Online Exclusives
Congenital chylous ascites: A report of a case treated with hemostatic cellulose and fibrin glue
We report a case of an infant with recurrent chylous ascites who was unresponsive to conventional medical treatment. An exploratory laparotomy revealed no macroscopically visible sites of lymph leakage that could be ligated. Lymph exudation was noted in areas near the subhepatic recess and in the lesser sac surrounding the pancreas, which was not amenable to suture. The treatment consisted of the placement of a hemostatic mesh composed of oxidized cellulose (Surgicel®) on these areas, with a thin layer of fibrinogen/thrombin glue over the mesh (Tissucol®).Mesenteric suture granuloma caused by retained fragments of suture material in a girl who had a laparotomy 12 years previously
The authors report a case of a mesenteric suture granuloma in a 12 year-old-girl who had a small bowel resection for a complicated intussusception at the age of 5 months. At later exploration a whitish round tumor located on the anti-mesenteric side of the intestine was found. Several small intestinal loops also abutted on the tumor. Pathologic examination showed fibrosis and a granuloma containing linear colored braided suture material with multinucleated giant cell. As mesenteric suture granulomas have a complex appearance and mimic a soft tissue tumor during imaging, it is important for a surgeon to know about this condition and to consider the history of previous surgery when evaluating the images of patients presenting with an abdominal or pelvic mass.Acute gastric volvulus: An unreported long-term complication of pericardial drainage
We report the case of a girl who had tetralogy of fallot (TOF) repaired at birth without any associated diaphragmatic hernia. At the age of 2½ years, she experienced an upper gastrointestinal occlusion. At laparoscopy an organoaxial gastric volvulus was observed related to a peritoneal adhesion secondary to pericardial drainage that had been performed at the time of the TOF repair. After reduction of the volvulus, a phrenofundopexy was done. Postoperatively, the child has remained asymptomatic with a follow-up of 24 months.Hydrothorax following delayed extravascular migration of a totally implantable venous access device in a child
Totally implantable venous access devices are widely used in pediatric oncology. The authors encountered a 10-year-old boy with implantation of the device at the age of 7 years owing to acute lymphoblastic leukemia. In the recent half-year, the device was not used except for regular heparin flushing. However, hydrothorax occurred when fluid therapy was required from the device during this admission. Thoracoscopic approach showed extravascular migration and intrapleural malposition of the catheter.Benign cystic mesothelioma of the peritoneum in a male child
The benign cystic mesothelioma of the peritoneum is a rare lesion that occurs predominatly in women of reproductive age and has a high propensity for local recurrence. It is very rare in childhood, especially in boys, being reported in only 4 cases. A new case of benign cystic mesothelioma of the peritoneum in an 11-year-old boy is reported. The lesion occupied the entire left abdomen, arising from the transverse mesocolon, and it was accompanied by 4 small cysts. The patient had a coexistent right-sided renal agenesis.Management of postdural puncture headache with epidural saline patch in a 10-year-old child after inguinal hernia repair: A case report
Spinal anesthesia (SA) is becoming increasingly popular among pediatric anesthetists. Postdural puncture headache (PDPH) has been reported in children. PDPH generally spontaneously resolves within a few days with bed rest and nonopioid analgesics, but it may last for several days. If the symptoms persist, an epidural blood patch is considered as an effective treatment. We describe the successful use of an epidural saline patch in a 10 year-old child with PDPH who did not respond to conservative treatment.Assessment of subtotal nasal reconstruction in a child after 6 years of follow-up
Nasal amputation in the child is infrequent, and the procedure is not clearly defined. Early reconstruction certainly improves the child's life and social integration. The major risk is unsatisfactory growth of the reconstructed nose, which may persuade some surgeons to postpone the operation. The evaluation of this nasal reconstruction in a 5-year-old boy who had undergone subtotal amputation of the nose after 6 years of follow-up tends to confirm the therapeutic choice of early nasal reconstruction in the child.Childhood thoracic actinomycosis: case report
Actinomycosis is a rare bacterial infection. It has a pseudotumoral appearance when localized to the lungs or mediastinum. The diagnosis is often delayed because clinical presentation is nonspecific, bacteriologic diagnosis is difficult, and culture growth is slow. The diagnosis is mainly based upon histologic identification of actinomycotic sulfur granules. Actinomycosis is usually sensitive to penicillin G. Surgical treatment is reserved for failure of medical treatment and complications. We report a case of thoracic actinomycosis in a 13-year-old boy.Laparoscopic-assisted perineal pull-through vaginoplasty
Hematometrocolpos is the result of vaginal obstruction and can become an emergency in the pubertal period. The treatment of imperforate hymen is well defined, but the treatment of vaginal atresia is more complex. We report a case of hematometrocolpos secondary to distal vaginal atresia that was operated on in the pubertal period. The patient had isolated distal atresia without persistence of the urogenital sinus. A combined abdominal laparoscopic and perineal approach and a posterior vaginoplasty were carried out.Swyer-James-MacLeod syndrome in a surgically treated child: a case report and brief literature review
Swyer-James-Macleod syndrome (SJMS) is a rare, complex disease characterized by unilateral hyperlucent lung or lobe owing to loss of pulmonary vasculature and alveolar hyperdistention. Treatment is generally conservative, and surgical management is rare. In fact, only 4 reports on surgically treated children with SJMS are available in the literature. We describe an 8-year-old patient with a history of recurrent respiratory infections since 2 months old. The patient presented with cough and dyspnea on effort.Invasive thymoma in a child: a rare case report
Thymomas are neoplasms of the anterior mediastinum and generally occur between the fourth and sixth decades of life. In children, they are rare, with few reported cases. We describe a 9-year-old boy with invasive thymoma treated successfully by surgery alone. The patient was previously healthy and under treatment for a community-acquired pneumonia. A chest radiograph showed an opacity at the left lung base, and thoracic computed tomographic scan showed a mass with thick walls and liquid content situated in the lingula with no cleavage plane with the mediastinum.Complete urogenital nonunion
A 7.5-year-old boy was admitted to our department with left undescended testis. On surgical exploration, the vas deferens and epididymis were normal in appearance in its route to the scrotum, but no obvious testis or testis-like structure was identified. Exploration was extended to the abdominal cavity via the processus vaginalis, and the testis was found near the sigmoid colon without any connection to the vas deferens and epididymis. The testis was freed from surrounding structures preserving the testicular vasculature, and an orchidopexy was performed.Giant ureteral polyps causing proximal ureter obstruction: emphasis on the surgical method and ureteroscopy
We describe here the case of a 13-year-old boy who had right flank pain for 3 months. An intravenous pyelogram showed filling defects in the right upper part of the ureter as well as hydronephrosis. Because the diseased part of the ureter was about 5 cm in length and we wished to avoid short ureter after surgery, we performed a minimal segmental resection of the ureter including the entire stalk. Perioperative ureteroscopic examination showed another polyp 3 cm below the primary polyp, which was also removed.Adenomatoid tumor of the testis in a child
Adenomatoid tumors are rare benign neoplasms thought to be of mesothelial origin. Although most reported cases arise from the epididymis, rare cases have been reported in the spermatic cord, testicular tunica, ejaculatory ducts, prostate, and suprarenal recess. We describe a 4.5-year-old boy who presented with a relatively asymptomatic right testicular mass that was resected and confirmed to be adenomatoid tumor of the testis by histopathology. Because of its rarity, the clinical and histopathologic aspects are discussed.Solitary neurofibroma arising from the infratemporal fossa in a child
Neurofibromas are derived from the nerve sheath and are commonly located in the head and neck region. They usually occur between the ages of 30 and 50 years. Neurofibromas arising from the infratemporal fossa are quite rare, especially in children. We describe a solitary neurofibroma arising from the infratemporal fossa in an 8-year-old boy who presented with a painless mass in his right cheek. Computed tomographic scan showed a soft-density, not well-circumscribed mass located in the right infratemporal fossa.Benign calcifying fibrous-myofibroblastic tumor mimicking myositis ossificans in a 22-month-old girl
Myositis ossificans circumscripta (MOC), with nonneoplastic heterotopic bone formation in soft tissue and skeletal muscle, is rare in children. Extraskeletal osteosarcoma is a very rare malignant mesenchymal neoplasm of soft tissues in children. At onset, it may be difficult to distinguish MOC from a musculoskeletal infection or neoplasm, particularly in the absence of trauma, and a biopsy is frequently required. However, differentiating MOC from malignant neoplasm is imperative. We describe the case of a 22-month-old girl who presented with a benign fibrous-myofibroblastic tumor mimicking MOC.Lipoblastoma: a rare lesion in the differential diagnosis of childhood mediastinal tumors
Lipoblastoma is a rare, benign, fatty tissue tumor that occurs in childhood. The location of this tumor in the mediastinum and extension to the chest wall is uncommon. We describe a 12-month-old male infant with a mediastinal lipoblastoma discovered because of a chest wall swelling. Computed tomography showed the deep component and fatty content of the lesion suggestive of the diagnosis. Total excision of the mass was carried out. The histologic examination of the lesion confirmed the diagnosis of lipoblastoma.Laparoscopic repair of traumatic abdominal wall hernia from handlebar injury
A 14-year-old boy was seen at an outside hospital after falling over the handlebar of his bicycle and was discharged home. He was subsequently seen in our emergency department with complaints of persistent abdominal pain. A computed tomography scan of the abdomen revealed disruption of the muscles of the upper right abdominal wall containing the hepatic flexure of the colon, with a small amount of intraperitoneal free fluid noted. The patient underwent laparoscopic exploration using 3 ports (2-5 mm and 1-12 mm) and 2 separate stab incisions.Castleman disease: an unusual diagnosis of a portal mass in an 8-year-old boy
An 8-year-old boy presented with a mass located in the portal hilum and hepatosplenomegaly, and the presumed initial diagnosis was lymphoma. The pathology result was Castleman disease of hyaline vascular type. Castleman disease is an unusual diagnosis that should be kept in mind in the differential diagnosis of portal masses. In the case of solitary lesions, total excision can be curative.Hepatoblastoma in association with bilateral polycystic kidneys
We describe the first known case of hepatoblastoma associated with bilateral autosomal recessive polycystic kidney disease in a preterm twin boy. The diagnostic and therapeutic considerations are addressed. The patient survived after primary hepatectomy operation and administration of modified adjuvant chemotherapy.Small bowel intussusception with pelvic plastron secondary to acute appendicitis in child
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.Pediatric alveolar echinococcosis invading the diaphragm and spreading to the chest and abdominal wall
Hepatic alveolar echinococcosis (AE) is an endemic disease in certain parts of the world and relatively rare in children. This report describes a 9-year-old girl with hepatic AE invading the diaphragm and directly spreading to the chest and abdominal wall. She was treated by surgical extirpation and albendazole therapy. In advanced hepatic AE, combined therapy of surgical and medical intervention is thought to improve the prognosis.Renal cell carcinoma originating in a renal cyst in a 12-year-old girl
We report a 12-year-old girl with renal cell carcinoma originating in a cyst of the left kidney. Ultrasonography revealed 2 small hyperechoic masses in the luminal side of a cyst. Although hypervascularity was not detected in the cyst by computed tomography, the possibility of malignancy could not be ruled out because of the presence of 2 solid masses. Therefore, partial left nephrectomy was performed. On histopathologic examination, the 2 solid masses within the cyst were found to be renal cell carcinoma.Liver transplant for relapsed undifferentiated embryonal sarcoma in a young child
Undifferentiated embryonal sarcoma of the liver is a rare hepatic malignancy of childhood with a historically poor prognosis. Recent improvements in outcomes have been reported in small numbers of cases with the use of combination therapy involving aggressive surgical resection and chemotherapy. Complete surgical resection is frequently difficult to achieve when the location of the tumor is along the margins of the major hepatic vessels (portal vein, hepatic vein, and hepatic artery). Here we report a case of undifferentiated embryonal sarcoma of the liver that recurred along surgical hepatic vein margins in a 9-year-old boy who subsequently underwent orthotopic liver transplantation from a cadaveric donor.Ectopic nephrogenic rests in children: the clinicosurgical implications
Ectopic nephrogenic rests (ENR) are rare. The incidental discovery of these lesions in children has particular clinicosurgical implications, especially given the association between ENR and the development of extrarenal Wilms' tumors (ERWT).Primary intestinal lymphangiectasia successfully treated by segmental resections of small bowel
Primary intestinal lymphangiectasia is a rare cause of protein-losing enteropathy and usually presents with intermittent diarrhea or malnutrition. Diagnosis depends largely on its pathologic condition demonstrating greatly dilated lymphatics mainly in the lamina propria of the mucosa. We report a case of primary intestinal lymphangiectasia, of the diffuse type, presenting with abdominal pain and voluminous diarrhea in a previously healthy 8-year-old boy. He had periumbilical pain for 3 months before presentation.Neuroendocrine tumor of the common hepatic duct, mimicking a choledochal cyst in a 6-year-old child
We report a rare case of a neuroendocrine tumor of the extrahepatic biliary tree in a child. A 6-year-old girl who presented with jaundice and pruritus was found to have elevated liver enzymes along with a cystic dilatation of the common hepatic duct. After further diagnostic testing, a working diagnosis of a type I choledochal cyst was established. Laparotomy revealed hydrops of the gall bladder, an elongated and dilated cystic duct and a cystic dilatation of the common hepatic duct. An unusually thickened common bile duct was also noted at the time.Benign cystic mesothelioma in a child
An 11-month-old male presented with massive ascites and respiratory distress with no known etiology. Laparotomy confirmed ascites with multiple large cystic structures that originated in the left retroperitoneum. Grossly, it resembled lymphangioma; however, histopathologic diagnosis was benign cystic mesothelioma (BCM), an entity that presents mainly in women of childbearing age. After resection, the child had 2 recurrences for the following year, the first of which required resection. He also underwent resection of a congenital cystic adenomatoid malformation of the right lung.Subcutaneous emphysema, pneumomediastinum, pneumothorax, pneumoperitoneum, and pneumoretroperitoneum by insufflation of compressed air at the external genitalia in a child
A 7-year-old girl with concurrent subcutaneous emphysema, pneumomediastinum, pneumothorax, pneumoperitoneum, and pneumoretroperitoneum arrived at our facility. Compressed air at 5 atm of pressure was insufflated through the nozzle of a spray gun over her external genitalia. She was admitted for a small amount of genital bleeding and significant subcutaneous emphysema extending from the cheek to the upper body. Radiographic examination of the abdomen was suggestive of a visceral perforation, but she was managed conservatively and discharged in satisfactory condition without surgical intervention.Pediatric blunt vertebral artery injury: case report and treatment plan
Aggressive screening for blunt cerebrovascular injuries in patients with trauma has led to the identification and successful treatment of these injuries. We report the case of an 8-year-old boy who sustained a vertebral artery injury after a motor vehicle collision. Computed tomography angiogram showed an 8-mm thrombosed segment of the vertebral artery. The patient was initially anticoagulated with a heparin drip and transitioned over to treatment with enoxaparin sodium (Lovenox). With few reports in the literature of blunt cerebrovascular injuries in the pediatric population, a review of the appropriate screening parameters, treatment plans, and follow-up is helpful for the practicing physician.Embryonal rhabdomyosarcoma of the ampulla of Vater in early childhood: report of a case and review of literature
Embryonal rhabdomyosarcoma of the ampullary region is a very rare childhood tumor (2 reported cases), and herein we describe a child presenting with obstructive jaundice at early age owing to such tumor in the ampullary region. Successful management with multidisciplinary approach is discussed with reference to the literature.Choledochoduodenal fistula caused by blunt abdominal trauma in a child
We report a 15-year boy who presented with obstructive cholangiopathy and pancreatitis after blunt abdominal trauma. A magnetic resonance cholangiopancreatography showed dilated common bile duct, dilated hepatic ducts, and a suspicious choledochoduodenal fistula. An endoscopic retrograde cholangiopancreatography revealed a parapapillary choledochoduodenal fistula. An operation of choledochojejunostomy, excision of common bile duct, and cholecystectomy was done for recurrent cholangitis. Abdominal symptoms completely subsided one month later.Primary paratesticular neuroblastoma: a case report and review of literature
Only 4 infants with primary paratesticular neuroblastoma have been previously described. To the author's knowledge, this case would be the first report of a child who is older than 1 year whose lesion is in his right hemiscrotum. After simple tumorectomy was performed; he was tumor free at 4 years of follow-up. Patients older than 1 year with localized primary paratesticular neuroblastoma may have good prognosis after simple tumorectomy without further therapy.Multiple jejunoileal perforations because of intestinal involvement of miliary tuberculosis in an infant
Infants are more susceptible to tuberculous bacilli and may develop severe extrapulmonary and miliary forms of the disease. However, miliary tuberculosis (MT) presenting with multiple intestinal perforations as an initial manifestation of the disease is extremely rare in children. The authors describe an infant who underwent emergency laparotomy because of jejunoileal perforations secondary to intestinal involvement of MT to emphasize the characteristics of the abdominal disease and the importance of controlling systemic disease to achieve a favorable outcome.Infected urocolpos and generalized peritonitis secondary to labia minora adhesions
Labia minora adhesions (LMA) are a common finding in young girls. Usually, this condition is asymptomatic and spontaneously disappears during adolescence. We report on a case revealed by infected urocolpos and peritonitis and whose treatment finally required surgical reduction labioplasty.A rare cause of hemorrhagic shock in children: bladder hemangioma
We report the first case of urinary bladder hemangioma that caused hemorrhagic shock consequent to massive hematuria. A 2-year-old girl was presented with hemorrhagic shock and macroscopic hematuria. After rapid resuscitation was performed, radiologic investigations demonstrated a solid enhancing mass originating from the dome of bladder. Partial cystectomy was made. Histopathologic examination of resected specimen revealed cavernous hemangioma. Although bladder hemangiomas are rare benign tumors, it should be kept in mind that they can lead to life-threatening complications when the diagnosis is delayed.Intestinal obstruction secondary to a colonic lithobezoar
A bezoar is an accumulation of indigestible exogenous matter in the stomach and intestine. A myriad of ingested substances have been found impacted in the digestive tract. Bezoars are uncommon causes of intestinal obtruction during childhood. Lithobezoar, an accumulation of ingested stones within the alimentary tract, is an extremely rare clinical entity. We report one such case in a 9-year-old boy with a history of pica and long-term constipation resulting in intestinal obstruction secondary to a colonic lithobezoar.Common characteristics of jejunal heterotopic gastric tissue in children: a case report with review of the literature
An 11-year-old boy underwent laparotomy for intermittent intussusceptions because of a polypoid lesion located in the proximal jejunum. The polypoid lesion was diagnosed as heterotopic gastric mucosa (HGM). Jejunal HGM is a very rare entity, and review of the literature revealed common characteristics in children with this pathologic condition. The usual presenting age is about 14 years, and the common clinical picture is intermittent intussusceptions. Jejunal HGM is usually polypoid and predominantly located within a few centimeters distal to ligament of Treitz.Successful treatment of congenital esophageal web by endoscopic electrocauterization and balloon dilatation
We report a 3-year-old boy who presented with a foreign body impacted in the esophagus and had a poor tolerance of solid food since he was 5 to 6 months old. In the last 2 years, he developed progressive dysphagia, anorexia, vomiting, and poor weight gain. An esophagoscopy and barium esophagogram revealed an esophageal web in the distal third of the esophagus. Three courses of endoscopic balloon dilatation resulted in transient improvement in his dysphagia and vomiting; a follow-up barium esophagogram and esophagoscopy showed limited improvement of the esophageal stenosis.Bronchioloalveolar carcinoma arising in a congenital pulmonary airway malformation in a child: case report with an update of this association
An 8-year-old girl was evaluated for a mass in the left pulmonary lobe. Her clinical history was remarkable for an intermittent dry cough since the age of 2, with recurrent episodes of purulent sputum and fever. She underwent left lower lobectomy, which was found to be a bronchioloalveolar carcinoma arising in a type 1 congenital pulmonary airway malformation at pathologic examination. No additional therapies were undertaken. Two years after resection, imaging studies showed 5 contralateral pulmonary nodules suggestive of disseminated disease with a poor outcome.Isolated injury of the superior mesenteric artery caused by a lap belt in a child
Isolated vascular injuries are rare in cases of blunt abdominal trauma, and superior mesenteric artery injury is extremely rare but potentially lethal. The incidence of this kind of life-threatening injury has increased in recent years. The diagnosis of these isolated injuries is difficult, and its delay is associated with a higher morbidity and mortality. The authors report on the case of a child with an isolated injury of the superior mesenteric artery caused by a lap belt, during a motor-vehicle crash which was successfully managed.Lymphoplasmacytic sclerosing pancreatitis presenting as a pancreatic head mass in a child: case report and management recommendations
Lymphoplasmacytic sclerosing pancreatitis (LPSP) is an autoimmune form of chronic pancreatitis found most commonly in elderly men and only rarely in children. A 10-year-old boy presented with a 3-week history of obstructive jaundice. Imaging studies showed a pancreatic head mass, hepatic ductal dilatation, and involvement of the portal vein. A preliminary diagnosis of malignancy was based on endoscopic ultrasound characteristics and fine-needle aspiration cytology. The patient underwent a pancreaticoduodenectomy.Primary abdominal lymphonodular cryptococcosis in children: 2 case reports and a literature review
Cryptococcus neoformans is an important opportunistic fungal pathogen that is acquired via the respiratory tract. It causes several clinical syndromes and most commonly presents as meningitis. The establishment of C neoformans infections in immunocompetent individuals could be owing to increased virulence, dose of the organism, or genetically determined differences in the ability to generate a protective immune response against the organism.Multiple lymph node metastases in a boy with primary testicular carcinoid, despite negative preoperative imaging procedures
A testicular tumor in a 12-year-old boy proved to be a carcinoid tumor. An extensive investigation including a computed tomographic scan of the abdominal and pelvic region as well as both 123I-labeled metaiodobenzylguanidine and 111In-coupled octreotide scintigraphy was normal. Because histopathologic examination of the primary surgical specimen revealed tumor growth in the resection border of the spermatic vessels, a second operation with unilateral lymph node dissection was performed. Surprisingly, 3 lymph node metastases were found.Ciliated hepatic foregut cyst in a young child
Ciliated hepatic foregut cysts are a rare entity usually found in adults. We present a case of a 3-year-old boy incidentally noted to have a radiographically complex liver cyst on computed tomographic scan. Given the complex appearance, the cyst was excised. Pathology revealed a ciliated hepatic foregut cyst. This is the second child and youngest patient affected with this lesion reported in the literature. The etiology of the lesion and an argument for surgical removal in pediatric patients are presented.
