Iliac artery stenosis in a child with cutis marmorata telangiectatica congenita

Cutis marmorata telangiectatica congenita (CMTC) is a rare congenital disorder. We describe an 8-year-old boy with CMTC who presented with symptomatic claudication and diminished distal pulses. Imaging showed severe stenosis of the right common iliac artery, and the child underwent uncomplicated ilio-iliac bypass using prosthetic graft. This is the first report of a patient with CMTC and major vessel stenosis, successfully treated with a prosthetic graft bypass.

An injectable tissue-engineered embolus prevents luminal recanalization after vascular sclerotherapy

BACKGROUND/PURPOSE

Sclerotherapy for vascular malformations is often limited by luminal recanalization. This study examined whether an injectable tissue-engineered construct could prevent this complication in a rabbit model of venous sclerotherapy.

METHODS

Ethanol sclerotherapy of a temporarily occluded jugular vein segment was performed in 46 rabbits, which were then divided into 3 groups. Group I (n = 16) had no further manipulations. In groups II (n = 15) and III (n = 15), 0.5 mL collagen hydrogel was injected intraluminally, respectively, devoid of and seeded with autologous fibroblasts. At 1, 4, and 20 to 24 weeks postoperatively, vein segments were examined for patency and resected for histological evaluation. Statistical analysis was by Fisher's Exact test.

RESULTS

All vein segments were occluded at 1 and 4 weeks in all groups, despite histological evidence of progressive endothelial ingrowth. However, at 20 to 24 weeks, angiography demonstrated restoration of vessel patency in groups I (3/6) and II (3/5), but not in group III (0/6; P = .043), in which histology confirmed an obliterated lumen for all vessels.

CONCLUSION

An injectable, fibroblast-based, engineered construct prevents midterm to long-term recanalization in a leporine model of vascular sclerotherapy. This novel therapeutic approach may prevent recurrence of vascular malformations after sclerotherapy, thus reducing the need for repeated procedures and morbid operative resections.

Fetal Surgery in Otolaryngology

OBJECTIVE

To evaluate the efficacy, safety, and outcome of prenatal imaging and fetal surgery in the diagnosis and management of fetal airway obstruction caused by cervical teratoma or lymphatic malformation.

SETTING

Tertiary care medical center. Patients A retrospective study of all consecutive fetal patients with cervical teratoma or lymphatic malformation between January 2001 and December 2003.

RESULTS

The indication was potential airway obstruction due to a fetal neck mass in 8 patients. Prenatal images were obtained by ultrasonography and magnetic resonance imaging, and were consistent with teratoma in 4 patients. The mean cervical mass was 8.3 x 7.3 x 6.7 cm, with airway obstruction suspected in all 4 patients. All 4 patients were successfully delivered by ex utero intrapartum treatment, during which 3 newborns required tracheotomy and 1 was successfully intubated. Prenatal images were consistent with lymphatic malformation in the remaining 4 patients. The mean cervical mass was 4.6 x 4.4 x 3.4 cm. There was no indication of airway obstruction based on prenatal images. All 4 patients had an uncomplicated vaginal delivery.

CONCLUSIONS

Technological advances in prenatal ultrasonography and magnetic resonance imaging have improved the ability to diagnose congenital abnormalities in utero. This allows for proper assessment of the airway to prevent any unexpected problems at delivery. We believe that many airway emergencies can be avoided by prenatal imaging and initiation of airway management in the prenatal period.

Effects of race, insurance status, and hospital volume on perforated appendicitis in children

OBJECTIVE

Previous research suggests that perforated appendicitis is more common in Medicaid patients, but the roles of minority race and hospital volume remain largely unstudied. We sought to investigate the association of perforated appendicitis in children with minority race, insurance status, and hospital volume.

METHODS

We conducted a retrospective, population-based cohort study of 33184 children who had an International Classification of Diseases, Ninth Revision diagnosis code for acute appendicitis in The Kids' Inpatient Database, a pediatric database from 22 states in 1997. A multivariate logistic regression model was developed to determine patient and hospital characteristics predictive of perforated appendicitis.

RESULTS

Of 33184 children with acute appendicitis, 10777 (32.5%) were perforated. In multivariate analysis, black (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.10-1.39) and Hispanic (OR: 1.19; 95% CI: 1.10-1.29) children were more likely to have perforated appendicitis than white children. Perforation was also more likely in Medicaid patients (OR: 1.30; 95% CI 1.22-1.39) compared with privately insured children. Annual hospital volume of cases of appendicitis was not significantly associated with perforation in multivariate analysis.

CONCLUSIONS

Perforated appendicitis disproportionately affected both children of minority race and children insured by Medicaid. No effect of hospital volume was observed. To reduce this racial disparity, efforts should focus on the causes of delayed diagnosis and the treatment of appendicitis in children of minority race.

Kaposiform hemangioendothelioma without Kasabach-Merritt phenomenon

Kasabach-Merritt phenomenon is a serious coagulopathy associated with kaposiform hemangioendothelioma (KHE), tufted angioma, and possibly other vascular neoplasms. KHE presenting in the absence of Kasabach-Merritt phenomenon is rare, although tufted angioma frequently occurs without thrombocytopenia. We retrospectively reviewed 10 cases of KHE without Kasabach-Merritt phenomenon. The tumors appeared as soft tissue masses with the overlying skin being either normal, erythematous, or violaceous. There were no radiologic or microscopic differences in noncoagulopathic KHE as compared with coagulopathic KHE. Evidence of platelet trapping and hemosiderin deposition was seen histologically, despite normal serum platelet levels. All KHE were less than 8 cm in diameter, suggesting that tumors that grow no larger than this size are less likely to trap platelets in sufficient quantity to cause thrombocytopenia. Our series confirms that KHE appears with a wide spectrum of behavior and response to treatment. The decision as to whether or not to treat a noncoagulopathic KHE should be based on the size and location of the tumor and the possible side effects of therapy.

Blue rubber bleb nevus syndrome: surgical eradication of gastrointestinal bleeding

OBJECTIVE

We report the largest clinical experience to date of surgically treated patients with blue rubber bleb nevus syndrome (BRBNS).

SUMMARY BACKGROUND DATA

BRBNS is a rare congenital disorder presenting with multifocal venous malformations of the skin, soft tissues, and gastrointestinal (GI) tract. Patients with BRBNS develop anemia from chronic GI bleeding, and require lifelong treatment with iron and blood transfusions. An aggressive surgical approach to treat the GI venous malformations of BRBNS has been considered unlikely to be successful because of the large number of lesions, their position throughout the GI tract, and the likelihood of recurrence. Based on our belief that eradicated lesions would not recur, we undertook the removal of all GI tract lesions in an effort to eliminate bleeding.

METHODS

Ten patients with BRBNS were treated from 1993 to 2002. Lesions were identified using complete GI endoscopy. The multiple venous malformations were removed by a combination of wedge resection, polypectomy, suture-ligation, segmental bowel resection, and band ligation.

RESULTS

Patient ages ranged from 2 to 36 years, and patients received an average of 53 prior blood transfusions. A mean of 137 focal GI venous malformations per patient were resected at operation (range 4-557), with a mean operative duration of 14 hours (range 7-23 hours). Only 1 patient who had a less extensive procedure developed recurrent GI bleeding. The mean follow-up period was 5.0 years (range 2.9-10.3 years).

CONCLUSIONS

We believe that an aggressive excisional approach is indicated for the venous anomalies that cause GI bleeding in BRBNS.

Enhancement of intravascular sclerotherapy by tissue engineering: short-term results

BACKGROUND/PURPOSE

Treatment of vascular malformations with sclerotherapy is often complicated by reexpansion secondary to endothelial recanalization. This study examined the use of an autologous fibroblast construct to enhance intraluminal scar formation after sclerotherapy.

METHODS

New Zealand rabbits (n = 15) underwent ethanol sclerotherapy of a segment of the facial vein. After intraluminal saline flush, animals were equally divided into 3 groups. In group I, no further manipulations were performed. In groups II and III, collagen hydrogel was injected into the sclerosed vein, respectively, without and seeded with autologous green fluorescent protein-labeled fibroblasts. One week postoperatively, the vein segments were examined for patency and resected for histology.

RESULTS

The sclerosed vein segments remained occluded in all animals. Histological examination of luminal thrombi demonstrated numerous viable fibroblasts in group III, whereas there were none in the control specimens from groups I and II. The presence of the injected autologous green fluorescent protein-labeled fibroblasts within thrombi of group III was confirmed by immunohistochemistry.

CONCLUSIONS

An injectable tissue-engineered construct enhances sclerotherapy of the jugular vein in a leporine model by reliably delivering fibroblasts that populate the resultant thrombus. Further analysis of this novel therapeutic concept as a means to augment permanent scar formation and reduce luminal recanalization is warranted.

Esophageal atresia, duodenal atresia, and unilateral lung agenesis: a case report

The association of pure esophageal atresia, duodenal atresia, and unilateral lung agenesis has not been reported previously. Here the authors present a case of a newborn with this constellation of anomalies that underwent staged repair. The primary principle guiding treatment was the avoidance of iatrogenic injury to the single lung. Therefore, the order of operations proceeded as follows: (1) placement of a decompressing gastrostomy tube, (2) repair of the duodenal atresia, and (3) repair of the esophageal atresia. The congenital closed loop obstruction caused by the esophageal and duodenal atresias was beneficial in that it resulted in growth by stretching of the distal esophagus, allowing a tension-free primary repair of the esophageal atresia.

Infantile hepatic hemangiomas: clinical and imaging findings and their correlation with therapy

OBJECTIVE

This study was undertaken to determine different imaging patterns in infantile hepatic hemangiomas and to explore the relationship between clinical presentations, imaging findings, and response to therapy.

MATERIALS AND METHODS

The imaging studies and clinical records of all patients with infantile hepatic hemangiomas from two tertiary children's hospitals were reviewed. Univariate and multivariate stepwise logistic regression techniques were used to determine whether clinical presentation and imaging variables differentiated the type of treatment required.

RESULTS

Typical hemangiomas appeared as focal or multifocal T2-hyperintense spheres with centripetal contrast enhancement and dilated feeding and draining vessels. Three atypical patterns included focal mass lesions with central varix with or without direct shunts, focal mass with central necrosis or thrombosis, and massive hemangiomatous involvement of the liver with abdominal vascular compression. In general, patients with focal lesions without high flow needed no treatment, and those with central varix and direct shunts developed severe high-output cardiac failure that responded quickly to embolization. The pattern of massive replacement of liver was associated with hypothyroidism, abdominal compartment syndrome, and a high mortality rate. Multivariate analysis of 55 patients indicated that congestive heart failure was the only independent predictor of treatment (p = 0.005). The presence of a shunt was the only independent factor associated with embolization or surgery (p = 0.002).

CONCLUSION

Although the imaging features of infantile hepatic hemangiomas vary to some extent, MRI features are typical in most patients and certain imaging findings are predictive of the clinical course. MRI is the technique of choice in diagnosing infantile hepatic masses.

Wilms tumor screening is unnecessary in Klippel-Trenaunay syndrome

BACKGROUND

Children with hemihypertrophy are screened for Wilms tumor, because this condition is a risk factor for developing the neoplasm. Patients with Klippel-Trenaunay syndrome (KTS) are often considered potential candidates for Wilms tumor, because they have unilateral overgrowth of the lower limb. In our experience, however, an association between KTS and Wilms tumor has not been observed.

METHODS

To determine whether KTS and Wilms tumor are associated, we reviewed our institutional experience for patients with both diagnoses and searched the Klippel-Trenaunay literature for patients with Wilms tumor. The National Wilms Tumor Study Group database also was studied to identify patients with KTS. Two-sided exact binomial tests were used to evaluate whether patients with 1 condition had an increased risk for the other. Ninety-five percent confidence intervals for these 2 risks were compared with the general population risks of Wilms tumor (1 in 10 000) and KTS (1 in 47 313).

RESULTS

None of the 115 patients with KTS followed at our institution developed Wilms tumor. One case of Wilms tumor has been reported in 1363 patients with KTS in the literature, giving a confidence interval of (1/57 377) and (1/267). None of the 8614 patients in the National Wilms Tumor Study Group database had KTS, giving a confidence interval of (0, 1/2336). Because the risks of KTS and Wilms tumor in the population fall within these confidence intervals, one cannot conclude that the risks of KTS among Wilms tumor patients or Wilms tumor among KTS patients are any different from the corresponding risks in the general population.

CONCLUSIONS

Patients with KTS are not at increased risk for developing Wilms tumor and thus should not undergo routine ultrasonographic screening.

Contouring buttock reconstruction after sacrococcygeal teratoma resection

PURPOSE

Massive sacrococcygeal teratomas are typically resected and closed in a "chevron" fashion. The resultant scar may leave protuberant "dog ears" and extend across and below the infragluteal creases down onto the posterior thighs, causing undesirable buttock deformity. Given the redundant skin often available, the authors sought to develop a closure technique to minimize deformity and unpleasant scars.

METHODS

At the time of resection of 2 sacrococcygeal teratomas, attention was directed to minimizing redundant skin, restoring normal buttock contour, and avoiding scars crossing the infragluteal crease. After properly securing the anal location, serial polygonal skin excisions were performed, working the excess tissue centrally rather than peripherally, leaving 2 right-angled scars on each buttock.

RESULTS

Each infant underwent successful reconstruction with a normal buttock contour without redundancy. All scars on the buttocks can be easily covered by bathing attire.

CONCLUSIONS

The excess skin expanded by large sacrococcygeal teratomas affords an opportunity to apply straightforward tissue rearrangement principles to reconstruct the buttocks with a normal contour and hidden scars.

Diagnosis of acute appendicitis in children using a clinical practice guideline

PURPOSE

In October 2000, our institution implemented a clinical practice guideline (CPG) utilizing selective computed tomography (CT) and ultrasound scan (US) for the evaluation of children with suspected appendicitis. The authors sought to determine surgical outcomes and diagnostic accuracy in the CPG period.

METHODS

The authors retrospectively analyzed the medical records of patients evaluated under the CPG at their institution between January 1 and December 31, 2001. Depending on a patient's clinical presentation, the CPG recommends immediate surgery or further evaluation with CT or US. CPG patients were identified if they received an appendectomy or a CT or US for suspected appendicitis. Negative appendectomy and perforation rates, as well as admissions for inpatient observation were compared with control patients treated for suspected appendicitis at our hospital in 1997, before frequent utilization of imaging studies.

RESULTS

In the CPG period, 571 patients were evaluated for acute appendicitis, with 272 undergoing an appendectomy. Whereas 513 patients (90%) received a CT or US, only 34 patients (6%) were admitted to the surgical service for serial examinations. Patients with a histologically normal appendix decreased from 27 of 255 (10.6%) in 1997 to 15 of 272 (5.5%) in 2001 (P =.03). Fifty-seven patients (22.2%) in 2001 had a perforated appendix compared with 65 (28.5%) in 1997 (P =.11). The CPG, incorporating clinical judgment and selected imaging, had a sensitivity of 98.8%, a specificity of 95.2%, and positive and negative predictive values of 94.4% and 99.0%, respectively.

CONCLUSIONS

A clinical practice guideline selectively utilizing CT and US is highly accurate in the diagnosis of acute appendicitis, minimizing the need for inpatient admission for serial examinations.

Management of spontaneous colonic perforation in Ehlers-Danlos syndrome type IV

A 14-year-old girl with a family history of fatal colonic rupture, presented with a 2-day history of abdominal pain and signs of peritonitis. At laparotomy, a full-thickness perforation of the sigmoid colon was found, which was exteriorized as a loop colostomy. Subsequently, molecular studies of the patient's cultured fibroblasts found a point mutation in the COL3A1 gene, confirming a diagnosis of Ehlers-Danlos syndrome type IV (EDS-IV). Four and a half years later, a total abdominal colectomy and ileoproctostomy were performed, restoring intestinal continuity. At 5 years follow-up, the patient has had no further complications. Although spontaneous colonic perforation is a well-reported manifestation of EDS-IV, a consensus on the surgical management of this complication in EDS-IV has yet to be determined. Given the high rate of reperforation in EDS-IV when the colon is left in place and the low incidence of reported small bowel and rectal perforations, subtotal colectomy is a reasonable treatment. Primary anastomosis and avoidance of an end-ileostomy was possible in this young patient, with no evidence of anastomotic leakage nor reperforation to date. Lifelong close follow-up should be continued in these patients, because the natural history of this anatomy in EDS-IV is not known.

The effect of hospital volume of pediatric appendectomies on the misdiagnosis of appendicitis in children

BACKGROUND

Although appendicitis is a common pediatric surgical condition, it is often misdiagnosed. Because higher hospital volume has been associated with improved outcome for many surgical procedures, the current study investigates whether hospital volume of pediatric appendectomies is associated with misdiagnosis of appendicitis in children.

METHODS

The Kids' Inpatient Database is a national sample of pediatric discharges from 2521 hospitals in 22 states in 1997. In this study, misdiagnosis was defined as a patient with a principal International Classification of Diseases, Ninth Revision procedure code for nonincidental appendectomy without a corresponding diagnosis code for appendicitis. Hospitals were stratified into 5 groups based on the number of nonincidental appendectomies performed on children in 1997: lowest (<1 per month), low (>or=1 per month but <1 per week), medium (1-2 per week), high (2-3 per week), and highest (>or=3 per week). Using generalized estimating equations to control for clustering within hospitals, we developed a logistic regression model of the effect of hospital volume on misdiagnosis while adjusting for patient age, gender, race, and insurance status.

RESULTS

In the database, 37,109 nonincidental appendectomies were performed on children 1 to 18 years old in 1997. Of those, 3103 (8.4%) were misdiagnosed. Of all appendectomies, 24,655 (66.4%) were performed at lowest- or low-volume hospitals. After adjusting for patient characteristics, lowest- (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.0-2.2) and low- (OR: 1.6; 95% CI: 1.1-2.3) volume hospitals had a significantly increased likelihood of misdiagnosis compared with highest-volume hospitals. Misdiagnosis at medium- (OR: 1.5; 95% CI: 1.0-2.2) and high- (OR: 1.4; 95% CI: 0.9-2.2) volume hospitals was similar to misdiagnosis at lower-volume hospitals, although not statistically different from highest-volume hospitals.

CONCLUSIONS

Almost two thirds of pediatric appendectomies are performed at hospitals performing <1 pediatric appendectomy per week. Lower hospital volume of pediatric appendectomies is associated with a significantly increased likelihood of misdiagnosis of appendicitis in children.

Long-term remission of Crohn's disease treated with thalidomide: a seminal case report

A 31-year-old female with severe Crohn's disease for 15 years who had been treated with corticosteroids and 6-mercaptopurine, was treated with thalidomide initially for erythema nodosum. While on thalidomide all symptoms of Crohn's disease disappeared and she was able to discontinue all other drugs. At this writing she has been on thalidomide as sole therapy for over 4 years with the exception of a 5-week hiatus, during which time her symptoms recurred, but again disappeared after resumption of thalidomide therapy. This case suggests that thalidomide may be a useful therapy for Crohn's disease and provides impetus for a clinical trial of thalidomide for Crohn's disease.

Stimulation with fatty meal (Lipomul) to assess gallbladder emptying in children with chronic acalculous cholecystitis

OBJECTIVE

Chronic acalculous cholecystitis previously has been diagnosed by hepatobiliary scan stimulated with intravenous octapeptide of cholecystokinin. This compound may soon be unavailable in the United States. The goal of this study was to describe the characteristics of children with chronic acalculous cholecystitis diagnosed by hepatobiliary scintigraphy with oral Lipomul challenge, and to evaluate their clinical response to cholecystectomy.

METHODS

Retrospective chart review of patients with no gall stones detected by abdominal ultrasound or computed tomography with gallbladder ejection fraction (GBEF) <35% after Lipomul challenge who subsequently underwent cholecystectomy. Fifteen patients with a mean age of 14.9 +/- 0.9 years were included. The mean duration of symptoms before evaluation was 8.2 +/- 2.5 months.

RESULTS

The mean GBEF after Lipomul challenge was 16.7% +/- 2.7%. All patients had abdominal pain. Ninety percent had right upper quadrant pain and 86% had typical biliary colic. Pain was precipitated by fatty meals in 73.3%. Histopathologic analysis of the gallbladder demonstrated chronic cholecystitis in 80% of cases. The mean postoperative follow-up was 20 +/- 5 months. Six months after the surgery, nine patients (60%) were asymptomatic, five (33%) had marked improvement of symptoms, and one (6%) was unchanged. At the time of latest follow-up, symptoms had reappeared in two patients who had been asymptomatic at the 6-month visit (13%). Seven patients (46%) remained asymptomatic, five (33%) had marked improvement but continued to have some persistent symptoms, and one (6%) was unchanged.

CONCLUSIONS

Chronic acalculous cholecystitis may be responsible for right upper quadrant pain in children without gallstones. A GBEF <35% at 30 minutes after Lipomul challenge may be useful in identifying patients who could benefit from cholecystectomy. Lipomul may be a good alternative to cholecystokinin for gallbladder stimulation during scintigraphy.

Angiographic features of rapidly involuting congenital hemangioma (RICH)

Rapidly involuting congenital hemangioma (RICH) is a recently recognized entity in which the vascular tumor is fully developed at birth and undergoes rapid involution. Angiographic findings in two infants with congenital hemangioma are reported and compared with a more common postnatal infantile hemangioma and a congenital infantile fibrosarcoma. Congenital hemangiomas differed from infantile hemangiomas angiographically by inhomogeneous parenchymal staining, large and irregular feeding arteries in disorganized patterns, arterial aneurysms, direct arteriovenous shunts, and intravascular thrombi. Both infants had clinical evidence of a high-output cardiac failure and intralesional bleeding. This congenital high-flow vascular tumor is difficult to distinguish angiographically from arteriovenous malformation and congenital infantile fibrosarcoma.

Effect of an imaging protocol on clinical outcomes among pediatric patients with appendicitis

OBJECTIVE

In 1998, we implemented a clinical imaging protocol in which children with suspected appendicitis underwent ultrasonography (US) followed by computed tomography (CT). We sought to determine the impact of the US-CT protocol on changes in perforation and negative appendectomy rates.

METHODS

Children with unequivocal presentations for appendicitis went to the operating room without entering the imaging protocol. Using a modified time series design, we analyzed a prospective and retrospective cohort of consecutive patients who were admitted from the emergency department for suspected appendicitis. The perforation and negative appendectomy rates were computed for the periods before and after implementation of the imaging protocol and adjustment for time trends was made.

RESULTS

A total of 1338 children were identified. Eight hundred ten (60.5%) children had equivocal clinical findings. A total of 920 patients were admitted for suspected appendicitis before the protocol was implemented; 526 (57.2%) of the 920 children had appendicitis, and 186 (35.4%) of them had perforation. A total of 91 (14.7%) of 617 had negative appendectomies. After the protocol was implemented, 418 patients were admitted for suspected appendicitis; 328 (78.5%) had appendicitis with 51 (15.5%) perforated. There were 14 (4.1%) of 342 cases of negative appendectomies. After implementation of the imaging protocol, the perforation rate decreased from 35.4% to 15.5%, and the negative appendectomy rate decreased from 14.7% to 4.1%. After secular time trends were adjusted for, the imaging protocol continued to have a strong association with a reduction in perforation rate and negative appendectomy rate.

CONCLUSION

The implementation of an imaging protocol using US and CT resulted in a marked decrease in the perforation and negative appendectomy rates in children with suspected appendicitis.

Abdominal wall defects

Survival for newborns with congenital abdominal wall defects (primarily omphalocele and gastroschisis) has improved, but controversy remains regarding etiology, anatomy and embryology, the role of prenatal diagnosis and mode of delivery, and initial management. A number of recent studies have added to our knowledge and understanding of several of these topics, while several others have raised questions regarding traditional initial management of these infants. Continued improvement in the survival of these infants can be anticipated with further understanding of the in utero and antepartum diagnosis and management of infants with these common congenital abnormalities.

The placenta as a cell source in fetal tissue engineering

PURPOSE

This study was aimed at determining whether fetal tissue constructs can be engineered from cells derived from the placenta.

METHODS

A subpopulation of morphologically distinct cells was isolated mechanically from specimens of human placenta (n = 6) and selectively expanded. The lineage of these cells was determined by immunofluorescent staining against multiple intermediate filaments and surface antigens. Cell proliferation rates were determined by oxidation assays and compared with those of immunocytochemically identical cells derived from human amniotic fluid samples (n = 6). Statistical analysis was by analysis of variance (ANOVA). After expansion, the cells were seeded onto a polyglycolic acid polymer/poly-4-hydroxybutyrate scaffold. The resulting construct was analyzed by both optical and scanning electron microscopy.

RESULTS

The immunocytochemical profile of expanded placental cells was consistent with a nontrophoblastic, mesenchymal origin. Their proliferation rate in culture was not significantly different when compared with mesenchymal fetal cells isolated from human amniotic fluid; however, it was greater than previously reported rates for similar cells obtained from postnatal or adult tissues. Construct analysis showed dense layers of cells firmly attached to the scaffold without evidence of cell death.

CONCLUSIONS

Subpopulations of nontrophoblastic, mesenchymal cells can be isolated consistently from the human placenta. These cells proliferate as rapidly as fetal mesenchymal amniocytes in vitro and attach firmly to polyglycolic acid scaffolds. The placenta can be a valuable and practical source of cells for the engineering of select fetal tissue constructs.

Cardiac relocation and chest wall reconstruction after separation of thoracopagus conjoined twins with a single heart

Separation of thoracopagus conjoined twins with a single heart and the twin reversed arterial perfusion sequence yielded a single surviving infant with a protuberant heart covered by ribs and soft tissue from the nonsurviving twin. At 13 months of age, the heart was relocated in the chest after caudal mobilization of the diaphragms. The protective tissue cage was removed and a normal chest contour established. This technique also may be useful in the treatment of thoracic ectopia cordis.

Prenatal diagnosis of vascular anomalies

BACKGROUND/PURPOSE

Vascular anomalies are diagnosed prenatally with increasing frequency. The authors reviewed a group of children treated at their center who had an abnormal prenatal diagnosis to determine (1) fetal age at which the vascular anomaly was detected, (2) general diagnostic accuracy, and (3) impact on ante- and postnatal care. Their findings are compared with reported cases and series. The authors clarify appropriate terminology and underscore the need for interdisciplinary participation of specialists in the field of vascular anomalies.

METHODS

Patients referred during prenatal life and children with a history of abnormal antenatal findings seen at our vascular anomalies center during a 1-year period (September 1999 through August 2000) were included in this study. The fetal age at diagnosis, pre- and postnatal diagnoses, antenatal course, and neonatal outcome were obtained from the parents, through chart reviews, and through telephone interviews with the treating obstetricians.

RESULTS

Twenty-nine patients with vascular anomalies were identified: 17 had a correct prenatal diagnosis, and 12 had an incorrect diagnosis, an overall diagnostic accuracy of 59%. Capillary-lymphatic-venous malformations (CLVM) most often were correctly diagnosed (67%), followed by lymphatic malformation (LM, 62%) and hemangioma (59%). In the infants who received correct diagnoses in utero, there were no fetal deaths and there was no neonatal morbidity. Maternal steroids were administered for a fetus with an intrahepatic hemangioma and deteriorating cardiac function, with subsequent stabilization and successful delivery of a healthy neonate. Among infants with incorrect diagnoses, there was 1 postnatal death, 1 case of erroneous gender assignment, 1 case of unnecessary fetal surgical intervention, 1 unnecessary neonatal laparotomy, and 1 delay in diagnosis of a malignancy. Cesarean section was done for 65% of correctly diagnosed cases, (including 2 ex utero intrapartum [Exit] procedures) and for 33% of incorrectly diagnosed cases. Most diagnoses were made during the mid- to late second trimester and third trimester; only 4 cases (14%) were detected before 20 weeks.

CONCLUSIONS

In this series, accurate diagnosis optimized antenatal care by providing an opportunity for planning deliveries, for pharmacologic fetal intervention in 1 case, and for appropriate parental counselling. Inaccurate diagnosis was associated with significantly increased morbidity and mortality. Finally, the intrauterine diagnosis of LM should be distinguished from posterior nuchal translucency, an obstetric term applied to fetal lymphatic abnormalities detected in the first and second trimesters that do not manifest as postnatal LM.

Visceral vascular anomalies

Gastrointestinal endoscopy is an essential modality often used for initial diagnostic assessment and staging of visceral vascular anomalies, especially when bleeding is the presenting symptom. Some lesions have a pathognomonic appearance on endoscopy. Others are less clearly identifiable and require a multidisciplinary assessment, including histopathology, for a correct diagnosis. Proper application of nomenclature is crucial to prevent the institution of improper therapies. Advanced endoscopic methods, including endosonography and various hemostatic techniques, are useful to evaluate the depth and character of gastrointestinal wall involvement and to provide minimally invasive treatment when appropriate.

Aggressive multimodal treatment of pleuropulmonary blastoma

Pleuropulmonary blastoma is a rare intrathoracic neoplasm almost solely confined to childhood. Survival is poor. The authors report 2 children with extensive intrathoracic disease who are long term survivors after multimodal therapy. Both children received multiagent neoadjuvant chemotherapy, followed by surgical resection to remove all gross tumor. Postoperative chemotherapy was given to both children; radiotherapy was also given in the second case because of a question of positive tumor margins. Experience supports the use of multimodal therapy, including an aggressive surgical approach in the potentially curative treatment of this tumor.

Life-threatening anomalies of the thoracic duct: anatomic delineation dictates management

Congenital anomalies of the thoracic duct are rare, poorly characterized, and difficult to manage. The spectrum of pathophysiologic perturbations, presenting symptoms, radiographic findings, and interventions performed in 4 patients are shown. Accurate anatomic delineation of the malformation was only possible by direct injection contrast lymphangiography. Therapies tailored to address the anatomic aberrations included intralesional sclerotherapy, surgical excision and ligation, lymphovenous anastomosis, and omental interposition to interrupt dysfunctional collateral lymphatics to the lung. Accurate anatomic diagnosis of central lymphatic channel anomalies by contrast lymphangiography facilitates an individualized multidisciplinary approach to repair.

Perioperative considerations in a hypothyroid infant with hepatic haemangioma

Hepatic haemangiomas in infants are rare. An infant with both a hepatic haemangioma and a severe hypothyroid condition, unresponsive to conventional thyroxine therapy, will be described. This case presented here is the perioperative management of a critically ill infant who had myocardial depression secondary to hypothyroidism and a hepatic haemangioma that required embolization. To our knowledge, this is the first published report describing intravenous triiodothyronine as a therapeutic modality to stabilize a hypothyroid infant prior to undergoing a general anaesthetic.

Nonfixation of an atretic colon predicts Hirschsprung's disease

PURPOSE

After noting the colon to be nonfixed and coiled in the pelvis of a patient with colonic atresia and total colonic Hirschsprung's disease, the authors sought to determine whether this colonic position might be predictive of aganglionosis in the atretic colon.

METHODS

The authors reviewed all cases of colonic atresia treated in their institution over the past 2 decades with regard to colonic orientation and the presence of aganglionosis.

RESULTS

We identified 9 patients with colonic atresia. Two of these patients, as well as one patient with ileal atresia, also had long-segment Hirschsprung's disease. All 3 of these patients had foreshortened nonfixed colons located predominantly in the pelvis. None of the other 6 patients with colonic atresia had this configuration. Reviewing 12 reported cases from other institutions of total colonic aganglionosis associated with atresia, 7 appear to have had a pelvic nonfixed colon; colonic orientation could not be determined from the remaining reports. The diagnosis of Hirschsprung's disease was not established in any case before repair of the atresia, and each patient required a secondary enterostomy.

CONCLUSIONS

An early gestational atresia, occurring before secondary retroperitoneal fixation of the colon at approximately 11 weeks may result in interruption of caudal migration of enteric nerves manifesting as Hirschsprung's disease distal to the atresia. Moreover, the aganglionosis may be predicted by a foreshortened, nonfixed colon coiled in the pelvis. Thus, biopsy of the colon should be performed at initial exploration in all cases of atresia in which the colon is not properly fixated to avoid immediate or delayed anastomosis to an aganglionic colon.

Extrapleural thoracoscopic anterior spinal fusion: a modified video-assisted thoracoscopic surgery approach to the pediatric spine

Video assisted thoracoscopic surgery (VATS) has recently been developed as an alternative to thoracotomy for anterior spinal surgery. We report a case in which an extrapleural dissection was combined with VATS to further improve this approach.

Costs and effectiveness of ultrasonography and limited computed tomography for diagnosing appendicitis in children

BACKGROUND

A protocol of ultrasonography (US) followed by computed tomography with rectal contrast (CTRC) has been shown to be 94% accurate in the diagnosis of acute appendicitis in children.

OBJECTIVE

To evaluate the changes in patient management and costs of a protocol using US and CTRC in the evaluation of appendicitis in children.

DESIGN, SETTING, AND SUBJECTS

Prospective cohort study of 139 children between 3 and 21 years of age who had equivocal clinical findings for acute appendicitis seen in the emergency department of a large, urban pediatric teaching hospital between July 1998 and December 1998.

PROTOCOL

Children with equivocal clinical presentations for acute appendicitis were prospectively evaluated with US. Patients with positive findings for acute appendicitis went directly to the operating room. Patients with negative or equivocal findings on US underwent CTRC. Surgical management plans were recorded before imaging, after US, and after CTRC.

MAIN OUTCOME MEASURES

Surgical management plans before and after the imaging protocol as well as total hospital direct and indirect costs incurred or saved by each change in management were determined. Costs were obtained through the hospital's cost database and by ratios of costs to charges.

RESULTS

Of the 139 children, the protocol resulted in a beneficial change in management in 86 children (61.9%), no change in management in 50 children (36.0%) and an incorrect change in management in 3 children (2.1%). US alone resulted in a beneficial change in management decision in 12/31 children (38.7%), while US followed by CTRC resulted in a beneficial change in management in 74/108 children (68.5%). The protocol resulted in a total cost savings of $78 503.99 or $565/patient.

CONCLUSION

A protocol of US followed by CTRC in children with negative or equivocal US examinations results in a high rate of beneficial change in management as well as in total cost savings in children with equivocal clinical presentations for suspected appendicitis.

Perforated appendicitis: prospective outcome analysis for 150 children

BACKGROUND/PURPOSE

Controversy persists in the management of perforated appendicitis with regard to antibiotic choice and duration, operative timing, drain utilization, and wound closure. For 2 decades at the authors' institution, patients were treated with ampicillin, gentamicin, and clindamycin for 10 inpatient days, with drains in the abdomen, resulting in lower complication rates than most other published series. Managed care pressures have led to less aggressive medical management regimens with length of stay and financial factors viewed as principal outcome measures with little emphasis on clinical outcomes. In addition, there are little prospective data on clinical outcomes. The authors sought to determine whether our previously documented excellent quality outcomes could be maintained when modifications aimed at decreasing cost and length of stay in our protocol were instituted.

METHODS

The authors monitored prospectively clinical outcomes in patients with perforated appendicitis treated according to their clinical practice guidelines over a 43-month period. Patients received a single antibiotic, piperacillin-tazobactam, intravenously for 10 days. They were permitted to go home with a percutaneous intravenous catheter for the final 5 days if medical and social criteria were met. Other practices from our earlier protocol were continued, including immediate operation, placement of Penrose drains, and primary wound closure.

RESULTS

Of 150 patients treated on our protocol, major complications included intraabdominal abscess in 5 (3.3%), cecal fistula in 2 (1.3%), phlegmon in 3 (2.0%), wound infection in 4 (2.7%), and no small bowel obstructions requiring operation. None of these complications, nor their aggregate, were significantly more common than those reported in 373 patients treated over 11 years on the authors' prior protocol (chi2, P > .05).

CONCLUSIONS

Prospective outcome analysis of our protocol shows that a single broad-spectrum antibiotic (allowing portions of therapy to be delivered less expensively on an outpatient basis) effectively can treat postoperative appendicitis with very few infectious complications. These outcome data provide baseline against which future protocols can be compared. All treatment modifications aimed at decreasing costs must be analyzed to ensure quality of care is not unduly compromised.

Living on the edge: a phenomenological study of medically uninsured working Americans

An estimated 35 to 50 million Americans have no medical insurance; the vast majority are employed persons and their dependents. This phenomenological study was developed to make visible the experience of working Americans living on the edge-forced to walk a fine line between health and illness without the safety net of medical insurance. A purposive sample of 12 individuals was asked, "What is it like to be working and without medical insurance? Based on textual analysis, using an adaptation of Colazzi's method, themes were grouped into four theme clusters: A Marginalized Life, Up Against Rocks and Hard Places, Making Choices-Chancing It, and Getting By-More or Less. These are illustrated through commentary and direct quotation to depict an overall sense of the experience. Implications for nurses charged with addressing the needs of the medically uninsured and for nursing as a whole are discussed.

Endorectal pull-through abates gastrointestinal hemorrhage from colorectal venous malformations

BACKGROUND/PURPOSE

Lower intestinal venous malformations are rare anomalies resulting from errors in vascular morphogenesis. These lesions may cause significant chronic and acute gastrointestinal hemorrhage. Venous malformations are unresponsive to angiogenesis inhibitors. Although these anomalies generally are incompletely resectable because of diffuse pelvic and mesenteric involvement, the authors sought to abate bleeding by excluding the lesion from the gastrointestinal lumen.

METHODS

Three patients with circumferential transmural venous malformations of the colorectum, pelvis, and mesentery were identified. Imaging findings were similar among the patients and included circumferential septated bright signal on T2-weighted magnetic resonance imaging (MRI) contrast enhancement, and multiple phleboliths, seen best on computed tomography (CT). The lesion extended from the anus to the splenic flexure in 2 patients and throughout the entire colorectum in the other. Each had daily hematochezia for many years and required transfusions and chronic iron therapy. Although bleeding began in childhood in each patient, no therapy was successful until ages 7, 24, and 45. Colectomy, anorectal mucosectomy (through the pelvic venous malformation), and endorectal pull-through and anastomosis was performed (coloanal in 2 and ileoanal in 1).

RESULTS

Bleeding essentially has been eradicated in all 3 patients with 10- to 57-month follow-up. One patient received a 3-unit transfusion intraoperatively, and the other 2 received none. The most recent patient to undergo surgery, who has residual venous malformation in the remaining 1 cm of anal mucosa, has some mild difficulty with fecal control if her diet results in loose stool.

CONCLUSION

Colectomy with mucosectomy and endorectal pull-through should be considered for diffuse venous malformations of the colorectum before the development of large transfusion requirements.

Microlaparoscopy with conscious sedation in adolescents with suspected pelvic inflammatory disease

STUDY OBJECTIVE

To develop a protocol for emergency department microlaparoscopy with conscious sedation in adolescents with clinically suspected pelvic inflammatory disease (PID), and to evaluate the feasibility and tolerability of microlaparoscopy in this population.

DESIGN

Prospective study involving adolescents and young adults age 13 to 24 meeting clinical criteria for uncomplicated PID. Laparoscopy subjects underwent microlaparoscopy in the Children's Hospital Emergency Department (ED) and comparison subjects were admitted for treatment of PID. Chi-square, Mann-Whitney U tests, Wilcoxon Rank Sum tests, and repeated measures of analysis of variance (MANOVA) were used for analysis.

RESULTS

Twenty-four patients were enrolled: 6 laparoscopy subjects and 18 comparison subjects. Laparoscopy and comparison subjects did not differ with respect to age, mean white blood cell (WBC) count, mean temperature, or mean erythrocyte sedimentation rate. Mean surgical induction time was 13.5 minutes, operative time 19.0 minutes, and total procedure time 32.5 minutes. Mean requirement for midazolam was 2.8 mg and for fentanyl 225 microg. Pain assessment over the first 90 minutes did not differ significantly between laparoscopy and comparison subjects. Four of 6 laparoscopy subjects (67%) and 10 of 18 comparison subjects (56%) were diagnosed with PID (p = NS).

CONCLUSIONS

ED microlaparoscopy appears to be feasible, safe, and well tolerated in this small sample of adolescents and young adults with suspected PID.

Vascular anomalies of the mediastinum

Vascular anomalies, including hemangiomas and vascular malformations, comprise 3% to 6% of mediastinal masses in childhood. These lesions, whether in the mediastinum or elsewhere, often are misdiagnosed and treated inappropriately. Correct diagnosis almost always can be established by history, external physical examination of associated anomalies, bronchoscopy, and/or radiographic studies. Hemangiomas are benign tumors that involute spontaneously but may require antiangiogenic therapy or laser ablation to maintain airway patency prior to involution. Vascular malformations, most commonly lymphatic in origin, will not involute nor respond to drug therapy. Resection and/or sclerotherapy often are indicated.

Prolonged local myometrial blockade prevents preterm labor after fetal surgery in a leporine model

BACKGROUND/PURPOSE

Postoperative premature labor remains the foremost limiting factor to the development of fetal surgery. Most attempts at controlling this complication have involved the use of drugs delivered systemically to the mother. This study assessed the effects of prolonged local anesthetic blockade of the myometrium on preterm delivery after open fetal surgery.

METHODS

Eighteen New Zealand rabbits at 23 days' gestation (term, 31 to 33 days) were divided in three groups. In group I (n = 6), the most proximal fetuses of both uterine horns were submitted to open amputation of a forelimb; in a few animals, one of the uterine horns was empty, hence, only one fetus was manipulated. In groups II (n = 5) and III (n = 7), an identical surgical procedure was performed. In group II, immediately before hysterotomy, the myometrium was injected with 0.5 mL of 0.5% bupivacaine along the incision line. In group III, only saline was injected. In group II, before uterine closure, the incised area of the myometrium was injected with 1.5 mL of a novel suspension of biodegradable polylactic-co-glycolic acid microspheres loaded with 75% w/w bupivacaine and 0.05% w/w dexamethasone. This suspension previously has been shown to provide peripheral nerve blockade for approximately 5 days. In group III, microspheres without any drug were injected.

RESULTS

Abortion rates were significantly different among the groups: 83.3% (five of six) for the does in group I, zero in group II, and 71.4% (five of seven) in group III (P < .05). The absence of abortions observed in group II occurred despite the fact that the fetal mortality rate was significantly higher in this group (87.5%, seven of eight fetuses) than in groups I (0) and III (33.3%, 4 of 12 fetuses, P < .05).

CONCLUSIONS

Prolonged local blockade of the myometrium with bupivacaine inhibits preterm labor after fetal surgery in rabbits. The high fetal mortality rate observed in this study may be caused by "transplacental" transfer of the local anesthetic to the fetus. Notably, the abortifacient effect of a dead fetus was completely suppressed by the local blockade. Studies using microspheres with local anesthetics that do not cross the placenta, in animal models with longer gestational periods, are warranted.

Fetal response to neutral gas and liquid media for intraamniotic distension

PURPOSE

This study was aimed at comparing the effects of a neutral liquid and a neutral gas used as intraamniotic media on umbilical blood flow, O2 delivery, blood pressure, acid-base status, and electrolytes in the fetus at escalating intraamniotic pressures.

METHODS

Eight fetal lambs underwent invasive monitoring of common umbilical blood flow, blood pressure, blood gases, sodium, and hematocrit, as intraamniotic pressure was raised from 0 to 30 mm Hg. The animals were divided equally in two groups depending on the intraamniotic medium used (group I, warmed saline and group II, air). Maternal systemic blood pressure, O2 saturation, and temperature were kept constant.

RESULTS

In each group, a threshold level of intraamniotic pressure was evident, above which there was a significant decrease in the common umbilical artery blood flow, with concomitant fetal hypoxemia and hypercarbia. This intraamniotic pressure threshold was 20 mm Hg in group I (saline), but only 15 mm Hg in group II (air).

CONCLUSIONS

Although both a neutral liquid and a neutral gas can safely be used as intraamniotic media, a neutral liquid medium allows for a wider range of safe intrauterine working pressure (0 to 20 mm Hg), as compared with a neutral gas (0-15 mm Hg).

Lung abscess versus necrotizing pneumonia: implications for interventional therapy

OBJECTIVE

To assess and contrast the role of interventional therapy for two types of cavitating pneumonias: lung abscess and necrotizing pneumonia.

MATERIALS AND METHODS

We retrospectively reviewed the imaging, interventional therapy, and outcome of 14 children seen between February 1987 and January 1996 with lung abscess and 9 with necrotizing pneumonia. All children were treated with antibiotics prior to intervention. Pulmonary parenchymal fluid was percutaneously aspirated from ten lung abscesses and three necrotizing pneumonias. Percutaneous catheters drained five lung abscesses. Pleural drainage was performed for three lung abscesses and eight necrotizing pneumonias.

RESULTS

All 14 children with lung abscesses had positive Gram stains of the pulmonary fluid; 13 cultures were positive. All 14 defervesced within 48 h of intervention. None developed a bronchopleural fistula. All nine necrotizing pneumonias were presumed to be sequelae of prior pneumonia. Streptococcus pneumoniae was the only organism as documented by pleural fluid latex fixation in three patients, gram stain in two, and culture in only one. Seven of these children developed pneumatoceles, five developed bronchopleural fistulae, and three required long-term chest tubes for persistent pneumothoraces.

CONCLUSION

Aggressive interventional therapy can be diagnostic and therapeutic in the infected lung abscess. Interventional therapy can be harmful in postinfectious necrotizing pneumonia.

Allergic colitis: a mimic of Hirschsprung disease

BACKGROUND

Allergy to cow milk protein is a common cause of gastrointestinal symptoms in infancy. Milk allergy is usually a clinical diagnosis, and thus there have been few reports of the radiographic findings.

OBJECTIVE

To describe the barium enema findings of allergic colitis and differentiate them from Hirschsprung disease. Materials and methods. Four infants (age range 7 days-5 weeks) with constipation underwent barium enema to exclude Hirschsprung disease. Radiographic findings were correlated with the pathologic specimens from suction rectal biopsy.

RESULTS

All enemas revealed irregular narrowing of the rectum and a transition zone. Rectal biopsies in each case demonstrated ganglion cells and evidence of an allergic colitis, with inflammatory infiltrates in the lamina propria. A diagnosis of milk allergy colitis was made and symptoms resolved after removal of milk from the diet.

CONCLUSIONS

Milk allergy is common in infancy. The rectum is a primary target organ, with allergic colitis often diagnosed on clinical grounds alone. However, a child with allergic colitis may be referred to radiology for barium enema, especially if constipation is present. The radiologist should be aware of the unique imaging findings of allergic colitis, so as to avoid confusion with Hirschsprung disease and perhaps an unnecessary rectal biopsy.

Vascular anomalies. A primer for pediatricians

The future is bright for children with vascular anomalies. Children with vascular anomalies no longer have to languish in the interface between various medical specialties. Vascular anomalies centers are available for consultation. Not only are specialists focusing on the conditions, but basic science has brought us to the horizon of new insights into etiology and thus the possibility for new treatment. For children with vascular tumors, newer antiangiogenic agents are already in clinical trials. For children with vascular malformations, research in molecular genetics has begun to uncover the genes responsible for normal fetal vasculogenesis and angiogenesis. Molecular studies of familial vascular malformative syndromes are just beginning to pinpoint causative mutations. Next, animal models of vascular abnormalities will be engineered to elucidate pathogenesis, and these studies, in turn, should lead to development of novel therapies.

Fetal carotid blood flow during videofetoscopy

BACKGROUND/PURPOSE

Intracranial bleeding has been reported as one of the complications of both open and minimally invasive fetal surgery and putatively attributed to intraoperative fluctuations of carotid blood flow. The aim of this study was to look at fetal carotid blood flow and its relationship with umbilical blood flow, blood pressure, oxygen delivery, and acid-base status in the fetus at various intraamniotic pressures with both liquid and gas media during fetoscopic surgery.

METHODS

Six 115- to 130-day-gestation ewes underwent continuous invasive systemic blood pressure monitoring in the descending aorta. A hysterotomy was performed. A 6-mm ultrasonic blood flow probe was placed around the common umbilical artery at its origin from the fetal aorta. This was followed by placement of a double-lumen, 4F catheter in the fetal descending aorta through a femoral artery. A 4-mm ultrasonic blood flow probe was then placed around the fetal left common carotid artery. A pressure-monitoring, multiperforated catheter was placed inside the amniotic cavity. The fetus was repositioned inside the uterus, which was then closed. The abdominal wall was closed loosely. No further manipulation was performed for 1 hour. Intraamniotic pressure was raised from 0 to 30 mm Hg at 5-mm Hg intervals by infusing either warmed saline or medical air. Common umbilical artery and left carotid artery blood flows, blood pressure, blood gases, bicarbonate, sodium, and hematocrit were recorded in all fetuses at each 5-mm Hg interval. Maternal systemic blood pressure, O2 saturation, and temperature were kept constant.

RESULTS

Carotid blood flow remained stable within the intra-amniotic pressure range studied (0 to 30 mm Hg), despite the significant drop in common umbilical artery blood flow uniformly observed above 20 mm Hg when saline was infused and above 15 mm Hg when air was infused. There was fetal hypoxemia and hypercarbia concomitant with decreased common umbilical artery blood flow (however, without fetal acidosis, because of compensatory elevation of bicarbonate). Within the intraamniotic pressure range studied, fetal aortic blood pressure, sodium, and hematocrit did not vary significantly, even when there was decreased umbilical blood flow.

CONCLUSIONS

Fetal carotid blood flow is protected, possibly autoregulated, remaining stable even after umbilical blood flow decreases as a consequence of elevated intrauterine pressures up to 30 mm Hg during videofetoscopy. These data suggests that perioperative intracranial bleeding related to videofetoscopic surgery is caused by factors other than fluctuations of cerebral blood flow.

Gastrointestinal manifestations of vascular anomalies in childhood: varied etiologies require multiple therapeutic modalities

BACKGROUND/PURPOSE

Vascular anomalies, including hemangiomas and vascular malformations afford complex diagnostic and therapeutic challenges when gastrointestinal (GI) manifestations are present.

METHODS

Twenty-one patients evaluated or treated in our Vascular Anomalies Program from 1993 through 1997 were reviewed retrospectively with regard to presentation, treatment modalities, and outcome.

RESULTS

Four patients had hemangiomas, and 17 had various vascular malformations. GI symptoms began in infancy or early childhood in all patients. Manifestations included GI bleeding (n = 15), obstruction (n = 2), diarrhea (n = 2), ascites (n = 2), pain (n = 1), emesis (n = 1), ileo-ileal intussusception (n = 1), protein-losing enteropathy (n = 1), and hypersplenism (n = 1). Four patients had proven portal hypertension. Fourteen had associated musculoskeletal or cutaneous lesions. Congestive heart failure, partial anomalous pulmonary venous return, pulmonary edema, and pleural or pericardial effusion occurred in one patient each. Bleeding was the most common symptom of both hemangiomas and malformations. Of four patients with hemangiomas, three were treated with corticosteroids or interferon. Endoscopic banding and embolization of an associated arterioportal hepatic shunt were each used in one patient. One patient died. The malformations were treated with resection (n = 8), endoscopic banding or sclerosis (n = 7), percutaneous or intraoperative sclerosis (n = 5), embolization or device interruption (n = 3), and portosystemic shunt (n = 2). GI symptoms were ameliorated in 12 patients with malformation, improved in two, unchanged in two, and one died after prolonged palliation.

CONCLUSIONS

Vascular anomalies with gastrointestinal manifestations are heterogeneous in their presentation and type. Although bleeding is the most common symptom of both hemangiomas and vascular malformations, treatment differs. Pharmacological angiogenesis inhibition is the mainstay of hemangioma therapy. Resection, endoscopic or radiologic vascular obliteration, and portal decompression are important in treating vascular malformations. An individualized and interdisciplinary approach is often required to successfully diagnose and treat these complex lesions.

Videofetoscopically assisted fetal tissue engineering: skin replacement

BACKGROUND/PURPOSE

Treatment of several congenital anomalies is frequently hindered by lack of enough tissue for surgical reconstruction in the neonatal period. The purposes of this study were (1) introduction of a novel concept in perinatal surgery, involving minimally invasive harvest of fetal tissue, which is then processed through tissue engineering techniques in vitro while pregnancy is allowed to continue, so that, at delivery, the newborn can benefit from having autologous, expanded tissue promptly available for surgical implantation at birth; (2) analysis of the progress of an engineered fetal skin graft with time, after implantation in the neonate; and (3) study of the effects of current tissue engineering techniques on fetal keratinocytes and fetal dermal fibroblasts.

METHODS

Ten 90- to 95-day-gestation fetal lambs underwent surgical creation of two large paramedian excisional skin defects on the posterior body wall. Subsequently, fetal skin specimens no larger than 1.5 x 1.5 cm were videofetoscopically harvested. Fetal keratinocytes and dermal fibroblasts were then separately cultivated and expanded in vitro for 45 to 50 days, resulting in a total of approximately 250 to 300 million cells. Seven to 10 days before fetal delivery, all cells were seeded in two layers on a 16 to 20-cm2, 3-mm thick biodegradable polyglycolic acid polymer matrix. One to 4 days after delivery, the autologous engineered skin was implanted over one of two previously created skin defects. The second skin defect region received an absorbable polymer scaffold without cells as a control. If necessary, the original skin wounds were further amplified before implantation. Each animal provided at least one time-point for histological analysis of both types of repair through excisional biopsies performed at weekly intervals, up to 8 weeks postimplantation. Normal skin specimens were also used as controls.

RESULTS

Fetal and neonatal survival rates were 100%. Based on previous postnatal skin engineering studies, fetal dermal fibroblasts multiplied significantly faster in vitro (approximately fivefold) than expected. Fetal keratinocytes multiplied at expected postnatal rates. The engineered grafts induced faster epithelization of the wound (partial at 1 week and complete between 2 and 3 weeks postoperatively) than did the acellular ones (partial at 3 weeks and complete between 3 and 4 weeks postoperatively). Analysis of skin architecture showed a higher level of epidermal organization and less dermal scarring in the wounds that received the engineered, cell-implanted polymer scaffold.

CONCLUSIONS

(1) Videofetoscopically assisted fetal tissue engineering is a viable method for obtaining expanded autologous tissue for prompt surgical reconstruction at birth. (2) Fetal skin can be expanded and engineered in vitro at faster rates than expected postnatally, with current tissue engineering techniques. (3) Engineered autologous fetal skin induces a faster and more organized healing of neonatal skin defects than that observed with second intention. This concept may prove useful for the treatment of certain human neonatal conditions such as giant neoplasias, ectopia cordis, and other body wall defects.

Videofetoscopically assisted fetal tissue engineering: bladder augmentation

BACKGROUND/PURPOSE

Treatment of several congenital anomalies is frequently hindered by lack of enough tissue for surgical reconstruction in the neonatal period. Minimally invasive harvest of fetal tissue, which is then processed through tissue engineering techniques in vitro while pregnancy is allowed to continue so that at delivery a newborn with a prenatally diagnosed congenital anomaly can benefit from having autologous, expanded tissue promptly available for surgical reconstruction at birth. This concept was applied to a bladder defect.

METHODS

Bladder exstrophy was surgically created in ten 90- to 95-day gestation fetal lambs, which were divided in two groups. In group I, a small fetal bladder specimen was harvested through a minimally invasive technique (videofetoscopy). Urothelial and smooth muscle cells were then separately cultivated and expanded in vitro for 55 to 60 days, resulting in a total of approximately 200 million cells. Seven to 10 days before delivery, the cells were seeded in two layers in a 16- to 20-cm2, 3-mm thick biodegradable polyglycolic acid polymer matrix. One to 4 days after delivery, autologous engineered tissue was used for surgical augmentation of the exstrophic bladder. In group II, no harvest was performed, and the bladder exstrophy was primarily closed after delivery. In both groups, a catheter was left inside the bladder for 3 weeks, at which time a cystogram was performed and the catheter then removed. In all animals, at 60 days, another cystogram was performed and urodynamic studies of the bladder were performed. The bladder was then removed for histological analysis.

RESULTS

Fetal survival rate was 100%. One newborn died immediately after the implantation of the engineered bladder from an anesthetic accident. The other nine (four in group I and five in group II) survived. One of the animals from group I lost its bladder catheter prematurely and had a urinary leak detected only at the time of death. There were no other complications. The engineered bladders were more compliant (P < .05) and had greater capacity pressures greater than 20 mm Hg (P < .05) than those closed primarily. Histological analysis of the engineered tissue showed a multilayered urothelial lining on the luminal side and overlying layers of smooth muscle cells surrounded by connective tissue.

CONCLUSIONS

Videofetoscopically assisted fetal bladder engineering may be a viable alternative for prompt bladder reconstruction at birth. The architecture of autologous engineered fetal bladder tissue resembles that of native bladder. This concept may prove useful for the treatment of certain human neonatal conditions such as bladder and cloacal exstrophies.