Pediatric intervention: an update--part I

Nonvascular Pediatric Interventional Radiology

Interventional radiology procedures are increasingly in demand in both the adult and pediatric populations. Pediatric procedures mirror many of the adult procedures but with increased complexity due to considerations related to patient size and the requirements for sedation and radiation protection. This article reviews the various nonvascular pediatric interventional procedures and provides information on sedation and radiation protection. The aim is to provide a greater exposure to the possible treatment options for pediatric patients and to facilitate understanding of imaging after various interventions.

Gastrointestinal intervention in children

Interventional radiology is a rapidly growing discipline in paediatrics. Many non-vascular interventional techniques may be used in the gastrointestinal tract in children. The technically simpler and more common of these may be adopted by any paediatric radiologist with an interest in interventional radiology. Other rarer and more complex techniques are currently restricted to specialist centres with a higher overall caseload. This review emphasizes the common procedures such as oesophageal dilatation, gastrostomy, insertion of transgastric jejunal feeding tubes and biopsy. Less common salivary, hepatobiliary, pancreatic and intestinal interventions are also described.

CT findings in gastrocolic fistula following percutaneous endoscopic gastrostomy

We describe the CT findings in an initially asymptomatic boy aged 2 years 9 months with a gastrocolic fistula following percutaneous endoscopic gastrostomy (PEG) placement. The findings consisted of an unusual configuration of the gastrostomy tubing on an abdominal radiograph and upper gastrointestinal study indicating the possibility of transcolic PEG placement, which was confirmed with limited section CT. This well-known and major complication following a common procedure may be recognized on plain abdominal radiography, but it has not to our knowledge been documented previously on CT in a child.

Image-guided interventions in neonates

Minimally invasive interventional radiological procedures can be invaluable in the care of neonates and infants. These procedures have proven to be useful in a wide variety of clinical situations, improving patient care, comfort and safety. Most techniques in adult interventional radiology have been adapted for use in pediatric patients, covering the spectrum of diagnostic and therapeutic intervention. Procedural techniques are similar, but require considerations of patient size, sedation, and support personnel in order to render optimal care. Proper physician training is imperative to provide the necessary confidence and expertise, and post-procedural follow-up is required to maximize positive outcomes. This paper discusses many of the procedures that may be performed in neonates, and offers suggestions and techniques for successful outcomes.

Image-guided therapy and minimally invasive surgery in children: a merging future

Minimally invasive image-guided therapy for children, also known as pediatric interventional radiology (PIR), is a new and exciting field of medicine. Two key elements that helped the rapid evolution and dissemination of this specialty were the creation of devices appropriate for the pediatric population and the development of more cost-effective and minimally invasive techniques. Despite its clear advantages to children, many questions are raised regarding who should be performing these procedures. Unfortunately, this is a gray zone with no clear answer. Surgeons fear that interventional radiologists will take over additional aspects of the surgical/procedural spectrum. Interventional radiologists, on the other hand, struggle to avoid becoming highly specialized technicians rather than physicians who are responsible for complete care of their patients. In this article, we briefly discuss some of the current aspects of minimally invasive image-guided therapy in children and innovations that are expected to be incorporated into clinical practice in the near future. Then, we approach the current interspecialty battles over the control of this field and suggest some solutions to these issues. Finally, we propose the development of a generation of physicians with both surgical and imaging skills.

Percutaneous imaging-guided abdominal and pelvic abscess drainage in children

Percutaneous imaging-guided drainage is the first-line treatment for infected or symptomatic fluid collections in the abdomen and pelvis, in the absence of indications for immediate surgery. The technology and expertise needed to perform percutaneous abscess drainage are widely available and readily adapted for use in the pediatric population. Catheter insertion procedures include the trocar and Seldinger techniques. Imaging guidance for drainage is most commonly performed with ultrasonography (US), computed tomography, or US and fluoroscopy combined. Abscesses in locations that are difficult to access, such as those deep in the pelvis, subphrenic regions, or epigastric region, can be drained by using the appropriate approach-transrectal, transgluteal, intercostal, or transhepatic. Although the causes of abscesses in children differ slightly from those of abscesses in the adult population, the frequency of successful treatment with percutaneous abscess drainage in children is 85%-90%, similar to that in adults. With expertise in imaging-guided drainage techniques and the ability to adjust to the special needs of children, interventional radiologists can successfully drain most abscesses and obviate surgery. Successful adaptation of abscess drainage techniques for pediatric use requires attention to the specific needs of children with respect to sedation, dedicated resuscitation and monitoring equipment, avoidance of body heat loss, minimization of radiation doses, and greater involvement of family compared with that in adult practice.

Imaging of renal tumours in infancy and childhood

There is a large range of benign and malignant renal neoplasms. This article lists the most benign, indeterminate and malignant renal tumours that occur during infancy and childhood. It briefly describes the most important entities, including their imaging features, and important complications. Differential diagnosis and pitfalls are discussed, and a brief suggestion for a standardised imaging algorithm is proposed. Although modern imaging techniques, including colour Doppler sonography, helical or multidetector CT, and MR have significantly improved imaging potential, the definite diagnosis on tumour entity still is established only by histology.

Imaging guided interventional procedures in paediatric uroradiology--a case based overview

OBJECTIVE

To describe the potential and application of interventional image guided procedures in the paediatric urinary tract.

PATIENTS AND METHODS

The different techniques are illustrated using case reports. The examples comprise established indications such as percutaneous nephrostomy for compromised kidneys in obstructive uropathy and infection, sonographic guided renal biopsy including monitoring or treatment of complications after biopsy, and evaluation and balloon dilatation of childhood renal artery stenosis. There are new applications such as treatment of stenosis in cutaneous ureterostomy or sonographically guided catheterism for deployment of therapeutic agents.

RESULTS

Generally, the procedures are safe and successful. However, complications may occur, and peri-/post-interventional monitoring is mandatory to insure early detection and adequate management. Sometimes additional treatment such as percutaneous embolisation of a symptomatic post biopsy arterio-venous fistula, or a second biopsy for recurrent disease may become necessary.

CONCLUSION

Imaging guided interventional procedures are performed successfully in a variety of diseases of the paediatric urinary tract. They can be considered a valuable additional modality throughout infancy and childhood.