Initial experience with non-breath-hold magnetic resonance cholangiopancreatography: a new noninvasive technique for the diagnosis of choledochal cyst in children

BACKGROUND/PURPOSE

Magnetic resonance cholangiopancreatography (MRCP) is an emerging tool for the noninvasive evaluation of the pancreaticobiliary tree.

METHODS

Non-breath-hold MRCP was used in three children to evaluate choledochal cyst; a first for this new modality of diagnostic imaging. In all cases, the intrahepatic and extrahepatic bile ducts, and the pancreatic duct were clearly visualized.

RESULTS

Two cases were found to have a fusiform choledochal cyst, and non-breath-hold MRCP demonstrated pancreaticobiliary malunion and a long common channel. In the remaining case, the size and location of the huge cyst prevented visualization of any pancreaticobiliary malunion. Endoscopic retrograde cholangiopancreatography (ERCP) in this patient failed to provide any additional information. All patients underwent cyst excision with hepaticoenterostomy, and made an uneventful recovery.

CONCLUSIONS

Our initial experience suggests that non-breath-hold MRCP is a reliable method for the diagnosis of choledochal cyst in children and could replace ERCP.

Tumor necrosis factor alpha in children with sickle cell disease in stable condition

Tumor necrosis factor alpha (TNF-alpha) is known to induce wasting in humans and animals. This study was undertaken to determine TNF-alpha concentrations in children with sickle cell disease (SCD) and whether high TNF-alpha levels are more likely to be present in children with growth deficits, infection, or pain crisis. Tumor necrosis factor alpha was measured using enzyme immunoassay in 143 blood samples obtained from 101 children. Mean TNF-alpha levels were higher in patients (50 pg/mL) than in 21 control children (19 pg/mL) and in 26 laboratory employees (20 pg/mL). During the follow-up period, 35%, 38%, and 28% of children with SCD had infection, pain crisis, or a blood transfusion, respectively. Mean TNF-alpha concentrations were higher in children who had an infection than in those who did not. No significant effect of pain crisis or blood transfusion was observed. Tumor necrosis factor alpha concentrations were above normal (> 40 pg/mL) in 15% of controls, 34% of children with SCD, and 52% of children with SCD who had an infection and 33% of those who did not. A higher percentage of children who had elevated TNF-alpha levels had weight (46% versus 31%) or height (50% versus 28.6%) deficits than children who had normal TNF-alpha levels. These results indicate that most children with SCD in stable condition have normal TNF-alpha concentrations and that those with high TNF-alpha levels are more likely to have growth deficits.

Modified Boerema technique for the closure of congenital abdominal wall defects to prevent incisional herniation and infection

Tension and infection often cause wound dehiscence or incisional herniation after the fascial closure of congenital abdominal wall defects in neonates. To overcome these problems, a modification of the Boerema technique (a method for repairing large incisional hernia in adults) was applied to repair abdominal wall defects in 14 neonates. The efficacy of this technique is discussed in this report.

Torsion of autotransplanted splenic tissue in Gaucher disease

A 12-year-old girl who underwent a splenectomy followed by heterotopic splenic autotransplantation for treatment of hypersplenism secondary to Gaucher disease at the age of 3 years presented with acute lower abdominal pain. Radiological investigations were highly suggestive of torsion of the autotransplanted splenic tissue, which was confirmed during subsequent laparotomy. This is the first known report of torsion of autotransplanted splenic tissue.

Endometrial carcinoma in a young patient with polycystic ovarian syndrome: first suspected at time of embryo transfer

Adenocarcinoma of the endometrium is a rare condition in women under 40 years of age. However, patients with anovulatory polycystic ovarian syndrome are at risk of developing endometrial carcinoma due to the unopposed and prolonged effect of oestrogen on the endometrium. This case report discusses the dilemma of various treatment options for early disease in such patients.

The Jehovah's Witness family, transfusions, and pediatric day surgery

The pediatric otolaryngologist and anesthesiologist, when encountering a family of the Jehovah's Witness (JW) faith, should be aware of the potential problems which may arise when deciding to proceed with surgery. Two case reports are presented which illustrate the difficult situations which can occur when unanticipated complications (i.e. profound bleeding) arise perioperatively. An overview of the history and common tenets of the JW faith, previous legal perspectives, pertinent clinical information from the medical literature, and the protocol of The Children's Hospital, Denver, for dealing with this sensitive issue (drafted with the cooperation of the local JW Hospital Liaison Committee) are presented.

Pancreaticobiliary maljunction associated with nondilatation or minimal dilatation of the common bile duct in children: diagnosis and treatment

It is known that the etiology of congenital biliary dilatation (CBD) is closely associated with pancreaticobiliary maljunction (PBMJ). Treatment of CBD today is primary excision of the cyst followed by hepaticoenterostomy. However, PBMJ without dilatation of the biliary tract has recently been reported and its treatment is still controversial. In adults, simple cholecystectomy without biliary reconstruction is often performed, because it usually presents as an anomaly of the gallbladder. Over 30 years, we have encountered 8 patients with PBMJ without dilatation of the common bile duct in 180 pediatric cases of CBD. The presenting symptoms of these patients were those of pancreatitis i.e. abdominal pain associated with elevation of serum amylase levels. Five cases presented with jaundice or a history of pale colored stools. Endoscopic retrograde cholangiopancreatography was performed to confirm the diagnosis. Five (62.5%) of these 8 patients were found to have dilatation of the common channel, which was seen in 50 (29%) of the 172 other cases with biliary tract dilatation. Three cases (37.5%) had proven protein plugs or debris at the level of the common channel, and this was observed in 28 (16%) of the 172 other cases. It is strongly suggested that the manifestation of clinical symptoms in these patients results from stasis or obstruction at the level of the common channel. In children who present with recurrent pancreatitis, PBMJ must be suspected even if the common bile duct appears to be normal. It is difficult to resolve these anomalies without operative repair. The authors consider that radical treatment of PBMJ is required in these children to prevent serious long-term complications.

Hepaticoenterostomy after excision of choledochal cyst in children: a 30-year experience with 180 cases

In the long-term follow-up of patients with choledochal cyst, postoperative ascending cholangitis and/or stone formation in the intrahepatic bile ducts (IHBD) owing to anastomotic stricture present serious problems. To prevent the formation of anastomotic strictures, some surgeons recently have performed hepaticoenterostomy at the hepatic hilum, with a wide stoma, in all patients with choledochal cyst. The authors of the present study review the surgical procedures performed on a total of 180 children with choledochal cyst and discuss the treatment of choice, with special reference to the types of hepaticoenterostomy. The medical records and radiographs of all patients treated for choledochal cyst between January 1964 and December 1993 at the authors' institutions were reviewed. A total of 180 patients (mean age at time of surgery, 4.3 years) had follow-up for a mean of 11.1 years; 174 of them had cyst excision and hepaticoenterostomy, and six had cystoenterostomy. Of the 174 patients who underwent cyst excision, 171 had a conventional hepaticoenterostomy; two had an intrahepatic cystoenterostomy, and one had a hepaticoenterostomy at the hepatic hilum. IHBD stones with or without cholangitis developed postoperatively in four (2.3%) of the 171 patients who had conventional hepaticoenterostomy. The age at time hepaticoenterostomy of these four patients was 12, 7, 16, and 6 years. Postoperative IHBD stone formation and cholangitis were not found in 121 patients under 5 years of age. The authors recommend conventional hepaticoenterostomy as the treatment of choice for children with choledochal cyst. Hepaticoenterostomy at the hepatic hilum is indicated in only selected cases.

Sibling occurrence of biliary atresia and biliary dilatation

Familial occurrence of extrahepatic biliary atresia (EHBA) or biliary dilatation has been reported; however, the genetic influences on these disorders are still obscure. The authors previously reported the occurrence of biliary dilatation and EHBA in sisters, which is extremely rare. Recently, a similar pair of sisters was treated; one had pancreaticobiliary maljunction with minimal dilatation of the common bile duct, and the other also had EHBA. The authors' investigations suggest that there may be common etiologic factors for EHBA and biliary dilatation, such as pancreaticobiliary maljunction; however, other factors are required to complete the process and cause biliary atresia.

Carbon dioxide laser removal of polymethylmethacrylate

Polymethylmethacrylate remains an excellent method of securing orthopaedic implants. However, revision surgery may be necessary when loosening of the prosthesis has occurred with symptomatology. Removal of polymethylmethacrylate during revision surgery can be difficult. Care must be taken to avoid damage to the remaining bone and surrounding soft tissue. This study was undertaken to characterize the efficacy of the carbon dioxide (CO2) laser for cement removal in vitro and in vivo. The CO2 laser did not damage adjacent bone or soft tissue via lateral heat transfer in vitro and in vivo. The maximum bone cortex temperature during CO2 laser removal was 56 degrees C. This was lower than the 60 degrees C temperature encountered during initial cement insertion and curing. The CO2 laser preferentially penetrates polymethylmethacrylate with absorption versus apparent relative reflection with bone. The products of vaporization from CO2 laser removal of polymethylmethacrylate were removed safely (to < 12.2 ppm) with a smoke evacuator without risk to the patient or operating room personnel. Removal of polymethylmethacrylate by CO2 laser was performed in 117 patients undergoing revision operations, including 78 total hip revisions, 33 total knee revisions, 3 total elbow revisions, and 3 spine revisions. No perforation or fracture of bone occurred with the use of the laser. There was no statistical difference in surgical time, blood loss, infection rate, or hospital stay when the CO2 laser was used. There were no cases of osteonecrosis or obvious soft tissue necrosis caused by the laser. The infection rate was 3.4% (4/117) when the laser was used for cement removal.

Laser discectomy

Discectomy with lasers is a technically easy procedure and permits a surgeon to place a predictably sized and configured defect in a predetermined position in the intervertebral disc. In a small series of patients, the procedure appears effective in controlling symptoms in a high percentage of patients. The efficacy of the procedure and wider acceptance will depend on the results of multicenter clinical trials.

Red urine from red deer grazed on pure red clover swards

Twenty-four red deer hinds with their calves were released on to a newly established pure red clover sward and, 2 days later, red staining of the tail, perineum and hocks was observed. This was presumed to be of urinary origin. Observation of micturition showed that when urine was passed, it was a normal straw colour but it turned scarlet-red about 1 hour after exposure to air. Midstream urine remained the normal colour when held under a pure nitrogen atmosphere immediately after micturition, but it turned red when held in air in the dark, suggesting that the colour change was due to an oxidative rather than a photosensitive reaction. All deer grazing red clover were affected but this did not occur in deer grazing ryegrass/white clover swards. No adverse effects were observed in the deer grazing the red clover, and calf growth was significantly higher than on ryegrass/white clover, suggesting that the red urine had no effect on health or productivity. Blood and urine analyses showed no signs of haemolysis, haematuria or haemoglobinuria. Preliminary chemical analyses suggest that the compounds involved are not those found in the urine of sheep grazing oestrogenic clover. The nature of the compounds have yet to be determined.

Treatment versus non-treatment of hip dislocations in ambulatory patients with myelomeningocele

Thirty myelomeningocele patients with untreated hip dislocations who had functional quadriceps and good ambulatory capability were evaluated for hip pain, hip motion and sitting ability: they had no pain, good to excellent hip motion and no difficulty in sitting. Three were wheelchair-bound. Nine had a limb-length inequality requiring a shoe lift. They were compared with a similar series of 11 patients who underwent open reduction of a dislocated hip with a two-year follow-up. Two patients in this group had improved and three had worse sitting balance. Serious perioperative complications occurred in six patients. The authors conclude that surgical reduction of paralytic hip dislocations in ambulatory myelomeningocele patients is costly and offers little obvious benefit.

The histochemistry of isocitric and oestradiol-17 beta dehydrogenases in the endometrium of postmenopausal women treated with oestrogens and progestogens

Endometrium was obtained from postmenopausal women during treatment with either oestrogen alone or on the third, sixth, tenth or twelfth day of combined therapy with oestrogens and progestogens. The activities of oestradiol-17 beta and isocitric dehydrogenases were measured in homogenates of the whole tissue and the enzymes were also located histochemically. Oestradiol dehydrogenase was located exclusively within the epithelium, whilst isocitric dehydrogenase was found in both epithelium and stroma, and also in stromal arterioles. Histochemically, oestradiol dehydrogenase was found in all the specimens which exhibited biochemical activity but in none of those from which it was absent. Isocitric dehydrogenase however, was seen in all tissue sections despite widely varying levels of biochemical activity in the homogenate. The method for measuring isocitric dehydrogenase activity was therefore nonspecific, whilst that for oestradiol dehydrogenase was reliable and low levels of enzyme activity could be detected. The latter technique may therefore be useful to predict the sensitivity of endometrial carcinomata to progestogens.

The histochemistry of oestradiol-17 beta and isocitric dehydrogenases in endometrial carcinoma

Specimens of endometrial carcinoma were obtained from 8 women, four of whom had previously been treated with oral medroxyprogesterone acetate 200 mg daily for 7 days. The activities of oestradiol-17 beta and isocitric dehydrogenases and nuclear oestradiol receptor concentrations were measured in the homogenised tissue and both enzymes were located histochemically. Histochemical evidence of oestradiol dehydrogenase activity was found in all but one of the specimens with biochemical activity. This anomalous specimen was obtained from a woman who had not been treated with MPA and whose endometrium exhibited only low levels of enzyme activity. The histochemical staining caused by isocitric dehydrogenase was intense but bore no relation to the biochemical measurement of enzyme activity in the homogenate. The modified technique for the histochemical demonstration of oestradiol dehydrogenase activity although not quantitative gave results similar to the biochemical methodology. It may therefore be useful as a simple test of the prediction of the sensitivity of endometrial carcinoma to progestogens.

Regional and total skeletal measurements in the early postmenopause

In a cross-sectional study of 70 early postmenopausal women, regional bone measurements were compared with total body calcium (TBCa). Spinal and forearm trabecular bone were mainly related to age and time since menopause. In contrast, TBCa and forearm integral (cortical and trabecular) and cortical bone were unrelated to age, although the time since menopause also had some influence. Forearm integral and cortical bone measurements were quite well correlated with TBCa (r = 0.84 and 0.73, respectively, P less than 0.001). The correlation between spinal bone measurements and any of the forearm measurements, even purely trabecular bone, was weak (r less than 0.52, P less than 0.001). Our results show quite clearly that forearm bone measurements cannot be used to predict bone density in the vertebrae. Loss of ovarian function affects bone in general, and trabecular bone in particular. Bone measurements at specific anatomical sites are clearly necessary for studies of metabolic bone diseases and their response to treatment.