Long-term outcome of liver transplantation in childhood: A study of 20-year survivors

We report the results of a study of survival, liver and kidney functions, and growth with a median follow-up of 24 years following liver transplantation in childhood. From 1988 to 1993, 128 children underwent deceased donor liver transplantation (median age: 2.5 years). Twenty-year patient and graft survival rates were 79% and 64%, respectively. Raised serum aminotransferase and/or γ-glutamyl transferase activities were present in 42% of survivors after a single transplantation. Graft histology (35 patients) showed signs of chronic rejection in 11 and biliary obstruction in 5. Mean total fibrosis scores were 4.5/9 and 3/9 in patients with abnormal and normal serum liver tests, respectively. Glomerular filtration rate was <90 mL·min^-1 in 35 survivors, including 4 in end-stage renal disease who were undergoing dialysis or had undergone renal transplantation. Median final heights were 159 cm for women and 172 cm for men; final height was below the target height in 37 patients. Twenty-year survival after childhood liver transplantation may be close to 80%, and final height is within the normal range for most patients. However, chronic kidney disease or altered liver biochemistries are present in over one third of patients, which is a matter of concern for the future.

Organization in response to massive afflux of war victims in civilian practice - experimental feedback from the November 2015 Paris terrorist attacks

The arrival of a large number of war-weapon casualties at a civilian trauma center requires anticipation. A plan defining the management principles and the respective roles of the involved physicians and nurses and their interaction with each other is essential. Uni-directional patient flow associated with adequate numbers of staff physicians and nurses under the leadership of a medical director is essential to prevent the overwhelming of the trauma center. Routine and regular interaction between the pre-hospital medical flow control system and the medical director, on one hand, and between surgical teams and the medical director, on the other, are necessary to know when to apply "damage control" surgical techniques. Based on the feedback of a level 1 trauma center that received 53 victims of the November 13, 2015 terrorist attack in Paris, we present the factors of success, and the stumbling blocks.

[Duodenal duplication revealed by acute pancreatitis]

INTRODUCTION

Duodenal duplications are rare congenital malformations whose revealing signs are highly variable and nonspecific.

OBSERVATION

We report the case of a female infant who presented with neonatal acute pancreatitis complicated by recurrent ascites, profound hypoalbuminemia responsible for pleural and pericardial effusions, revealing a duodenal duplication cyst. The unusual and original clinical presentation as well as the difficulty detecting the duplication radiologically delayed the diagnosis. A prolonged medical treatment with octreotide, albumin infusions, and exclusive parenteral nutrition led to an almost total disappearance of the ascites before surgery. The outcome was favorable after surgical removal of the duplication with 1 year of follow-up.

CONCLUSION

The diagnosis of duodenal duplication can be difficult and it may be necessary to repeat the ultrasound examinations. Surgical resection is delicate, especially when there is an abundant pancreatic ascites. Therefore, an adequate prolonged medical treatment to reduce this ascites is recommended before the surgery.

Transcatheter Arterial Chemotherapy Using Doxorubicin, Iodized Oil and Gelfoam Embolization in Hepatocellular Carcinoma

Computed tomography (CT) was performed in 54 patients with hepatocellular carcinoma three weeks after transcatheter arterial chemotherapy using iodized oil and doxorubicin with or without gelfoam embolization. Patients with iodized oil retention in the tumor greater than 50 per cent of tumor size survived longer than patients with retention of less than 50 per cent. Differences were also found within Okuda stages I and II, but they were significant only in Okuda stage I (p<0.0001). These results suggest a possible relationship between iodized oil retention and survival. In addition to Okuda stage, several factors affected iodized oil retention: tumor vascularity, tumor size, portal thrombosis and Gelfoam embolization. These factors may thus influence the prognosis after transcatheter arterial chemotherapy.

Ovarian tumors in children and adolescents: a series of 41 cases

OBJECTIVE

Pictorial review with a detailed semiological analysis of ovarian tumors in children and adolescents to provide a relevant diagnostic approach.

PATIENTS AND METHODS

Retrospective study (2001-2011) of 41 patients under the age of 15 who underwent surgery for an ovarian mass with a definite pathological diagnosis.

RESULTS

Sixty-two percent of the lesions were benign, 33% were malignant and 5% were borderline. Germ cell tumors were most frequent (77.5%), followed by sex cord stromal tumors (12.5%) and epithelial tumors (7.5%). Malignant tumors were more frequent in children between 0 and 2 years old. On imaging, calcifications and fat were specific for germ cell tumors; the presence of a mural nodule was predictive of a mature teratoma (P<0.001). Predictive factors for malignancy were clinical, including abdominal distension (P<0.01) or a palpable mass (P=0.05), biological, including increased hCG and/or AFP levels (P<0.001) and radiological, including tumors larger than 12 cm (P<0.05), tumoral hypervascularity (P<0.01) and voluminous ascites (P<0.01).

CONCLUSION

This semiological analysis confirms the role of imaging in diagnosing the etiology of ovarian lesions in children and adolescents and emphasizes the importance identifying tumoral hypervascularity, which, in addition to classic criteria, is highly predictive of malignancy.

Congenital portosystemic shunts in children: recognition, evaluation, and management

Congenital portosystemic shunts are present in one in 30,000 children. Among the associated risks of severe complications are neonatal cholestasis, benign and malignant liver tumors, hepatopulmonary syndrome, portopulmonary hypertension, and encephalopathy. They can be detected on prenatal ultrasonograms, during the investigation of a positive galactosemia screening test in neonates or of a complication, or be found fortuitously on an abdominal ultrasound. Small intrahepatic shunts may resolve spontaneously within one year of age, but other shunts such as extrahepatic, persistent ductus venosus or persisting intrahepatic shunts, must be closed in one or two steps, by interventional radiology techniques or surgically. The plasticity of the intrahepatic portal system allows revascularization of the liver after shunt closure, even when no intrahepatic portal structures can be detected on imaging studies. This leaves little or no place for liver transplantation in the management of these children.

The long-term outcome of hepatic artery thrombosis after liver transplantation in children: role of urgent revascularization

Hepatic artery thrombosis (HAT), one of the most severe complications of pediatric orthotopic liver transplantation (OLT), often compromises graft and/or child survival. Of 590 OLT performed in 516 children over a 20-year period, 45 were complicated by early HAT, during the first 2 weeks after transplantation. Systematic Doppler ultrasonographic detection of HAT allowed successful surgical revascularization in 19 instances, resulting in a 20-year graft survival rate of 77% versus 24% of cases when revascularization was not attempted or failed. A combination of surgical emergency revascularization, biliary interventional radiology, biliary surgery and/or retransplantation resulted in an 80% 20-year patient survival rate, identical to that of transplanted children who did not experience early HAT. The majority of long-term survivors with their initial graft had normal liver tests, no biliary dilation on ultrasonography and minimal or moderate fibrosis on liver histology. A failed attempt at revascularization did not significantly alter patient survival. Despite these encouraging results, for the children and their parents to overcome the entire process in terms of reoperations, repeated radiological interventions, number of hospitalizations and emotional stress, remains an ordeal of such magnitude that it justifies renewed efforts to progress in the prevention of this complication.

[What is the value of the chest radiography in making the diagnosis of children pneumonia in 2011?]

According to the French national health authority guidelines, the diagnosis of childhood pneumonia is based on clinical suspicion and radiological confirmation. The chest radiography is an expensive procedure, and potentially deleterious by its radiating character. We have attempted to clarify its diagnostic value in community acquired pneumonia in children through a literature review using the Pubmed search engine with the following keywords: "pneumonia, child, radiograph".

CONCLUSION

The indication of chest radiography in severe pneumonia achieved unanimity among the various scientific societies. In contrast, in mild forms, tendency of the available data is to not recommend the routine use of chest radiography; further randomised and prospective studies are necessary to confirm this trend. Finally, because of the frequency of atypical presentations in children, chest radiography retains all its usefulness in the etiologic diagnosis of fever of unknown origin.

[Transrectal drainage of pediatric pouch of Douglas abscesses under suprapubic US guidance: technique and results]

Pelvic abscesses are not always amenable to percutaneous drainage. Transrectal drainage of pouch of Douglas abscesses, performed blindly by surgeons for many years, is not familiar to radiologists. The purpose of this article is to describe our technique for the drainage of pouch of Douglas abscesses under suprapubic US guidance and report our results in a series of 7 pediatric patients with deep pelvic abscess not amenable to percutaneous drainage after failure of antibiotics. The procedure was performed under general anesthesia. All procedures were successful and without complication. The drainage catheter was well tolerated in all cases with short post-drainage hospital stay. After failure of medical management, this technique can be used irrespective of patient age or sex using US transducers and drainage catheters routiney available in any radiology department.

[Results of a national survey about the use of sedation scales in emergency prehospital medicine]

The primary goal of sedation in emergency prehospital care is to guarantee the security of the mechanically ventilated patients by optimising their adaptation to the respirator. If the French prehospital guidelines are well codified, their applicability in routine clinical practice seem to be rather empirical. The aim of this national survey was to evaluate the use of the clinical sedation scales by the prehospital physicians. This prospective and clinical practice survey was begun in January 2005. An anonymous questionnaire was sent to the physicians working in the 377 Mobile Intensive Care Unit of the 105 French Emergency Medical Service System. The total response rate from physicians was 28% (n=497). Only 29% of the physicians (n=145) declared to use a sedation scale for a mechanically ventilated patient. The Ramsay score was used in 97% of the cases (n=141).The principal reasons given by the physicians for not using the sedation scales were their ignorance in 57% of the cases (n=200) and the systematic choice of a deep sedation in 42% of the cases (n=147). For 18% of them (n=62), the use of sedation scores was considered too complicated. The final results show that the utilisation ratio of the sedation scores is very low in emergency prehospital medicine and suggest that an effort toward improving the use of sedation in prehospital emergency medicine is necessary.

[Noninfectious febrile inflammatory syndromes in children: diagnosis and usefulness of diagnostic procedures]

OBJECTIVE

To determine the causes and to quantify the benefits obtained from further diagnostic investigations in children presenting with a non infectious inflammatory fever.

METHODS

The records of 62 children aged from two-months to 15 years (median: four years) admitted to a paediatric department between 1990 and 2000 for the evaluation of a fever associated to an inflammatory syndrome, defined as temperature over 38 degrees C with an increase of the erythrocyte sedimentation rate (ESR) more than 20 mm/h and/or a serum C-reactive protein level (CRP) > 20 mg/L, and excluding overt infectious diseases, were retrospectively reviewed.

RESULTS

Of these patients, 79% children (49 cases) had inflammatory systemic disease, 3.2% (two cases) had malignancy, and 17.8% (11 cases) had undiagnosed disorders. The most frequent disease was Kawasaki disease (22 children), especially in young children. Increase of ESR above 100 mm/h and of CRP above 100 mg/L was present in 59% of Kawasaki disease, 71% of idiopathic juvenile arthritis, 100% of malignancies and 7% of unknown diagnoses. Increase of ESR below 50 mm/h and of CRP below 50 mg/L was present in 75% of hemophagocytic syndromes and 46% of unknown diagnosis. The polymorphonuclear count, hepatic function evaluation, triglycerides levels, abdominal ultrasound, abdominal computed tomography, echocardiography, biopsies were useful diagnosis tools. Technetium scintigraphy was helpful only when abnormalities were found on physical examination.

CONCLUSION

The diagnosis of Kawasaki disease must be quickly suspected in febrile young children with inflammatory syndrome without infection. ESR and CRP values, abdominal ultrasound and echocardiography are helpful tools for the diagnostic procedure.

[Sonography of the pediatric abdomen: liver and biliary tract]

Ultrasound is a routine imaging modality that is quite valuable to assess the pediatric abdomen. The objective of this article is to describe the sonographic appearance of the liver and bile ducts in children. Our goal is to emphasize normal variants and specific pediatric diseases, even if some of them may be encountered in adults.

Postshunt encephalopathy in liver transplanted children with portal vein thrombosis

BACKGROUND

Surgical portosystemic shunting has been reported to alleviate successfully portal hypertension in liver transplanted recipients with portal vein thrombosis.

METHODS

We report two liver transplanted children with portal vein thrombosis who developed post-shunt acute encephalopathy. In one child, a mesocaval H-type shunt was created surgically because of bleeding related to Roux-en-Y loop varices at 3 months posttransplantation; in the other, a large spontaneous splenorenal shunt was discovered at the time of diagnosis of portal vein thrombosis on day 34 posttransplantation and was preserved.

RESULTS

Post-shunt encephalopathy developed 6 months and 2.7 years after transplantation, causing death in one child.

CONCLUSIONS

This report illustrates the risk and the possible dismal outcome of post-shunt encephalopathy in liver transplanted children. Therapeutic procedures other than portosystemic shunting that will restore an hepatopetal portal flow to the liver graft should be considered in liver-transplanted children with portal vein thrombosis.

[Papillary solid tumor of the pancreas in a child: a case report]

We present a case of a papillary solid neoplasm of the head of the pancreas incidentally diagnosed after an abdominal trauma in a thirteen year old boy. Imaging features (US, CT) of the lesion were not specific enough to permit a precise diagnosis with certainty. Preoperative percutaneous needle biopsy can give presumptive evidence which may guide the treatment. Prognosis is fairly better than other pancreatic neoplasms in children (particularly pancreatoblastoma). Treatment relies only on surgery.

[Cyclic filling cystourethrography in the study of febrile urinary tract infection in children]

PURPOSE

To assess the value of cyclic voiding cystourethrography (VCUG) for the detection of reflux in a large population of children with urinary tract infection.

MATERIALS AND METHODS

234 patients (67% less than 3 years of age) underwent VCUG with two fillings in 214 cases and three fillings in 139 cases. Appearance or increase in the grade of reflux compared with previous filling was expressed as "modification of the radiology report" (MRR). The amount of contrast material, the duration of fluoroscopy and the number of films were recorded.

RESULTS

The rate of reflux was 18.4% at the first filling, 16% at the second filling with 9.8% MRR and 14.7% at the third filling with 10% MRR. These results were the same for children younger and older than 3 years. For children under three years, if one considered reflux grade higher than 1, the MRR was 9.6% at the second filling and 7.5% at the third while it was 5.8% and 3% for older children. On average, the use of contrast material increased 50% with a third filling, number of films was not modified and the time of fluoroscopy increased by 6 sec per filling.

CONCLUSION

VCUG is recommended in all children. The detection of reflux higher than grade 1 is more frequent with multiple fillings in children under 3 years. The increase in radiation exposure and cost seems negligible.