin Zhou, Wen-bo Pang, Ya-jun Chen, Jin-zhe Zhang — 2010-03-01

Abstract: Purpose: The purpose of the study was to review a 10-year experience of operative procedures for rectovestibular fistula with normal anus (RVFNA) at one institution.Materials and Methods: From January 1999 to December 2008, 182 female patients of RVFNA were treated surgically in the Department of Surgery, Beijing Children's Hospital, Capital Medical University, China. The patients' age ranged from 4 months to 15 years, with a mean age of 3.4 years. Fourteen children had a failed previous operation in other institutions. One hundred fifty-six patients (85.71%) had a definite history of vulvar inflammation within 3 months after birth and fecal leakage thereafter. In 61 of the 156 patients, a perineal abscess appeared after an episode of diarrhea. Four cases (2.20%) had associated anomalies of the VACTERL type. One hundred seventy-three patients (95.05%) had 1 external opening, whereas 9 others (4.95%) had 2 external openings separated by a skin bridge. In all cases, the internal orifice opened above the dentate line. The fistula in 135 cases (74.18%) presented as an opening with a small diameter (<5 mm). In our series, vestibular-rectal pull-through procedure was performed in 98 cases, transanal procedure in 69 cases, and anterior perineal anorectoplasty in 15 cases. None had a diverting colostomy.Results: Recurrence of fistula occurred in 5 to 10 days after operation in 21 cases (11.54%). Eight of them healed spontaneously after daily sitz bath with 3% boric acid, whereas other 13 patients (7.14%) required reoperation. Follow-up was obtained by telephone or by personal visit in the outpatient department, from 3 months to 10 years (median, 5.7 years). All the patients were continent and had regular bowel movement.Conclusions: Most RVFNA was acquired after infection. Procedure requiring extensive perineal dissection and diverting colostomy are unnecessary in most RVFNA cases. We performed simple resection in most patients with satisfactory results. In the cases with a large external opening and abnormal perineal appearance, a more extensive perineal dissection might be necessary.

Evaluation of 28 years of surgical treatment of children and young adults with familial adenomatous polyposis

2010-03-01

Abstract: Background: In this retrospective study, 28 years of surgical treatment of children and young adults with familial adenomatous polyposis (FAP) was analyzed.Methods: Forty-three patients were operated on before the age of 26 years. Endoscopic aspects, operative data, and complications were analyzed, and the resection specimens were reevaluated. Functional outcome was assessed by telephone questionnaire.Results: Primary ileorectal anastomosis (IRA) was performed in 34 patients with a mean age of 16 years (range, 7-25 years). Primary ileal-pouch anal anastomosis (IPAA) was performed in 9 patients at a mean age of 19 years (range, 15-24 years). Secondary excision of the rectum was performed in 7 patients. Overall, rectal carcinoma was present in 4 patients, at the age of 35, 36, 37, and 38 years. Two patients, aged 39 and 40 years, died because of invasive carcinoma with distant metastasis. The functional outcome and postoperative complications after both procedures were similar to those described in literature for children with FAP. Most patients did not experience alterations in lifestyle, and there was no urinary incontinence.Conclusions: In this retrospective study, both IRA and IPAA showed to be feasible techniques in young patients with FAP. A prospective study with a sufficient follow-up is needed to compare both techniques in this specific group of patients.

Laparoscopic management of persistent complete rectal prolapse in children

Magid Ismail, Khaled Gabr, Rafik Shalaby — 2010-03-01

Abstract: Background: Rectal prolapse is a relatively common condition in children. The multiplicity of surgical approaches used for rectal prolapse indicates that there is no single approach universally accepted and applicable to all cases. The laparoscopic approach promises to become the criterion standard for the management of full-thickness rectal prolapse in children. The aim of this study was to review our experience over the last 5 years and to evaluate the results that can be achieved by using laparoscopy in management of complete rectal prolapse in children.Patients and Methods: Forty patients presented with complete rectal prolapse and fecal incontinence grades (3-4) according to Rintala scale (37 secondary to prolapse and 3 neuropathic) had been operated upon laparoscopically from August 2003 to August 2008. They were subjected to clinical examination, investigations, pre- and postoperative electromyogram activities for external sphincter, puborectalis, and pelvic floor muscles. The pathophysiologic changes for each case was identified and dealt with laparoscopically (laparoscopic suture rectopexy, laparoscopic mesh rectopexy, laparoscopic resection rectopexy, and laparoscopic levatorplasty).Results: Among the 40 children with complete rectal prolapse, 22 were males and 18 females. Their median age was 9 years (range, 4-14 years). All cases (n = 40) showed a redundant rectosigmoid junction. Additional laxity of the pelvic floor was present in 32, rectoanal intussusception in 27, anterior wall rectoanal intussusception in 3, and rectosacral hernia in 5 cases. All procedures were completed laparoscopically. The median duration of surgery was 60 minutes (range, 50-70 minutes) for suture rectopexy, 90 minutes (range, 60-110 minutes) for mesh rectopexy, 110 minutes (range, 95-160 minutes) for resection rectopexy, and 120 minutes (range, 100-150 minutes) for laparoscopic levatorplasty. No intraoperative complications occurred in this study. Median postoperative hospitalization was 3 days (range, 2-5 days). Electromyogram studies showed statistically significant improvement during rest, minimal volition, and squeezing in all cases except those children with spina bifida and meningomyelocele. The only complications were postoperative constipation and external colonic fistula. Significant improvement of the continence score was achieved in all cases. The average follow-up time was 36 months. There were no recurrences.Conclusion: The use of laparoscopy in the management of complete rectal prolapse is safe, effective, and associated with improved functional outcome. It saved the patients multiple operations and is associated with minimal postoperative pain and short hospital stay.

Laparoscopic repair for choledochal cyst: lessons learned from 190 cases

Liem Nguyen Thanh, Pham D. Hien, Le A. Dung, Tran N. Son — 2010-03-01

Abstract: Objective: The aim of this study is to report the technical details, early outcomes, and lessons learned from laparoscopic repair of 190 cases of choledochal cyst.Method: The operation was performed using 4 ports. The cystic duct was identified and divided. The liver was elevated by 2 stay-sutures: one on the round ligament and the other on the distal cystic duct. The choledochal cyst was isolated and removed completely, and then biliary-digestive continuity was reestablished.Results: From January 2007 to April 2009, 190 patients were operated on. There were 144 girls and 46 boys. Ages ranged from 2 months to 16 years (mean, 46.9 ± 29.3 months). Cyst diameter ranged from 10 to 184 mm. A total of 106 patients were classified as Todani type I cysts, and 84 were type IV. Cystic excision and hepaticoduodenostomy were performed in 133 patients and hepaticojejunostomy in 57 patients. The operating time varied from 70 to 505 minutes (mean, 186 minutes). Conversion to open surgery was required in 2 patients. Intraoperative blood transfusion was required in 4 patients. There were no perioperative deaths. Postoperative anastomotic leakage occurred in 7 patients, resolving spontaneously in 6 and requiring a second operation in 1. Postoperative hospital stay ranged from 5 to 27 days (mean, 7.2 ± 3.3 days). Follow-up occurred between 1 and 24 months postdischarge (mean, 9 ± 2.2 months) and was obtained in 161 patients (84.7%). Of these patients, cholangitis occurred in 4 patients (2.4%).Conclusion: Laparoscopic repair is a safe and effective procedure for choledochal cyst.

Direct measurement of hepatic blood flow during living donor liver transplantation in children

2010-03-01

Abstract: Background: The changes in liver blood flow associated with living donor liver transplantation (LDLT) in children have not yet been studied. The aim of the present study was to investigate changes in hepatic hemodynamics before and after pediatric partial liver transplantation.Methods: In 7 pediatric recipients with congenital cholestasis and native liver Child-Pugh classes B and C, portal vein flow (PVF) and hepatic arterial flow (HAF) were measured using an ultrasonic transit time flow meter before removal of the native liver and after transplantation and compared with donor left PVF and donor left HAF.Results: The mean portal contribution to total hepatic blood flow was markedly decreased in the recipient native liver compared with that in the donor (69% ± 15% vs 32% ± 15%; P = .0003) and after reperfusion changed to almost the same ratio as that in the donor liver (73% ± 18%; P < .0001).Conclusion: The extreme imbalance between PVF and HAF that is common in implanted partial liver in adult LDLT recipients was not observed in pediatric LDLT. After transplantation of an appropriately sized liver graft, the portal contribution to total liver blood flow normalized to the value for normal liver.

Characterization of pediatric Wilms' tumor using Raman and fluorescence spectroscopies

Chad A. Lieber, Mustafa H. Kabeer — 2010-03-01

Abstract: Purpose: Raman spectroscopy has been successfully demonstrated as an effective tool for tissue characterization and diagnosis, but nearly all studies have interrogated adult tissues and diseases. In this study, we demonstrate the application of Raman spectroscopy and its background autofluorescence for pediatric Wilms' tumor diagnosis.Methods: Eight tumors were measured in this study, along with matched normal kidney tissue in 6 cases. Spectral comparisons were drawn, and diagnostic use was assessed using both the Raman spectral features as well as the inherent tissue fluorescence.Results: The fluorescent background spectra were able to discriminate normal kidney from Wilms' tumor with 81% sensitivity and 100% specificity. The Raman spectra obtained 93% sensitivity and 100% specificity.Conclusions: This pilot study shows that both autofluorescence and Raman spectra provide diagnostic use in discriminating Wilms' tumor from normal kidney. These techniques may be used individually or in tandem to develop a real-time intraoperative screening and diagnostic device.

Outcome of central hepatectomy for hepatoblastomas

2010-03-01

Abstract: Background/Purpose: Central hepatoblastomas (CHBL) involving liver segments (IV + V) or (IV + V + VIII) are in contact with the portal bifurcation. Their resection may be achieved by central hepatectomy (CH) with thin resection margins on both sides of the liver pedicle, by extended right or left hepatectomy with thin resection margins on one side, or by liver transplantation with thick free margins. The aim of this study is to assess the operative and postoperative outcome of CH for hepatoblastoma.Methods: This was a retrospective monocentric study of 9 patients who underwent CH for CHBL between 1996 and 2008.Results: The operative time was 4 hours 50 minutes (2 hours 20 minutes to 7 hours), vascular clamping lasted 30 minutes (0-90 minutes), and the amount of blood cell transfusion was 250 mL (0-1800 mL). Two patients had biliary leakage requiring percutaneous drainage. Median follow-up time was 27 months (14-120 months). All of 8 nonmetastatic patients are alive and disease-free; 1 metastatic patient died of recurrent metastases at last follow-up. Although 3 of 9 patients had surgical margins less than 1 mm, none, including the patients who died from metastases, had local recurrence.Conclusions: Our study demonstrates the feasibility of CH for CHBL without operative mortality or local recurrence. Central hepatectomy is an alternative to extensive liver resections in selected patients.

Tracheal compression by aberrant innominate artery: clinical presentations in infants and children, indications for surgical correction by aortopexy, and short- and long-term outcome

2010-03-01

Abstract: Background: Aberrant innominate artery (AIA) may cause various degrees of tracheal compression (TC).Purpose: The aim of this study is to define the clinical manifestations of AIA-induced TC and outcome after aortopexy in infants and older children.Methods: Children with significant AIA-induced TC were evaluated, and information after surgery or conservative management was obtained by telephonic interview after 1 to 4 years since discharge.Results: Overall, 15 infants (mean age, 8 months; group A) and 13 older children (mean age, 56 months; group B) were evaluated. Although median age at onset of symptoms was comparable in the 2 groups, mean delay to diagnosis was higher in group B (P < .0001). Analysis of the most prevalent symptoms showed that reflex apneas were more frequent in group A (P = .02), whereas chronic “intractable” cough was more frequent in group B (P < .001). Because of the type and severity of symptoms and the degree of TC, 16 patients underwent aortopexy. Follow-up evaluation showed, in all but 1 patient, a significant improvement in symptoms and quality of life, measured by a modified Visick score.Conclusions: Aberrant innominate artery-TC leads to a variety of respiratory disorders, with a difference in prevalence between infants and older children. When choice of treatment is based on clinical presentation and degree of TC, a good clinical outcome may be obtained also in children in whom aortopexy is indicated, that is, those presenting initially with more severe symptoms.

Thoracoscopic treatment of pediatric lung abscesses

Kelly K. Nagasawa, Sidney M. Johnson — 2010-03-01

Abstract: Objective: Lung abscesses in the pediatric population are relatively rare. We present our consecutive series of thoracoscopically treated pediatric lung abscesses.Methods: A retrospective review of children who underwent thoracoscopic drainage of intraparenchymal lung abscesses between October 2006 and January 2009 at a tertiary referral center.All patients had associated parapneumonic empyema and underwent drainage of the abscess concurrently with thoracoscopic treatment of the empyema.Results: Eleven children (4 boys and 7 girls) had thoracoscopic intervention for lung abscesses. A total of seventeen abscesses were drained. All procedures were completed thoracoscopically. There were no mortalities or long-term bronchopleural fistulas. No child required a formal thoracotomy, lung resection or a second operation. Mean duration of postoperative hospital stay was 11.0 days (range, 3-36). Mean length of stay was 19.5 days (range, 6-77 days). Mean duration of postoperative chest tube was 3.6 days (range, 2-8). Mean length to defervescence was 4.8 days (range, 1-11 days).Mean duration of postoperative antibiotics was 23.6 days (range, 3-56). Eight children had organisms identified from intraoperative cultures.Conclusions: Thoracoscopic drainage of pediatric lung abscesses is a viable and safe treatment option. Thoracoscopic abscess drainage is associated with minimal morbidity and may result in faster recovery and a shorter course of antibiotics.

Method to our madness: an 18-year retrospective analysis on gastroschisis closure

2010-03-01

Abstract: Background: The advent of preformed silos has facilitated routine bedside placement often without any attempt of intestinal reduction. It is unclear whether a strategy of routine silo (RS) placement with delayed fascial repair is beneficial over attempted primary repair (aPR) and silo placement only for those patients who cannot be reduced. We retrospectively compared clinical outcomes of neonates having aPR to those having RS placement to determine the impact of routine silo use and silo duration on gastroschisis care.Methods: Neonatal records from patients with gastroschisis at a single children's hospital between 1990 and 2008 were reviewed. Demographic and outcome data were recorded and subjected to statistical analyses. Documentation of attempted intestinal reduction was used as a surrogate marker for aPR. The remaining patients were placed in the RS group.Results: Two hundred forty-eight neonates with gastroschisis were identified. Thirteen were excluded for congenital or clinical issues which precluded aPR. Of the remaining 235 patients, neonates with RS had significantly more ventilator days (6.2 vs 4.4; P = .0011), more time of total parenteral nutrition (36.5 vs. 28.5; P = .0018), longer length of stay (LOS, 46.5 vs. 40.5; P = .0011), and greater hospital charges ($216,000 vs $172,000; P < .0001) than patients who had aPR. There was no significant difference observed in complications or survival. Linear regression modeling demonstrated that time to closure was significantly related to LOS as an independent variable. Each day to closure was associated with 2.2 extra days of hospitalization and approximately $9557 in hospital charges.Conclusion: Although limited by retrospective biases, this study demonstrates that time to closure is the most significant variable related to LOS in gastroschisis. This relationship is intuitive since longer time to closure is probably determined by the severity of gastroschisis. The method of closure, by primary repair or silo, is of secondary importance. Conversely, unnecessarily increasing the time to closure may increase the LOS. The speed of reduction, whether through primary repair or by silo, should be guided by physiologic principles.

Risk factors for early peritoneal dialysis catheter failure in children

Randolph K. Cribbs, Larry A. Greenbaum, Kurt F. Heiss — 2010-03-01

Abstract: Background: There is uncertainty regarding the optimal approach for surgical placement of peritoneal dialysis (PD) catheters in children. Operative technique, catheter selection, and patient variables (eg, age or prior surgical history) may influence catheter lifespan.Methods: A retrospective review of all PD catheters placed at a tertiary children's medical center during a 6-year period was performed. Our primary outcome was catheter function 2 months after placement. Data were analyzed using Student 2-tailed t test or χ2 analysis.Results: There were 121 PD catheters placed in 81 patients. The median primary functional catheter lifetime was 109 days. Primary PD catheter failure (within 2 months) occurred in 36 catheters (30%). Patients with primary catheter failure (8 ± 7 years) were younger than patients with a functioning catheter at 2 months (12 ± 5 years; P = .002). Catheters placed without simultaneous omentectomy were more likely to fail (P = .042). Catheter failure rate was not significantly different based upon operative technique or catheter type.Conclusion: Omentectomy at the time of catheter placement decreased the risk of early catheter failure. In contrast, type of catheter or laparoscopic placement did not influence the likelihood of early catheter failure.

Infant communicating hydroceles—do they need immediate repair or might some clinically resolve?

2010-03-01

Abstract: Purpose: Infant hydroceles that are communicating by history (fluctuation in size) or examination (reducible fluid) are often repaired soon after presentation. We have followed a series of infant boys with such hydroceles and reviewed their early natural history.Materials and Methods: Since 1998, we have followed 174 infant boys presenting with an apparent communicating hydrocele without immediate surgical repair. All boys were initially seen before 18 months of age and most (168) by 12 months. Most had been full term at delivery, although 32 had been premature (<37 weeks' gestational age) and 11 extremely so (<32 weeks). Most boys (120) had bilateral hydroceles at presentation.Results: Of the 110 boys followed to disposition, 69 (62.7%) had complete resolution without surgery by a mean age of 11.7 months. Forty-one patients (37.3%) underwent surgery for correction at a mean age of 14 months because of persistence in size or development of a hernia. Six developed a hernia during observation, none of whom had any episode of incarceration. Only 2 patients with apparent resolution subsequently had recurrence with a hernia. Age at presentation and gestational age at birth showed no effect on resolution. The hydroceles of 64 boys had improved in size after a mean follow-up of 13.9 months when last seen.Conclusions: Many infant hydroceles that are communicating by history or examination do resolve clinically without surgery and deserve observation. Progression to hernia was rare in our experience and did not result in incarceration. Consequently, little risk is taken by initial observation.

Effects of birth advancement in Chiari malformation in a surgical myelomeningocele model in rabbits

2010-03-01

Abstract: Background/Purpose: In myelomeningocele (MMC), Chiari II malformation progresses during gestation because of the continuous loss of cerebrospinal fluid at the site of the defect. Our purpose was to assess the impact of birth advancement (BA) and prenatal corticosteroid treatment (PCT) on Chiari malformation in a surgical MMC model in rabbits.Methods: A surgical MMC-like defect was created in 75 fetal rabbits. Animals were distributed into 4 groups depending on the treatment received: not treated and those undergoing BA + PCT, BA, or PCT. The degree of Chiari malformation in newborn rabbits was defined as the percentage of downward protrusion of the hindbrain between the end of the occipital bone and the beginning of the first vertebral arch.Results: The degree of hindbrain herniation was 80% (8.15) in the not treated group, 36.8% (10.57) in BA + PCT, 41.8% (8.27) in BA, and 44.4% (8.32) in PCT. The BA + PCT, BA, and PCT groups showed less severe hindbrain herniation than not treated animals (mean decrease, 39.86%; SD, 10.57; P = .000). There were no significant differences between the BA + PCT, BA, and PCT groups (P = .311).Conclusions: Birth advancement and prenatal administration of corticosteroids decrease the severity of the hindbrain herniation component of Chiari II malformation in surgical MMC in fetal rabbits.

Hydrocolloid dressing in pediatric burns may decrease operative intervention rates

2010-03-01

Abstract: Introduction: Partial-thickness scalds are the most common pediatric burn injury, and primary management consists of wound dressings to optimize the environment for reepithelialization. Operative intervention is reserved for burns that fail to heal using conservative methods. Worldwide, paraffin-based gauze (Jelonet) is the most common burn dressing; but literature suggests that it adheres to wounds and requires more frequent dressing change that may traumatize newly epithelialized surfaces. Hydrocolloid dressings (DuoDERM) provide an occlusive moist environment to optimize healing and are associated with less frequent dressing changes.Aim: The aim of the study was to retrospectively analyze pediatric burns in a single tertiary referral center over a 10-year period comparing the impact of Jelonet and DuoDERM dressings relative to operative intervention rates.Methods: All pediatric burns admitted between 1997 and 2007 were identified using the Hospital Inpatient Enquiry system. Demographics were collected from hospital records and theater logbooks. Acute, partial-thickness burns in patients younger than 15 years were analyzed according to dressing type applied (Jelonet or DuoDERM).Results: Two hundred forty-eight pediatric burns were analyzed between 1997 and 2007. One hundred thirty-nine patients were treated with Jelonet dressings, and 109 were treated with DuoDERM. Debridement and grafting were required in 60 (43%) of the Jelonet patients compared with 10 (9%) of the DuoDERM patients (P < .05). The DuoDERM-managed patients maintained a significantly lower graft rate on subanalysis of scalds excluding early grafting within 5 days (P < .001).Conclusion: Observational evidence suggests that DuoDERM leads to less operative intervention and should be preferentially used in pediatric burns.

Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children

2010-03-01

Abstract: Purpose: The aim of the study was to evaluate outcomes after a minimally invasive approach to pediatric subcutaneous abscess management as a replacement for wide exposure, debridement, and repetitive packing.Methods: A retrospective study was performed of all children who underwent incision and loop drainage for subcutaneous abscesses between January 2002 and October 2007 at our institution.Technique: Two mini incisions, 4-5 mm each, were made on the abscess, as far apart as possible. Abscess was probed, and pus was drained. Abscess was irrigated with normal saline; a loop drain was passed through one incision, brought out through the other, and tied to itself. An absorbent dressing was applied over the loop and changed regularly.Results: One hundred fifteen patients underwent drainage procedures as described; 5 patients had multiple abscesses. Mean values (range) are as follows: age, 4.25 years (19 days to 20.5 years); duration of symptoms, 7.8 days (1-42 days); length of hospital stay, 3 days (1-39 days); duration of procedure, 10.8 minutes (4-43 minutes); drain duration, 10.4 days (3-24 days); and number of postoperative visits, 1.8 (1-17). Bacterial culture data were available for 101 patients. Of these, 50% had methicillin-resistant Staphylococcus aureus, 26% had methicillin-sensitive Staphylococcus aureus, and 9% streptococcal species. Of the 115 patients, 5 had pilonidal abscesses, 1 required reoperation for persistent drainage, and 1 had a planned staged excision. Of the remaining 110 patients, 6 (5.5%) required reoperation—4 with loop drains and 2 with incision and packing with complete healing.Conclusion: The use of loop drains proved safe and effective in the treatment of subcutaneous abscesses in children. Eliminating the need for repetitive and cumbersome wound packing simplifies postoperative wound care. Furthermore, there is an expected cost savings with this technique given the decreased need for wound care materials and professional postoperative home health services. We recommend this minimally invasive technique as the treatment of choice for subcutaneous abscesses in children and consider it the standard of care in our facility.

Challenges of training and delivery of pediatric surgical services in Africa

2010-03-01

Abstract: Background: The practice of pediatric surgery in Africa presents multiple challenges. This report presents an overview of problems encountered in the training of pediatric surgeons as well as the delivery of pediatric surgical services in Africa.Methods: A returned structured self-administered questionnaire sent to pediatric surgeons practicing in Africa was reviewed and analyzed using SPSS version 11.5 (SPSS, Chicago, IL).Results: Forty-nine (57%) of 86 questionnaires were returned from 8 countries. Great variability in the requirements and training of pediatric surgeons, even within the same country, was found. Many surgical colleges are responsible for standardization and board certification of pediatric surgeons across Africa. There were 6 (12%) centers that train middle level manpower. Twenty-six (53%) participants have 1 to 2 trainees, whereas 22 (45%) have irregular or no trainee. A pediatric surgical trainee needs 2 to 4 (median, 2) years of training in general surgery to be accepted for training in pediatric surgery, and it takes a trainee between 2 to 4 (median, 3) years to complete training as a pediatric surgeon in the countries surveyed. The number of pediatric surgeons per million populations is lowest in Malawi (0.06) and highest in Egypt (1.5). Problems facing adequate delivery of pediatric surgical services enumerated by participants included poor facilities, lack of support laboratory facilities, shortage of manpower, late presentation, and poverty.Conclusion: The training of pediatric surgical manpower in some African countries revealed great variability in training with multiple challenges. Delivery of pediatric surgical services in Africa presents problems like severe manpower shortage, high pediatric surgeon workload, and poor facilities. Standardization of pediatric surgery training across the continent is advocated, and the problems of delivery of pediatric surgical services need to be addressed urgently, not only by health care planners in Africa but by the international community and donor agencies, if the African child is to have access to essential pediatric surgical services like his or her counterpart in other developed parts of the world.

Fetal and neonatal rhabdoid tumor

Hart Isaacs — 2010-03-01

Abstract: Purpose: Few studies have focused on the behavior of rhabdoid tumor (RT) in the fetus and neonate. The purpose of this review is to show that perinatal RTs are associated with unusual findings and a poor prognosis.Methods: The author conducted a 40-year systematic review of the literature. Clinical presentation, pathology, management, and outcome of 72 fetuses and neonates with RTs are discussed.Results: Seventy-two fetuses and neonates presented with RTs detected prenatally (n = 12) and during the neonatal period (n = 60). The review consisted of 3 main groups: extrarenal noncentral nervous system (CNS) RT, renal RT, and CNS RT. There were some group differences in survival: extrarenal non-CNS RT (3/33 or 9.1%), renal RT (2/27 or 7.4%), and CNS RT (2/12 or 16.7%). Metastatic RT was present at diagnosis in more than half the patients (41/72 or 57%) who had a survival of 2.3%. The overall survival was 9.7%. For statistical results, there was no significant difference in survival among the 3 groups by type of tumor (P = .692). χ2 analysis for survival with and without metastases was not valid due to small sample size.Conclusions: The review shows that extrarenal RT was more common than either renal RT or CNS RT groups that is different than that observed in older individuals. Concomitant brain tumors were found in almost a third of fetuses and neonates. The CNS involvement occurred more often in patients with renal RT than in those with extrarenal RT. Metastatic disease at diagnosis was noted in more than half of the patients. Higher stage and presence of a CNS tumor were significant determinants in survival.

Rectosigmoid tubular duplication presenting as perineal sepsis in a neonate

Zhibo Zhang, Ying Huang, Dajia Wang, Pengjun Su — 2010-03-01

Abstract: Tubular rectal duplication is a very rare congenital anomaly. We report a case of tubular rectal duplication in a newborn baby who presented with perianal sepsis. The diagnosis was confirmed by barium enema, magnetic resonance imaging, and at operation. We performed total mucosectomy through a posterior sagittal incision combined with laparotomy. The patient was doing quite well at 17-month follow-up examination.

Acute colonic obstruction from Ladd bands: a unique complication from intestinal malrotation

Tal Raphaeli, Chinnaya Parimi, Kelly Mattix, Patrick J. Javid — 2010-03-01

Abstract: In patients with intestinal malrotation, Ladd bands are known to cause obstruction of the duodenum and small bowel. However, acute obstruction of the colon from Ladd bands has not been previously described. We report a case of complete obstruction of the hepatic flexure of the colon secondary to a Ladd band in a previously healthy teenage boy.

Diphallus with anorectal malformation-case report

Ramachandra Mukunda, Pradnya S. Bendre, Rajeev G. Redkar, Sandeep Hambarde — 2010-03-01

Abstract: Diphallus is a very rare condition. We report a case of a newborn with absent anal opening and duplication of external genitalia. Examination of the external genitalia showed two well formed penises with fully descended testis within each of the separate hemiscrotums along with soft tissue mass resembling accessory buttock behind the hemiscrotum. Staged reconstruction of duplicated genitalia and anorectal malformation was done. We achieved excellent cosmetic and functional external genitalia.

“Wandering Liver” in a neonate: case report and review of the literature

Jan F. Svensson, Titus Schlinzig, Sylvie Kaiser — 2010-03-01

Abstract: Wandering liver describes the phenomenon where the liver moves freely from the right side of the abdomen to the left. It is believed to be associated with a persistent ventral mesentery, and most reported cases were diagnosed during investigations of intestinal obstruction. The operative findings describe lax or absent suspensory ligaments of the liver and a long colonic mesentery. There are only a few presentations of asymptomatic wandering liver, and there is no clear course of treatment of those cases. We present a case of wandering liver in a prematurely born neonate and a review of the literature.

Congenital pouch colon with rectal atresia: a case report

2010-03-01

Abstract: The association of congenital pouch colon with rectal atresia is quite rare with only 2 cases previously reported in literature. We describe the third such case and the second instance to survive. Although the prior survivor was managed by a single-stage procedure, we successfully managed our case by staged procedures. In this case report, we discuss the etiology and surgical options available for this rare condition.

Primary pancreatic neuroblastoma: an unusual tumor in infancy

Hari R. Kumar, John A. Sandoval, Mark A. Lovell, Laura Z. Fenton, John F. Bealer — 2010-03-01

Abstract: Fetal imaging has dramatically impacted neonatal care by providing an advanced warning of many different congenital anomalies. The advancements and widespread use of fetal imaging has, however, increased the identification of various incidental findings that is creating new challenges for neonatal diagnosis and treatment. We report such a case where a fetal pancreatic neuroblastoma (NB) was incidentally detected by computed tomographic scan of the maternal abdomen. Primary pancreatic NB is a very uncommon childhood neoplasm that, to our knowledge, has never been previously reported in the English language presenting in either the prenatal or neonatal periods.A 21-year-old woman complaining of acute abdominal pain and carrying a 35 weeks' gestation fetus was referred for computed tomographic scan because of the concern of maternal appendicitis. That scan was inconclusive for appendicitis but did incidentally detect a fetal mass in the general region of the pancreas. At 36 weeks' gestation, the fetus developed signs of distress, which prompted a cesarean delivery. Neonatal workup confirmed the presence of an abdominal mass in the region of the pancreas, but precise anatomic localization was not possible. Also noted on neonatal workup were elevated urinary catecholamines consistent with a hormonal active tumor. These findings prompted an abdominal exploration of this neonate, which revealed a solid tumor contained in the distal pancreas. The mass was managed by an uncomplicated distal pancreatectomy. The neonate fully recovered, and histologic diagnosis revealed NB, whereas the postoperative urine catecholamines normalized. This case underscores the unintended clinical challenges created by widespread fetal imaging, while presenting the first prenatally diagnosed case in the English language medical literature and earliest treated patient with pancreatic NB.

Massive subcutaneous emphysema, pneumomediastinum, and pneumopericardium in children

2010-03-01

Abstract: Massive subcutaneous emphysema (SE), pneumomediastinum (PM), and pneumopericardium (PP) are rare conditions in the pediatric population. Air leak syndrome is a constellation of disorders that include SE, PM, PP, and pulmonary interstitial emphysema. In children, SE, PM, and PP are associated with obstructive airway disease most often in the case of asthma. Management may be conservative or involve invasive procedures that require surgical intervention. Here, we describe a case of massive SE, PM, and PP in a 10-year-old child after placement of a peripherally inserted central line and review the literature.

Treatment of adolescent gynecomastia

2010-03-01

Abstract: Purpose: Adolescent gynecomastia is common but variable in severity. The disease may be self-limited. Although antiestrogen therapy can be used in persistent gynecomastia, results are mixed. Subcutaneous mastectomy via a circumareloar incision is familiar to most pediatric surgeons and provides excellent cosmetic results in most cases. Severe gynecomastia may require alternative procedures. There is little information in the pediatric surgical literature to provide the pediatric surgeon with treatment options for these children. A variety of techniques have been used by plastic surgeons for female patients requiring breast reduction and are sometimes a useful addition to the surgical repertoire for the management of very large breasts in adolescent gynecomastia. We reviewed our experience with the use of inferior pedicle reduction mammaplasty and subcutaneous mastectomy in adolescents with gynecomastia and describe the techniques used.Methods: After obtaining institutional review board approval, a retrospective review was conducted on all patients operated on for gynecomastia from January 1999 to March 2009. Data recorded included patient demographics, diagnostic evaluation, medical and surgical treatment, complications, and outcome.Results: Twenty patients underwent an operation for gynecomastia. Eight patients had bilateral inferior pedicle reduction mammaplasty, and 12 patients underwent either unilateral or bilateral subcutaneous mastectomy. The mean age at operation was 15.5 years (range, 14-18 years). In all cases, the histopathologic feature was consistent with gynecomastia. There were no postoperative wound infections. One patient developed a seroma after subcutaneous mastectomy requiring drainage. The mean amount of tissue removed after bilateral reduction mammaplasty was 275.1 g. No patients had devascularization of the nipple-areolar complex or nipple loss. One patient had mild subcutaneous asymmetry after a reduction mammaplasty that required no further intervention. Seven patients (87%) had an excellent cosmetic outcome after reduction mammaplasty. Mean length of follow-up was 18.8 months.Conclusions: Although many adolescents with true gynecomastia have mild or self-limited disease, operative treatment may provide significant benefit to the remainder. Milder grades of gynecomastia can be managed with subcutaneous mastectomy. Selected severe cases can be safely and effectively treated with reduction mammaplasty.

Double Y glanuloplasty for glanular hypospadias

Ahmed T. Hadidi — 2010-03-01

Abstract: Purpose: A double Y glanuloplasty technique is described for the repair of glanular hypospadias with mobile meatus.Materials: Ninety-seven children with glanular hypospadias and mobile meatus were operated on using this technique in the period from January 2003 to January 2009. Mean age of patients was 12 (range, 4-60) months.Results: Patients were discharged home within 3 days. The operation resulted in a slit-like meatus. Follow-up ranged from 8 months to 6 years (mean, 45 months). Good cosmetic and functional results were obtained in 94 patients. Complications occurred in 3 patients (3%). Two patients experienced meatal stenosis. This was corrected using ventral meatotomy. One patient suffered from dehiscence of the wound and retraction of the meatus. The meatal retraction was corrected using a modified inverted Y Mathieu technique.Conclusions: The double Y glanuloplasty technique is suitable for appropriately selected patients with glanular hypospadias and mobile meatus. It provides a cosmetically natural vertical slit at the tip of the glans.

Steven Stylianos — 2010-03-01

The “seat belt sign” (SBS) has been reported to be highly associated with intraabdominal injury. This study defines its predictive value in identifying injuries in a large pediatric trauma population.

Steven Stylianos — 2010-03-01

Although most states have infant restraint laws, booster seat legislation for older children has not been implemented universally despite evidence of effectiveness. We examined injury and expenditures for motor vehicle (MV) occupant injury among children 3 to 8 years old covered vs uncovered by booster seat legislation.

Steven Stylianos — 2010-03-01

The incidence of concomitant, particularly noncontiguous, spine injuries in the pediatric population has not been well described. There is a balance between limiting radiation exposure and not missing concomitant injuries; understanding of this risk of concomitant spine injuries in this population is important. We hypothesize that the rate of concomitant spinal injuries in children is similar to adults.

Steven Stylianos — 2010-03-01

Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSIs) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years.

Federico G. Seifarth — 2010-03-01

Continuous epidural anesthesia attenuates perioperative stress and avoids the need for systemic opioids. In addition, it may prevent the need for postoperative mechanical ventilation. The aim of this study from the Sheba Medical Center, Tel Hashomer, Israel, was to prospectively follow the perioperative course of young infants treated with continuous thoracic/lumbar epidural anesthesia for major surgery.

Federico G. Seifarth — 2010-03-01

On behalf of the CDH Euro-Consortium, this review gives an overview of the disease spectrum of congenital diaphragmatic hernia (CDH). Etiologic factors, prenatal predictors of survival, new treatment strategies, and long-term morbidity are described. Early recognition of problems and improvement of treatment strategies in CDH patients may increase survival and prevent secondary morbidity. Multidisciplinary health care is necessary to improve health care for CDH patients. Absence of international therapy guidelines, lack of evidence of many therapeutic modalities, and the relatively low number of CDH patients call for cooperation between centers with an expertise in the treatment of CDH patients. To study these problems, the international CDH Euro-Consortium was started in 2006 to enhance collaboration in these areas of interest. The international CDH Euro-Consortium is an example of a collaborative network, which enhances exchange of knowledge, future research, and development of treatment protocols.

Federico G. Seifarth — 2010-03-01

The loss of normal anatomical barriers in neonates with congenital diaphragmatic hernia (CDH) can predispose children to gastroesophageal reflux (GER). In an attempt to improve postoperative feeding, the authors have added a modified anterior fundoplication to restore natural gastric and esophageal positioning.

Federico G. Seifarth — 2010-03-01

Recurrent tracheoesophageal fistula (RTF) complicates 5% to 11% of cases of children treated at birth for esophageal atresia with inferior tracheoesophageal fistula, and it represents an important problem of respiratory morbidity and mortality. The aim of this paper is to demonstrate the usefulness of large vascularized pleural flaps in the treatment of RTF and the prevention of recurrences.

Thomas A. Angerpointner — 2010-03-01

Various outcomes after transanal endorectal pull-through (TERPT) in patients with Hirschsprung disease have been reported. In this study, the postoperative course and functional outcome after TERPT in 25 patients with Hirschsprung disease are evaluated. Age at operation, sex, associated malformations, length of follow-up, presence of colostomy, indication for laparotomy, length of the aganglionic segment, results of rectal examination under general anesthesia 6 weeks after surgery, and necessity of a dilatation program or reoperation were evaluated. In addition, the following data were collected: bowel movements per day, fecal continence, incidence of diarrhea, and the necessity for laxants. Median age at surgery was 3.5 months. Median follow-up was 35 months. Calibration of the anus showed a normal age-related diameter in 12 of 20 children and a markedly reduced diameter in 8 of 20 children 6 weeks postoperatively. Seven of the latter children underwent a dilatation program. A redo pull-through procedure had to be carried out in 3 patients because of stenosis at the coloanal anastomosis (n = 1), constricting muscle cuff (n = 1), and a twisted pull-through (n = 1). Two children developed enterocolitis. The median frequency of bowel movements was 3/d. Laxative treatment was required in only 1 patient (4.5%). None of the patients had diarrhea. Eighteen children were continent (95%). One patient (5%) with trisomy 21 suffered from intermittent nonretentive fecal incontinence. None of the patients showed signs of bladder dysfunction. It is concluded that functional outcome in most patients after TERPT is satisfactory. The authors suggest that routine rectal digital examination and anal calibration under anesthesia 6 weeks postoperatively might detect occult stenoses and allow early initiation of therapeutic measures, which could decrease the incidence of enterocolitis, persistent constipation, and the necessity for further surgical interventions.

Federico G. Seifarth — 2010-03-01

Rectal prolapse is a relatively common pediatric surgical condition. It has a number of benign etiologies. Management is usually centered on regulating bowel habits. Surgery is considered after the failure of medical treatment. Numerous surgical techniques have been described with a spectrum of results. The authors adopted a limited abdominal approach to achieve a posterior rectopexy using an omental pedicle in intractable cases. This technique had not been performed in children previously.

Thomas A. Angerpointner — 2010-03-01

Biliary atresia (BA) is one of the most serious liver disorders in children. The purpose of the presented study was to investigate serum levels of bone morphogenetic protein 7 (BMP7) in BA children compared with healthy controls and to evaluate the association between serum BMP7 and the clinical outcome of BA patients post Kasai operation. Sixty-two BA patients post Kasai operation and 14 healthy controls were enrolled in the study. The patients were divided into 2 groups according to their serum total bilirubin levels (no jaundice, <2 mg/dL vs jaundice, >2 mg/dL) and alanine aminotransferase (ALT) levels (normal ALT, <15 IU/L vs elevated ALT, >45 IU/L). Serum BMP7 levels were determined by commercial enzyme-linked immunosorbent assay. The mean serum BMP7 was higher in BA patients as compared with healthy controls (P = .002). The BA patients with persistent jaundice had a higher BMP7 levels than those without jaundice (P = .001). Moreover, BMP7 levels in BA patients with elevated ALT were significantly higher than those in patients with normal ALT levels (P = .003). In addition, BA patients with portal hypertension had higher BMP7 levels than those without portal hypertension. It is concluded that significant increment of serum BMP7 was associated with a deterioration of hepatic function and progression of liver fibrosis. Serum BMP7 could be used as a prognostic marker of disease severity and progression in BA patients post Kasai operation.

A.J.A. Holland — 2010-03-01

The authors from Mumbai, India, present a 6-month-old female infant with a 2-month history of a 15 × 10-cm calcified abdominal mass. Preoperative computed tomography (CT) revealed that this was located in the upper retroperitoneal region, encapsulated, and contained rudimentary limbs, consistent with the diagnosis of fetus-in-fetu (FIF). At operation, while mobilizing the adherent duodenum, the attenuated and stretched common bile duct (CBD) was divided. This was recognized; and the duct was repaired primarily over a 5F feeding tube, with one end exteriorized. The mass was excised completely, and histopathology confirmed FIF. Result of tube cholangiogram 2 weeks later was normal, and the tube was removed. The patient remained well at 1 year.

Steven Stylianos — 2010-03-01

The existence and incidence of delayed splenic bleeding (DSB) in children are controversial, but the implications are significant. We sought to determine the incidence of DSB in children and to look for similarities between reported cases.

Thomas A. Angerpointer — 2010-03-01

The aim of this study was to analyze the experience of managing complete abdominal wound dehiscence in preterm neonates nonoperatively when primary closure was not possible. The authors used Intrasite gel (a carboxymethyl cellulose polymer that helps in wound debridement and healing) and occlusive Duoderm dressings. There were 7 neonates who developed abdominal dehiscence after laparotomy. The abdominal dehiscence was complete with visible intestines. The defect was allowed to granulate and epithelialize by application of Intrasite gel and Duoderm dressings. Dressings were changed every 3 days or earlier, if necessary. All babies responded well; that is, their wounds healed without the need for immediate surgery. One patient had a stoma in the middle of the wound that was managed with stoma bags during the same period. Time of total epithelialization ranged from 21 to 108 days. Two patients developed adhesive intestinal obstruction requiring surgery at 2 and 3 months after start of the treatment, respectively. It is concluded that abdominal wound dehiscence can be successfully managed with Intrasite gel and Duoderm dressings even if bowel is visible. However, some patients develop adhesive intestinal obstruction or a fecal fistula as a result either of their primary illness or of the treatment.

Thomas A. Angerpointner — 2010-03-01

Although congenital adrenal hyperplasia is the most common cause of genital ambiguity, its surgical treatment remains controversial and often difficult, especially in cases of high urethro-vaginal confluence. Many aspects are still uncertain, such as the timing of feminizing genitoplasty and type of surgical technique. The objective of this study was to provide a thorough review of the surgical management of children with congenital adrenal hyperplasia, discussing the evolution of feminizing genitoplasty and its different techniques, and also to critically appraise the available literature on timing of surgical intervention and genital reassignment. Prospective long-term studies evaluating the results of modern feminizing genitoplasty techniques are needed, as current evidence is based on outdated operations that are no longer in use. To date, there have been no studies comparing early and delayed feminizing genitoplasty with regard to psychologic outcomes. All families should be counseled regarding the controversies and treatment options, including the watchful waiting approach.

Steven Stylianos — 2010-03-01

Falls remain a major cause of childhood morbidity and mortality. To improve effectiveness of our prevention program, we used our electronic injury surveillance database to analyze patient variables and the incidence of fall-related brain injury.

Thomas A. Angerpointner — 2010-03-01

Although endoscopic third ventriculostomy (ETV) is a well-established procedure for the treatment of congenital and acquired hydrocephalus, there is still a controversy with regard to the higher risk of failure in younger infants compared with older children. The aim or this article was to define the effectiveness of ETV for hydrocephalus in infants younger than 6 months and to determine possible positive predictive factors. In a series of 125 consecutive patients who underwent ETV, 21 procedures were carried out in infants ranging in age from 23 to 180 days and without a previous history of shunting. The follow-up time was 49 to 82 months. The overall success rate of ETV was 67% (14/21). All failures occurred in the early postoperative period (average, 36 days; range, 25-88 days). The success rate varied with the etiology of the patients' hydrocephalus. The best results were obtained in patients with aqueductal stenosis, Dandy-Walker malformation, and myelomengocele. The least favorable results (50% failure rate) occurred in infants treated for posthemorrhagic and postmeningitic hydrocephalus. This study does not demonstrate a correlation between age and ETV success rate. The specific etiology of hydrocephalus is the most relevant prognostic factor in infants younger than 6 months.

Thomas A. Angerpointner — 2010-03-01

Carcinoid tumors are low-grade, malignant, neuroendocrine neoplasms. Although rare, they represent the most common primary bronchial tumors in childhood. The aim of this study was to analyze the long-term survival and surgical outcome in young patients operated on for carcinoid tumors. Fifteen pediatric patients underwent surgery at the authors' institution. There were 11 male and 4 female patients with a medium age of 15 years (range, 8-18 years). All carcinoids were centrally located and symptomatic. The authors performed 10 (66.7%) parenchyma-saving procedures (5 sleeve lobectomies, 3 sleeve resections of the main bronchus, and 2 bronchoplasties with lung resection) and 5 (33.3%) standard resections (3 bilobectomies and 2 lobectomies). There were 13 typical and 2 atypical carcinoids. Three patients (20%) had nodal metastases. There were no surgery-related deaths or complications. At long-term follow-up, all patients presented with regular growth; and all but one were alive. Two (13.3%) patients needed reoperation. The results suggest that surgical treatment yields good results in the management of pediatric bronchial carcinoids. Relapses can be successfully managed by reoperations. They can occur even after many years, underlining the importance of long-term follow-up.

Letter to the editor regarding patency of processus vaginalis in abdominoscrotal hydrocele

Luigi Avolio, Piero Romano — 2010-03-01

We read with great interest the article by Dr José Luis Cuervo et al entitled “Abdominoscrotal hydrocele: its particular characteristics.” A few years ago we reported one of the largest series of abdominoscrotal hydrocele (ASH), and we, too, emphasized the difficulty of treatment of this poorly understood pathologic condition. Although we agree with Cuervo and his associates that “ASH is a condition that begins as a large scrotal hydrocele during the neonatal period and later expands, first, into the inguinal canal and, finally, into the abdominal cavity during the next few months of life,” we disagree with the conclusion that “the ASH is a noncommunicating hydrocele.”

Reply to Letter to the Editor

José L. Cuervo — 2010-03-01

We thank Dr Luigi Avolio for his interest and comments about our recent work. As we pointed out in our article , although various theories about the etiology of abdominoscrotal hydrocele (ASH) have been proposed, controversy still exists. Based on our clinical, ultrasonographic (US) and surgical observations, we concluded that the ASH is “a noncommunicating hydrocele that results from an imbalance between production and absorption of fluid within the limits of an abnormal tunica vaginalis.”

Abdominoscrotal hydrocele: a plea for a scrotal repair

Silvia Ceccanti, Ermelinda Mele, Denis A. Cozzi — 2010-03-01

We read with great interest the article by Cuervo et al on their perspectives about the etiology and management of the abdominoscrotal hydrocele. All 6 reported cases were characterized by an initial large scrotal hydrocele, which gradually increased in size and ultimately expanded into the abdominal canal. Once the diagnosis was made, all patients were deemed candidates for complete hydrocelectomy, which was carried out using an inguinal approach. They concluded that any tense neonatal scrotal hydrocele should be carefully examined monthly, monitored ultrasonographically if there is a tendency to expand into the inguinal canal, and submitted to surgery if an abdominoscrotal hydrocele develops.

Reply to Letter to the Editor by Cozzi et al

Jose L. Cuervo — 2010-03-01

We thank Dr Denis Cozzi for the interest and comments about our recent work. As we pointed out in our article , abdominoscrotal hydrocele “is a rare entity that shows a very different evolution from the typical scrotal hydrocele observed in the newborn and child.” In this way, only “patients with a tense scrotal hydrocele, present since the newborn period, should be observed carefully with clinical and US examinations and operated on whenever the diagnosis is confirmed.”

Announcements of Future Meetings

2010-03-01

Testicular thecoma in an 11-year-old boy with nevoid basal-cell carcinoma syndrome (Gorlin syndrome)

2010-03-01

Abstract: We report a case of testicular thecoma in an 11-year-old Japanese boy with nevoid basal-cell carcinoma syndrome (Gorlin syndrome). He presented with left testicular swelling and underwent a radical orchiectomy on suspicion of a malignant paratesticular tumor. The tumor arose from the testis exophytically and was diagnosed as a thecoma histopathologically. Ovarian thecoma-fibroma group tumors are closely associated with Gorlin syndrome or with abnormalities in PTCH, a candidate gene for the syndrome. The occurrence of an extremely rare testicular thecoma in this case (the second in the literature) suggests that such an etiological association may also exist in the pathogenesis of testicular tumors.

Small bowel intussusception with pelvic plastron secondary to acute appendicitis in child

2010-03-01

Abstract: We report an unusual case of a 3-year-old child with appendicitis complicated by ileoileal intussusception. Although acute complicated appendicitis and concurrent ileoileal intussusception represent a possible cause of an acute abdomen, very few cases have been reported in the literature.

Prenatal and postnatal ciliated hepatic foregut cysts in infants

2010-03-01

Abstract: Purpose: Ciliated Hepatic Foregut Cyst (CHFC) is a rare congenital lesion arising from the embryonic foregut. Since squamous cell carcinomas arising from CHFC have been reported in adults, complete resection should be considered. We report our experience with CHFC.Methods: We reviewed the charts of 2 patients who had surgery after prenatal detection of a CHFC and 2 patients with postnatal diagnosis.Results: Two patients had antenatally detected liver cyst. Postnatal ultrasonography showed a cyst in segment IV, with wall calcifications and sediments. Bile ducts were encased in the wall of the cyst. They underwent central hepatectomy with double biliary diversion and uneventful post operative course. The two other patients underwent non anatomical resection of a cyst on the left lobe and in segment IV, found prior or during liver surgery.Pathology examination showed cysts filled with mucinous fluid, surrounded by an epithelium composed of ciliated cells. One case had a squamous metaplasia.Conclusion: In infants, CHFC are found antenatally or incidentally. A solitary uni or mutilocular cyst with wall calcifications, sediments, located in the central liver segments should raise the diagnosis. Resection of large cysts in the central segments of the liver is challenging and biliary diversion should be considered.

Endovascular stenting of blunt thoracic aortic injury in an 11-year-old

2010-03-01

Abstract: Blunt traumatic thoracic aortic injury in children is very rare. Open surgical repair is the definitive treatment. Thoracic endovascular aortic repair (TEVAR) for trauma has been performed in adults with good outcomes. Its use has been adopted in pediatric population, and its role is evolving. We report a successful TEVAR in a critically injured 11-year-old boy. To our knowledge, this is the youngest patient to be successfully treated with TEVAR.

Bilateral scrotal abscesses caused by Klebsiella Pneumoniae in a newborn

Dacia Di Renzo, Nicola Pappalepore, Maurizia Colangelo, Pierluigi Lelli Chiesa — 2010-03-01

Abstract: The management of acute scrotal swelling can be challenging in neonatal age, with scrotal infections being great mimickers of testicular torsion. Only a few unilateral cases of scrotal abscess have been previously reported, mostly caused by Staphylococcus and Salmonella. We describe the case of a newborn who developed bilateral scrotal abscesses caused by Klebsiella pneumoniae and discuss the rarity of the case, regarding both the bilaterality and the pathogen, never reported before.

Single-port laparoscopic repair of a Morgagni diaphragmatic hernia in a pediatric patient: advancement in single-port technology allows effective intracorporeal suturing

Paul D. Danielson, Nicole M. Chandler — 2010-03-01

Abstract: We report a case of a foramen of Morgagni hernia repaired by a single-port laparoscopic technique. A 20-month-old (10 kg) boy underwent a 97-minute procedure through a 15-mm umbilical incision and had no complications. Although other pediatric single-port case series have been reported in the literature, this case represents the first time a diaphragmatic defect has been addressed. Moreover, unlike previous experiences that involved procedures of resection (appendectomy, cholecystectomy, etc), this case required operative repair and reconstruction with intracorporeal suturing via a single-access site. Advancement in instrument and port technology makes such procedures feasible in pediatric patients.

Heterotopic pancreas of the esophagus and stomach associated with pure esophageal atresia

Jinyoung Park — 2010-03-01

Abstract: Esophageal atresia with or without tracheoeosphageal fistula is a frequent congenital malformation that may be associated with other congenital anomalies. The combination of heterotopic pancreas of the esophagus and pure esophageal atresia, however, is rare. We treated a patient with esophageal atresia without tracheoesophageal fistula (type A) associated with heterotopic pancreas of the esophagus and stomach who developed a gastric perforation.

2010-03-01

Journal of Pediatric Surgery

Murine model of Hirschsprung-associated enterocolitis. I: Phenotypic characterization with development of a histopathologic grading system

Activated protein C reduces intestinal injury in an experimental model of necrotizing enterocolitis

Interdisciplinary management of infantile short bowel syndrome: resource consumption, growth, and nutrition

A new rat model of prenatal bowel obstruction: development and early assessment

Incidence of septicemia immediately after elective gastrointestinal contrast procedures in infants: a cohort study

Transrectal ultrasound and fluoroscopy-guided drainage of deep pelvic collections in children

Rectovestibular fistula with normal anus: a simple resection or an extensive perineal dissection?

Evaluation of 28 years of surgical treatment of children and young adults with familial adenomatous polyposis

Laparoscopic management of persistent complete rectal prolapse in children

Laparoscopic repair for choledochal cyst: lessons learned from 190 cases

Direct measurement of hepatic blood flow during living donor liver transplantation in children

Characterization of pediatric Wilms' tumor using Raman and fluorescence spectroscopies

Outcome of central hepatectomy for hepatoblastomas

Tracheal compression by aberrant innominate artery: clinical presentations in infants and children, indications for surgical correction by aortopexy, and short- and long-term outcome

Thoracoscopic treatment of pediatric lung abscesses

Method to our madness: an 18-year retrospective analysis on gastroschisis closure

Risk factors for early peritoneal dialysis catheter failure in children

Infant communicating hydroceles—do they need immediate repair or might some clinically resolve?

Effects of birth advancement in Chiari malformation in a surgical myelomeningocele model in rabbits

Hydrocolloid dressing in pediatric burns may decrease operative intervention rates

Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children

Challenges of training and delivery of pediatric surgical services in Africa

Fetal and neonatal rhabdoid tumor

Rectosigmoid tubular duplication presenting as perineal sepsis in a neonate

Acute colonic obstruction from Ladd bands: a unique complication from intestinal malrotation

Diphallus with anorectal malformation-case report

“Wandering Liver” in a neonate: case report and review of the literature

Congenital pouch colon with rectal atresia: a case report

Primary pancreatic neuroblastoma: an unusual tumor in infancy

Massive subcutaneous emphysema, pneumomediastinum, and pneumopericardium in children

Treatment of adolescent gynecomastia

Double Y glanuloplasty for glanular hypospadias

Letter to the editor regarding patency of processus vaginalis in abdominoscrotal hydrocele

Reply to Letter to the Editor

Abdominoscrotal hydrocele: a plea for a scrotal repair

Reply to Letter to the Editor by Cozzi et al

Announcements of Future Meetings

Testicular thecoma in an 11-year-old boy with nevoid basal-cell carcinoma syndrome (Gorlin syndrome)

Small bowel intussusception with pelvic plastron secondary to acute appendicitis in child

Prenatal and postnatal ciliated hepatic foregut cysts in infants

Endovascular stenting of blunt thoracic aortic injury in an 11-year-old

Bilateral scrotal abscesses caused by Klebsiella Pneumoniae in a newborn

Single-port laparoscopic repair of a Morgagni diaphragmatic hernia in a pediatric patient: advancement in single-port technology allows effective intracorporeal suturing

Heterotopic pancreas of the esophagus and stomach associated with pure esophageal atresia

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