Is hepatocellular carcinoma the same disease in children and adults? Comparison of histology, molecular background, and treatment in pediatric and adult patients

Pediatric hepatocellular carcinoma (HCC) is rare, resulting in scattered knowledge of tumor biology and molecular background. Thus far, the variant in children has been treated as a different entity from adult HCC. We weigh the hypothesis that HCC in the pediatric and adult groups may be the same entity and may benefit from the same treatment. Although certain differences between adult and pediatric HCC are obvious and certain types of HCC may ask for a customized approach, in conventional HCC, similarities predominate, warranting treatment aiming at common molecular targets in adult and pediatric HCC patients.

Hereditary Protein S Deficiency in Young Adults with Arterial Occlusive Disease

Protein S is the vitamin K dependent cofactor of activated protein C. It has an important role in the regulation of blood coagulation and fibrinolysis. Hereditary protein S deficiency is associated with familial venous thrombophilia. Since a few patients with arterial occlusions have been reported to be protein S deficient, it is speculated that hereditary protein S deficiency may be also a risk factor for the development of arterial thrombosis. In a group of 37 consecutive patients with arterial occlusive disease presenting before the age of 45, three patients were found heterozygous for hereditary protein S deficiency. None of the patients had a protein C deficiency or an antithrombin III deficiency. Family investigations showed a clear association between the hereditary deficiency and venous thrombosis, but a relation between the deficiency and arterial thrombosis was less obvious. A review of previous literature on patients with arterial thrombosis and protein S deficiency revealed that more extensive studies are needed to demonstrate whether or not hereditary protein S deficiency is a risk factor for the development of arterial thrombosis.

Cushing syndrome as presenting symptom of calcifying nested stromal-epithelial tumor of the liver in an adolescent boy: a case report

BACKGROUND

Ectopic adrenocorticotropic hormone-producing primary liver tumors are rare, especially in children. We report the case of an adolescent boy of mixed Dutch and Moroccan descent with an adrenocorticotropic hormone-producing calcifying nested stromal-epithelial tumor with long-term follow-up. Thus far, only two such cases have been reported.

CASE PRESENTATION

A 16-year-old boy of mixed Dutch and Moroccan descent presented with Cushing syndrome and a palpable abdominal mass. A calcifying nested stromal-epithelial tumor was diagnosed. Postoperatively, his plasma adrenocorticotropic hormone concentration normalized. He remains in complete remission 13 years after tumor resection.

CONCLUSIONS

Calcifying nested stromal-epithelial tumor should be in the differential diagnosis of liver tumors, especially if associated with Cushing syndrome as significant morbidity and mortality may be associated. Literature on the topics involved is comprehensively reviewed.

Transverse colon volvulus in children: A case series and a review of the literature

Volvulus of the transverse colon is very rare in children. Three cases that occurred in a short time span are described and the scarce literature is reviewed. All patients presented with colonic obstruction and in all three the condition was diagnosed at laparotomy, as CT-scanning is not an available option in either of the two institutions. The transverse colon had not become gangrenous but was resected after detorsion for redundancy. The postoperative course was complicated and relaparotomy had to be performed for reobstruction in all cases. Only if the 'reverse' bean sign is recognized on the preoperative plain abdominal radiograph this rare diagnosis can be suspected.

Age is not a prognostic factor in children with Wilms tumor beyond stage I in Africa

BACKGROUND

Patients under age 4 with stage I favorable histology (FH) Wilms tumor have a reported survival advantage. Among children above 10 years, a poorer prognosis has been associated with a higher prevalence of diffuse anaplasia.

PURPOSE

To determine if, in our practice, patients with Wilms tumors >8 years of age (stage II-V) have a poorer prognosis than those aged <8 years or <4 years.

PROCEDURE

Case-control study of 19 patients >8 years with Wilms tumor stages II-V who were identified from a cohort of 192 new patients (2002-2012). For each patient two controls were chosen matched for stage and histology, one 0-3 years and one 4-7 years. Neo-adjuvant chemotherapy was offered to all, combined with intensive supportive care. Postoperative treatment was determined by local stage and histology. OS and EFS at 5 years for the different age groups were compared.

RESULTS

Each age group contained 19 patients, of whom 6 had stage II tumors, 3 stage III, 8 stage IV, and 2 stage V. Histology was intermediate risk (IR) in 17 and high risk (HR) in 2. OS at 5 years was 80.8% and EFS was 79.2% for the whole group. No significant difference in outcome could be shown between age groups. Loss to follow up was 6/57 (11%).

CONCLUSIONS

The survival advantage of young age (<4 years) associated with stage I FH could not be demonstrated in higher stages. Age had no significant impact on prognosis although a trend to better outcome was seen in children <4 years.

Course of life into adulthood of patients with biliary atresia: the achievement of developmental milestones in a nationwide cohort

PURPOSE

To investigate the course of life of young adults diagnosed with biliary atresia (BA) in infancy by comparing patients who did and did not underwent transplantation with an age-matched Dutch reference group.

METHODS

All patients from the Dutch BA registry, aged >18 years, were invited to complete the course of life questionnaire.

RESULTS

Forty patients participated (response = 74%). Twenty-five had not undergone transplantation; 15 had undergone orthotopic liver transplantation. One significant between-group difference was found, namely in substance use and gambling. BA patients who underwent transplantation reported less use than the reference group (p = .01, moderate effect size). Additional moderate effect sizes were found for differences in psychosexual and social development and antisocial behavior. Patients who underwent transplantation had lower scores than one or both other groups.

CONCLUSIONS

Development of BA survivors who did not undergo transplantation seems not delayed, whereas that of transplanted patients does seem somewhat delayed. However, patients who underwent transplantation display less risk behavior. Larger samples are necessary to confirm these findings.

Quality of life and disease-specific functioning of patients with anorectal malformations or Hirschsprung's disease: a review

The objective of this review was to examine disease-specific functioning (ie, faecal functioning and disease-related psychosocial problems) and quality of life (QoL)in patients with anorectal malformations (ARMs) or Hirschsprung's disease across different developmental stages. A search on PubMed yielded 22 eligible studies which were analysed. Patients with ARM or Hirschsprung's disease report slightly more QoL problems than comparison groups. As compared with adolescents, children reported better QoL but worse disease-specific functioning. Relationships between disease-specific functioning and QoL remain unclear. Therefore, to disentangle the complex relationship between the faecal functioning of these patients and their QoL through childhood, adolescence and adulthood, longitudinal studies should examine disease-specific functioning with validated QoL questionnaires that include age-specific versions.

Outcome of total parathyroidectomy and autotransplantation as treatment of secondary and tertiary hyperparathyroidism in children and adults

BACKGROUND

Treatment safety and effectiveness of total parathyroidectomy and autotransplantation for secondary and tertiary hyperparathyroidism have been extensively proven in adults; the evidence for children, however, is scarce. Children and adolescents cannot simply be seen as young adults in the case of chronic kidney disease and hyperparathyroidism. The aim of this retrospective study was therefore, to evaluate whether parathyroidectomy with forearm autograft is as effective and safe in children and adolescents as in adults.

METHODS

A group of 64 adults and 8 children and adolescents treated for secondary or tertiary hyperparathyroidism were retrieved from our database. The outcomes were compared on patient demographics, operation results, and blood parameters consisting of parathyroid hormone (PTH) and calcium levels. Our results were compared with all currently available articles on parathyroidectomy in children with secondary or tertiary hyperparathyroidism (n = 11).

RESULTS

For adults, preoperative mean serum calcium was 2.67 +/- 0.29 mmol/l and mean parathyroid hormone (PTH) level was 120 +/- 86 pmol/l. For children, preoperative mean serum calcium was 2.62 +/- 0.20 mmol/l and mean parathyroid hormone (PTH) level was 80 +/- 38 pmol/l. Postoperative calcium and parathyroid hormone levels for adults dropped to 2.39 +/- 0.23 mmol/l and 30 +/- 53 pmol/l, respectively. Postoperative calcium and parathyroid hormone levels for children dropped to 2.41 +/- 0.16 mmol/l and 26 +/- 33 pmol/l, respectively. The effectiveness of parathyroidectomy with autotransplantation was 75% in children and 72% in adults. Thus, effectiveness did not differ significantly between children and adults.

CONCLUSIONS

Combining the results of our own study with a literature review on pediatric parathyroidectomy, we conclude that parathyroidectomy and forearm autograft is as effective a treatment for secondary and tertiary hyperparathyroidism in children and adolescents as it is in adults.

Management of trichobezoar: case report and literature review

Trichobezoars (hair ball) are usually located in the stomach, but may extend through the pylorus into the duodenum and small bowel (Rapunzel syndrome). They are almost always associated with trichotillomania and trichophagia or other psychiatric disorders. In the literature several treatment options are proposed, including removal by conventional laparotomy, laparoscopy and endoscopy. We present our experience with four patients and provide a review of the recent literature. According to our experience and in line with the published results, conventional laparotomy is still the treatment of choice. In addition, psychiatric consultation is necessary to prevent relapses.

[An unusual presentation of a periappendicular infiltrate]

A 17-year-old boy presented with an atypical manifestation of acute appendicitis. The clinical aspect, radiological investigations and peroperative aspect of the appendix were not conclusive but nevertheless a neuroendocrine tumour (carcinoid tumour) of the appendix was suspected. After ileocaecal resection and resection of pathological lymph nodes, histopathological evaluation revealed the diagnosis: a periappendicular mass without any sign of malignancy. In retrospect, ileocaecal resection was performed for a benign disease. This case illustrates that an unusual presentation of a common disease occurs more frequently than a typical presentation of a rare disease.

Paraplegia after thoracotomy under combined general and epidural anesthesia in a child

A 9-year-old boy underwent a thoracotomy for excision of his right third rib under combined general and epidural anesthesia for a Ewings sarcoma. Postoperatively, he was found to have a complete T2-3 paraplegia. Permanent paraplegia was described as a rare complication of thoracotomy in adults, and very rarely after epidural analgesia in adults and babies. This was the first report in a child.

Adults with corrected oesophageal atresia: is oesophageal function associated with complaints and/or quality of life?

The aim of this study was to evaluate oesophageal function after correction of oesophageal atresia in adults, and to investigate the association between complaints, oesophageal function and quality of life (QoL). Twenty-five adults were included who participated in previous follow-up studies, during which complaints of dysphagia and gastro-oesophageal reflux (GOR), results of upper gastrointestinal endoscopy, oesophageal biopsies and QoL had been collected. Manometry was performed in 20 patients, 24 h pH-measurements were performed in 21 patients. pH-values (sample time 5 s) were calculated using criteria of Johnson and DeMeester. Associations were tested with ANOVA and chi (2)-tests. Ten patients (48%) reported complaints of dysphagia, seven (33%) of GOR. The amplitude of oesophageal contractions was low (<15 mmHg) in four patients (20%). pH-measurements showed pathological reflux in three patients (14%). Patients reporting dysphagia more often had disturbed motility (P = 0.011), and lower scores on the domains "general health perceptions" (SF-36) (P = 0.026), "standardised physical component" (SF-36) (P = 0.013), and "physical well-being" (GIQLI) (0.047). No other associations were found. This study shows a high percentage of oesophageal motility disturbances and a moderate percentage of GOR after correction of oesophageal atresia. Patients reporting dysphagia, whom more often had disturbed motility, seemed to be affected by these symptoms in their QoL.

Bryant traction in paediatric femoral shaft fractures, home traction versus hospitalisation

AIM

To evaluate Bryant traction at home in terms of feasibility, morbidity, effect on length of hospital stay, outcome and costs.

PATIENTS AND METHODS

Retrospective analysis of 54 children treated for femoral shaft fracture (1991-2004). Results of 'home traction' (A, n=38) and 'hospital traction' (B, n=16) were compared. Data were collected regarding demographics, length of hospital stay, traction period, various aspects of the fractures, co-morbidity, morbidity, and follow-up. The parents' experience was evaluated by telephone questionnaire.

RESULTS

Two early treatment failures occurred. One patient stopped home traction at 8 days due to skin problems and had a spica cast applied at another hospital, with subsequent development of a compartment syndrome. The other patient was placed in a hip spica after 2 weeks of hospital traction because of difficulty in getting satisfactory X-rays. At follow-up, one unacceptable shortening of 3 cm had occurred in the home traction group. There was only a significant difference in hospital stay (A 7.0 days versus B 22.5 days), total traction period (A 28.0 days versus B 22.5 days) and costs (group B 3x versus group A). The parents were overall pleased with traction at home. Complications occurred as much in the home traction group as in the control group and fracture position at union was equal in both groups.

CONCLUSIONS

Treatment with home traction is feasible, simple and effective; it reduces hospital stay to 1 week, and costs to one-third. Good patient selection and instructions of the parents are mandatory.

Management of solid-pseudopapillary neoplasms of the pancreas: a comparison with standard pancreatic neoplasms

Background

Solid-pseudopapillary neoplasms (SPNs) of the pancreas are increasingly diagnosed, but the exact surgical management in terms of extent of the resection is not well defined.

Materials and Methods

Patients operated on in our hospital between January 1993 and March 2005 formed the study groups.

Results

From 659 consecutive resections for pancreatic neoplasms, 12 female patients (1.8%) with a median age of 21 years who underwent resection for (SPN) are compared with the remaining 647 pancreatic resection patients. Jaundice (SPN 0 versus PR 73%, p < 0.001) and weight loss (SPN 0 versus PR 49%, p = 0.001) occurred significantly less often. Neoplasms were distributed equally among the pancreatic head (SPN 5 out of 12 patients versus PR 88%, p < 0.001) and corpus/tail (SPN 6 out of 12 patients versus PR 8%, p < 0.001). The operative time was significantly shorter (SPN 233 min versus PR 280 min, p = 0.012), and there were significantly fewer complications (SPN 1 of 12 patients versus PR 48%, p = 0.007). The mortality was not different (SPN 0 versus PR 1.6%, p = 1.000), and the hospital stay was significantly shorter (SPN 9 days versus PR 15 days, p = 0.012). The median size of the neoplasms was significantly larger (SPN 6.9 cm versus PR 2.5 cm). The median number of lymph nodes harvested was significantly fewer (SPN 1 versus PR 6, p = 0.001), and lymph node metastases occurred significantly less often (SPN 0 versus PR 64%, p < 0.001). The 5-year survival of SPN patients was 100% and is significantly better compared with survival of patients with pancreatic adenocarcinoma (12%, p < 0.001) and ampulla of Vater adenocarcinoma (22%, p = 0.005).

Conclusions

Patients with solid-pseudopapillary neoplasms of the pancreas present differently and the course of the disease is more benign. These patients can be adequately managed by pylorus-preserving pancreatoduodenectomy or spleen-preserving distal pancreatectomy with excellent early and long-term results.

[A colo-colic invagination on the basis of MutYH-associated polyposis in a boy aged 14]

A 14-year-old boy presented with acute abdominal pain, vomiting and diarrhoea. Colo-colic intussusception was diagnosed by means of a colonic contrast X-ray. The intussusception was successfully reduced during this procedure. Hundreds of polyps were seen throughout the entire colon. Genetic research showed a mutation of the MutYH gene. Proctocolectomy with ileoanal pouch anastomosis was carried out. The pathology specimen showed an intramucosal carcinoma and multiple adenomas. MutYH-associated polyposis coli is an autosomal recessive disease that occurs as a result of a mutation in the MutYH gene. This will lead to polyposis coli. An intussusception is a rarely seen symptom. Patients need preventive surgical treatment because of the high risk developing a colorectal carcinoma.

Long-term outcome of elastic stable intramedullary fixation (ESIF) of femoral fractures in children

In 1993 a prospective data collection of all femoral fracture in children below 16 years of age was initiated in 4 hospitals in the Netherlands. Follow-up was at least two years, with the aim to evaluate leg length discrepancies (LLD). Over a period of 10 years, we included 136 patients < 16 years of age with femoral fractures. Seventy-one patients who were treated with an ESIF-(Elastic Stable Intramedullary Fixation) nail were studied: 44 boys and 27 girls, between the ages of 3-16 years, 23 of which had multiple injuries. Five patients had a Ist or IInd degree open fracture. The average length of stay (LOS) of children with an isolated fracture, was 10 days, and in case of multiple injuries: 12 days. Intra-operative complications were: a broken drill in 2 and an open reduction in 6 cases. Two patients with superficial wound infection were successfully treated with antibiotics. Seven patients had knee complaints of the nails, of which 3 had actually been displaced. Three other patients showed displacement of the nails at X-ray, but had no complaints. At six months follow-up, at the time of removal of the nails, 10 patients had a leg length discrepancy (LLD) exceeding 10 mm. Three children had a clinically significant rotational deformity at this time. Two and a half years after injury 6 patients showed a persistent LLD of more than 10 mm. In all 6 the fractured limb was longer. At ten years of follow-up the LLD persisted in 5 patients. One patient had a persistent clinically significant rotational deformity of more than 10 degrees . The advantages of ESIF-nails are: reduction of hospital stay and rapid mobilisation. The disadvantages: two operations (for insertion and removal) with a risk of complication. Long-term follow-up, preferably till growth stops, is necessary to conclude whether persistent lengthening of the fractured limb remains a problem.

Factors associated with recurrence and metastasis in sacrococcygeal teratoma

Background

Sacrococcygeal teratoma (SCT) is a relatively uncommon tumour, with a high risk of recurrence and metastasis. The factors associated with recurrence and metastatic disease were studied.

Methods

A retrospective review was conducted of 173 children with SCT treated between January 1970 and February 2003 at the paediatric surgical centres in the Netherlands. Risk factors were identified by univariate and multivariate analysis.

Results

Eight children died shortly after birth or around the time of operation. Nine children, all over 18 months old, had metastases at presentation. Four teratomas with metastasis showed mature histology of the primary tumour. Nineteen children had recurrence of SCT a median interval of 10 months (range 32 days to 35 months) after primary surgery. Risk factors for recurrence were pathologically confirmed incomplete resection (odds ratio (OR) 6·54 (95 per cent confidence interval (c.i.) 2·11 to 20·31)), immature histology (OR 5·74 (95 per cent c.i. 1·49 to 22·05)) and malignant histology (OR 12·83 (95 per cent c.i. 3·27 to 50·43)). Size, Altman classification, age and decade of diagnosis were not risk factors for recurrence. One-third of the recurrences showed a shift towards histological immaturity or malignancy, compared with the primary tumour. Seven patients died after recurrence, five with malignant disease.

Conclusion

This national study showed that SCT recurred in 11 per cent of the children within 3 years of operation. Risk factors were immature and malignant histology, or incomplete resection. Mature teratoma has the biological capability to become malignant.

Long-term results of boerema anterior gastropexy in children

OBJECTIVES

To analyze the long-term results of Boerema anterior gastropexy using the Visick grading system in a university teaching hospital.

METHODS

Retrospective review of 247 children with severe or complicated gastroesophageal reflux disease (GERD). Patients who underwent primary gastropexy between 1990 and 2001 were divided in 3 groups: (A) neurologic impaired patients (n = 83); (B) esophageal atresia patients (n = 36); and (C) patients without underlying disease (n = 128). The median length of follow-up after gastropexy was 7 years and 8 months (range, 1.5-13 years). Follow-up was carried out using a standardized questionnaire and was obtained by telephone. Postoperative recurrence of symptoms during follow-up was considered as failure of the operation.

RESULTS

Postoperative complications occurred in 20 patients (24%) in group A, in 13 patients (36%) in group B and in 23 patients (18%) in group C. Thirty-three patients died during the follow-up period, 5 of whom during the postoperative period. Six children could not be traced; thus, 208 were available for long-term follow-up. Postoperative failures occurred in 12 patients (23%) in group A, in 11 patients (31%) in group B and in 17 patients in group C (14%). Reoperation for recurrence of symptoms due to GERD was performed in 6 patients in group A, in 7 patients in group B and in 2 patients in group C. The final outcome at the time of interview was successful in 81% of group A, in 88% of group B and in 91% of group C.

CONCLUSIONS

In the long term, Boerema anterior gastropexy is an effective operation for complicated GERD in children without underlying disease as well as in neurologically impaired children and patients with esophageal atresia.

[The treatment of oesophageal atresia in The Netherlands]

The first description of oesophageal atresia dates back to 1670. Oesophageal atresia used to be regarded as a lethal disease, but since the successes of Leven and Ladd in 1939 and Haight in 1941 surgical correction is possible. The Dutch history ofoesophageal atresia begins in 1946. After the successes in America became known, several Dutch surgeons started to treat patients with oesophageal atresia, notably J.ten Kate, L.D.Eerland, M. Schoorl and P.J.Kooreman. In those days, paediatric surgery did not yet exist as a separate specialty. Today, paediatric surgery is concentrated in 6 paediatric surgical centres in the Netherlands. Thanks to the pioneers mentioned and the concentration of knowledge and expertise in the centres, the mortality ofoesophageal atresia patients in the Netherlands has decreased to approximately 9%, despite the fact that currently the gestational age and birth weight of patients is lower and the number of patients with comorbidity is higher.

[Children with blunt trauma to the liver]

In 3 children, 2 boys aged 13 years and an 8-year-old girl, blunt trauma to the liver was diagnosed after a fall. The first patient underwent drainage of abdominal fluid collection on multiple occasions and a stent was introduced in the biliary duct to ensure normal bile flow; the second patient was treated by arterial catheter embolisation of a segmental branch of the right hepatic artery; in the third patient, acute laparotomy was performed in view ofhaemodynamic instability and a large hepatic rupture was treated by packing. All patients recovered successfully. In the paediatric population, blunt trauma to the liver requires a multidisciplinary approach. For haemodynamically stable children, a conservative course can be taken. Arterial embolisation is the treatment of choice if there is a persistent need for volume resuscitation or blood transfusion. In case of massive haemorrhagic shock, the child should undergo laparotomy, and if the bleeding cannot be stopped, the liver should be packed according to damage-control principles.

Pre-operative diagnostic biopsy and surgery in paediatric liver tumours--the Amsterdam experience

AIM

To report 24 years of pre-treatment biopsy and surgical experience in primary liver tumours in children.

METHODS

Between 1979 and 2003, 53 children presented with a primary liver tumour of whom 48 who underwent surgical resection were evaluated (two died, two were unresectable, and one was transplanted). Biopsy data, per- and post-operative complications, mortality, and survival were retrospectively reviewed.

RESULTS

Benign tumours were diagnosed in eight patients. Surgical resection for a malignant tumour was performed in 40 patients (26 hepatoblastomas (HB), eight hepatocellular carcinomas (HCC) (four had fibrolamellar HCC), three rhabdomyosarcomas (RMS), one neuroblastoma, one non-hodgkin lymphoma (NHL), and one teratoma). Primary resection was performed in one HB, and four HCCs. The cumulative survival without evidence of disease was 73% for HB (median 7 years) and 88% for HCC (median 3.5 years).

CONCLUSION

The treatment results are comparable with those of larger international series except for HCC. The existing diagnostic pitfalls in differentiating between the various liver malignancies justify the use of a diagnostic biopsy.

Disseminated medullary thyroid carcinoma despite early thyroid surgery in the multiple endocrine neoplasia-2A syndrome

A 51/2-year-old boy, with a family history of multiple endocrine neoplasia (MEN)-2A syndrome, was evaluated for presence of MEN-2A and medullary thyroid carcinoma (MTC). DNA diagnostics confirmed MEN-2A. Basal (360 ng/L) and pentagastrin stimulated (430 ng/L) calcitonin (CT) levels were slightly elevated, plasma carcinoembryonic antigen (CEA) was normal. Within a year both tumor markers increased and total thyroidectomy was performed. Histologic examination did not show MTC. In the following years, both tumor markers increased progressively but despite the use of multiple imaging techniques no metastases were localized. After 6 years, biopsy of a palpable lymph node showed MTC. The boy was treated with total cervical, suprahyoidal, and mediastinal lymph node dissection, showing MTC in almost all nodes. Again, the tumor markers remained high. At this point in time, the disadvantages of further medical interventions were outweighed against the chance for cure and it was decided to shift the goal of treatment toward palliation rather than cure. At the last visit the boy was clinically well with persistent extremely high levels of plasma CEA and CT. In conclusion, when prophylactic thyroidectomy in the MEN-2A syndrome has failed, it may be best to withdraw from further interventions to prevent more damage.

[Kidney transplant survival rates and surgical complications in kidney transplants in children; experiences in the Emma Children's Hospital AMC]

OBJECTIVE

To describe surgical complications, and patient and kidney transplant survival rates in children who have had a kidney transplant.

DESIGN

Retrospective.

METHOD

Data were analysed concerning the children who had been treated with a renal transplantation in the period 1985-2001 because of terminal renal insufficiency in the Emma Children's Hospital of the Academic Medical Centre in Amsterdam, The Netherlands, with arbitrary end date October 7, 2002.

RESULTS

In the study period, 55 primary kidney transplantations were performed on 24 girls and 31 boys. 13 living related and 42 post mortem transplantations were performed. The extra-peritoneal approach was performed in all recipients. Up to October 7, 2002, 14 surgical complications (25%) developed: 4 cases of renovascular thrombosis, 4 urinary leakages, 6 urethral strictures, 1 urethral necrosis, 5 haematomas and 3 lymphoceles. 6 patients lost their grafts due to surgical complications (11%); 4 due to thrombosis, 1 due to urethral necrosis and 1 due to haemorrhage or haematoma. Due to hypertension secondary to the underlying kidney disease 2 patients died within one year after transplantation from hypertensive encephalopathy and cerebral bleeding respectively. The one- and five-year graft survival was 83% and 74% for living related transplantations respectively, and for post mortem transplantations 78% and 68% respectively. The main causes of graft loss were chronic rejection (9/21; 43%), acute rejection (4/21; 19%), thrombosis (4/21; 19%) and surgical complications (2/21; 10%). Primary nonfunction was the only factor with a negative prognostic value for graft survival.

Hepatoblastoma in a girl with biliary atresia: coincidence or co-incidence

Hepatoblastoma (HB) and biliary atresia (BA) are both rare conditions that occurred in the patient described. This is the second such case in the literature. An explanation for this apparent coincidence could possibly be found in the existance of pluripotent liver stem cells. In humans, small epithelial cells (SEC) behave as pluripotent stem cells. These are cells that can develop as biliary epithelial cells or as liver parenchymal cells, and are thought to be the precursor cell of HB. They are present in a much higher concentration in the livers of patients with BA, which may make them prone to develop HB.

Frequent adverse events after treatment for childhood-onset differentiated thyroid carcinoma: a single institute experience

Since the mortality rate for childhood differentiated thyroid carcinoma is nearly zero, the focus must be to minimise morbidity following treatment. Our aim was to analyse early and late adverse events. Twenty-five of 26 children treated between 1962 and 2002 were evaluated. Median follow-up was 14.2 years (range 0.9-39.4 years). All underwent total thyroidectomy, 15 (60%) with lymph node dissection and 15 (60%) with adjuvant radio-iodide therapy. Mortality was zero. Seven developed recurrent disease, two developed a third recurrence. Twenty-one (84%) had > or =1 adverse event. Eight had permanent hypoparathyroidism (PH), six permanent recurrent nerve paralysis (PRNP) and two Horner's syndrome. Risk factors for PH and PRNP were total thyroidectomy with lymph node dissection (RR: 6.45, P = 0.015) and recurrent nerve tumour encasement (RR: 8.00, P = 0.001), respectively. Other adverse events were fatigue (n = 5), scar problems (n = 4) and chronic myeloid leukaemia (n = 1). These results emphasise the need to improve treatment strategies.

Comparison between umbilical and transverse right upper abdominal incision for pyloromyotomy

BACKGROUND

Besides laparoscopic pyloromyotomy, the operation for pyloric stenosis has been performed using 2 standard open surgical exposures: the right upper quadrant (RUQ) incision and the semi-circumumbilical (UMB) incision. The aim of this study was to compare the morbidity and cosmetic results of both open exposures.

METHODS

Between 1990 and 1995, we performed 104 pyloromyotomies through a RUQ incision. These operations were retrospectively compared with 133 UMB incisions performed between 1995 and 1999.

RESULTS

There were no significant differences between the 2 groups regarding age at presentation, sex, and preoperative status. Only a significantly higher percentage of patients with a metabolic alkalosis before surgery was found in the UMB group, but this did not affect morbidity rate. The groups did not differ significantly with respect to mucosal perforations (P =.95), wound infections (P =.53), inadequate pyloromyotomies (P =.42), or other complications. The mean operating time was slightly longer in the UMB group (P <.025). The UMB approach produced a better cosmetic result, with an almost invisible scar.

CONCLUSIONS

This study has shown that the UMB approach has equal intra- and postoperative complication rates as compared with the RUQ approach. The main advantage of the UMB approach is that it produces an excellent long-term cosmetic result.

[Bilious vomiting due to malrotation, also in older children]

Three children presented with bilious vomiting due to malrotation at the age of 3, 5 and 12 years, respectively. They were treated surgically and recovered fully. In the period 1989-2002, 12 patients were operated for malrotation after the first year of life in the Emma Children's Hospital AMC, Amsterdam, the Netherlands. The mean age at operation was 5 years (range: 1-15). The most important symptoms were (bilious) vomiting and abdominal pain. Four patients had a history of bilious vomiting in the neonatal period. Nine patients had been previously admitted to a hospital with abdominal complaints. The most sensitive imaging technique was an upper gastrointestinal contrast study. Malrotation with intermittent volvulus can cause recurrent abdominal complaints and vomiting in children. Bilious vomiting is pathologic at any age and should lead to further investigations, preferably an upper gastrointestinal contrast study to exclude malrotation or other obstructions.

Oesophageal atresia in premature infants: an analysis of morbidity and mortality over a period of 20 years

AIM

To determine the morbidity and mortality of premature infants born with oesophageal atresia (OA) and to evaluate historical changes in morbidity and mortality over time.

METHODS

Retrospective analysis of morbidity and mortality of all patients admitted for OA, with or without tracheo-oesophageal fistula, between 1982 and 2002.

RESULTS

The study group consisted of 197 consecutive patients, of whom 55 (28%) were premature and 21 (11%) very premature. Type A atresia was found more often in very premature and premature infants than in those born at term (p = 0.02). Type E atresia was not found in the premature group (p = 0.004). At least one associated congenital anomaly was also present in 121 patients (61%). Postoperative complications developed more often in very premature and premature infants than in those born at term (p < 0.001). Gastro-oesophageal reflux was diagnosed in 32/76 premature infants and in 41/121 term infants (p = 0.001). Mortality among very premature and premature infants was higher than among those born at term (p = 0.003). Withdrawal of treatment was the most frequent cause of death.

CONCLUSION

Premature infants with OA have a higher morbidity and mortality than term infants with OA. The complications of prematurity contribute significantly to morbidity and mortality in premature infants with OA. There is no reason to refrain from the standard treatment of OA in premature infants with no severe associated congenital anomalies.

Liver transplantation for hepatoblastoma: results from the International Society of Pediatric Oncology (SIOP) study SIOPEL-1 and review of the world experience

BACKGROUND

For hepatoblastoma (HB) that remains unresectable by partial hepatectomy after chemotherapy, total hepatectomy with orthotopic liver transplantation (LTX) has been advocated as the best treatment option. The role of LTX in the overall management of HB is still, however, unclear.

PROCEDURE

The results of LTX from the first study of HB by the International Society of Pediatric Oncology, SIOPEL-1, were analyzed. In addition, the world experience of LTX for HB was extensively reviewed. Twelve patients in the SIOPEL-1 study underwent a LTX. Median (range) follow-up at Dec. 31, 2001 was 117 months (52-125) since LTX.

RESULTS

Overall survival at 10 years post-LTX was 85% for the seven children who received a "primary LTX" and 40% for the 5 children who underwent a "rescue LTX" after previous partial hepatectomy. In the world experience (147 cases), the overall survival rate at 6 year post-LTX was 82% for 106 patients who received a "primary LTX" and 30% for 41 patients who underwent a "rescue LTX." Multivariate analysis of patients undergoing primary LTX showed that only macroscopic venous invasion had a significant impact (P-value: 0.045 with a hazard ratio of 2.96) on overall survival.

CONCLUSIONS

Orthotopic LTX has added a new dimension to the treatment of HB unresectable by partial hepatectomy. Because of the rarity of the disease and to optimize results, children with extensive HB should be treated in centers with surgical expertise in pediatric major liver resection and LTX, in close collaboration with pediatric oncologists, radiologists, and histopathologists.

[Diagnostic image (122). A boy with serious rectal bleeding. Meckel's diverticulum]

An 11-year-old boy presenting with serious rectal bleeding had a negative Meckel scintigraphy. On a barium small bowel followthrough, a small accumulation of contrast was seen outside the contour of the ileum, caused by a Meckel's diverticulum after all.

Choledochal cysts: age of presentation, symptoms, and late complications related to Todani's classification

PURPOSE

The aim of this study was to compare presentation, complications, diagnosis, and treatment of choledochal cysts in pediatric and adult patients.

METHODS

Forty-two patients were analyzed after subdivision into 3 groups: group A, less than 2 years (n = 10); group B, 2 to 16 years (n = 11); group C, greater than 16 years (n = 21).

RESULTS

The cysts were classified as extrahepatic (n = 33), intrahepatic (n = 5), and combined (n = 4). Seventy-six percent of patients presented with abdominal pain, (20 of 21 group C), and 57% with jaundice, (10 of 10 group A). Cholangiocarcinoma occurred in 6 patients, 4 of whom had previously undergone internal drainage procedures. Excision of the extrahepatic cyst was performed in 27 of 37 patients. Five patients, of whom, 4 had cholangiocarcinoma, were beyond curative treatment at the time of diagnosis. Six patients had died at the closure of this study, 5 of them had carcinoma.

CONCLUSIONS

Presenting symptoms are age dependent with jaundice prevailing in children and abdominal pain in adults. In view of the high risk of cholangiocarcinoma, early resection and not internal drainage is the appropriate treatment of extrahepatic cysts. Patients who had undergone internal drainage in the past still should undergo resection of the cyst.

Excellent long-term outcome for survivors of apple peel atresia

BACKGROUND

Apple peel atresia is the rarest type of small bowel atresia. Because of its rare occurrence and high mortality rate, little is known about the long-term outcome of these children.

METHODS

The patient charts, operative reports, and office notes of 15 children with apple peel atresia from 6 pediatric surgical centers in the Netherlands were reviewed. Long-term follow-up was assessed through review of office notes and through questionnaires.

RESULTS

The median age at the time of operation was 1.5 days. Postoperatively, 53% suffered from cholestasis, and 40% were septic. Three patients died (20%). At follow-up at a median age of 24 months, 1 child showed growth retardation and 2 children suffered from short bowel syndrome. At the time of the questionnaire, all children showed normal growth and development.

CONCLUSIONS

Even though children with apple peel atresia often suffer serious morbidity like short bowel syndrome and sepsis during the postoperative course, late morbidity turned out to be low. If the patients survive the operative and direct postoperative period, and survive the morbidity associated with malnutrition and the long-term use of total parenteral nutrition, they have a good chance of having normal bowel function with normal growth and development.

Quality of life in patients with anorectal malformation or Hirschsprung's disease: development of a disease-specific questionnaire

PURPOSE

Hirschsprung's disease and anorectal malformation are congenital diseases of the digestive tract with sequelae into adulthood. The quality of life of patients with these diseases is largely unknown. The aim of the study was 1) to construct a self-report disease-specific instrument to assess the quality of life in these patients and 2) to evaluate its psychometric performance.

METHODS

An age-specific (6 and 7 years, 8-11 years, 12-16 years, and >17 years) questionnaire called the Hirschsprung's disease/anorectal malformation quality-of-life instrument was constructed. This questionnaire consists of 39 to 42 items, grouped into 10 to 11 scales that cover physical, emotional, and social functions as well as disease-related symptoms. Generic quality-of-life data were obtained in addition. A national sample of 715 patients aged six years and older completed the questionnaire (response rate, 61.9 percent).

RESULTS

Multitrait scaling analyses confirmed the hypothesized scale structure with exception of the scales related to diet for the two youngest groups. Cronbach's alpha ranged (with exception of the diet scales) from 0.62 to 0.91 for children (8-11 years), from 0.69 to 0.82 for adolescents (12-16 years) and from 0.57 to 0.91 for adults. Selective scales were able to discriminate between subgroups of adult patients known to differ in disease and disease severity. Relevant scales of the adult version showed substantial correlations (> 0.40) with comparable scales of the SF-36. In the two youngest age groups the differences between subgroups of patients were less significant, but in the expected direction.

CONCLUSIONS

With the exception of the scales related to diet, the Hirschsprung's disease/anorectal malformation quality-of-life instrument is an instrument with promising reliability and validity, to measure the disease-specific quality of life of patients with anorectal malformation or Hirschsprung's disease.

Esophageal squamous cell carcinoma 38 years after primary repair of esophageal atresia

The authors report a case of a 38-year-old man with an esophageal squamous cell carcinoma after repair of esophageal atresia with tracheoesophageal fistula. This carcinoma occurred at a young age, near to the scar of the old anastomosis, in a patient with no other apparent risk factors. It is hypothesized that stasis caused by impaired esophageal motility may be the underlying cause. A single case is not enough to unequivocally prove a possible relationship between esophageal atresia and the development of esophageal cancer. Now that the first generation of survivors of esophageal atresia is reaching middle aged adulthood, one should, however, be aware of a possible increased incidence in these patients. J Pediatr Surg 36:629-630.

The role of fine-needle aspiration cytology in children with persistent or suspicious lymphadenopathy

PURPOSE

The aim of this study was (1) To determine the value of fine-needle aspiration cytology (FNAC) in children with persistent or suspicious peripheral lymphadenopathy and (2) to analyze whether a history of previous malignancy influenced the accuracy of FNAC.

METHODS

A retrospective study in an Academic Children's Hospital of 73 FNACs of peripheral lymph nodes in 64 patients (35 boys and 29 girls; median age, 9 years; range, 15 months to 20 years) was performed between 1992 and 1997. Eleven patients were excluded because aspirated material appeared inadequate. Outcome was compared with results of subsequent surgical biopsies, clinical follow-up, or both. Patients were divided into group A "de novo" lymphadenopathy (n = 39) and group B lymphadenopathy and a history of previous malignancy (n = 23).

RESULTS

Group A: FNAC showed a benign diagnosis in 25 cases, a malignancy in 13, and was inconclusive in 1. Outcome was false-negative in 2 and false-positive in 1. Sensitivity and specificity were 86% and 96%, respectively. FNAC helped avoid additional surgical procedures in 27 cases (61%). However, if FNAC showed malignant lymphoma, open biopsy was inevitable (8 of 13) to establish proper classification. Group B: FNAC showed a benign diagnosis in 10 cases and a malignancy in 13. Outcome was false-negative in 1, and false-positive in 1. Sensitivity and specificity were 92% and 90%, respectively. FNAC helped avoid additional surgical diagnostic procedures in 25 cases (86%).

CONCLUSIONS

(1) Fine-needle aspiration cytology is a rapid, simple and accurate diagnostic procedure to differentiate between benign and malignant peripheral lymphadenopathy in children. FNAC can avoid open biopsy in at least 60% of cases. (2) A history of previous malignant disease does not influence the accuracy of the test.

SIOP treatment guidelines for renal tumours in small infants: fact or fantasy?

AIMS

Since as far back as 1980, SIOP (Société Internationale d>>Oncologie Pédiatrique) have advocated primary nephrectomy (PN) only for unilateral renal tumours in patients </=6 months of age. Patients aged 7-12 months have been pre-treated with chemotherapy before nephrectomy is performed. The aims of this study were: (1) to evaluate how the SIOP guidelines for infants 0-6 months and 7-12 months of age were followed in three Dutch centres for Paediatric Oncology before and after 1980, and (2) to carry out an inventory of the incidence of benign tumours in this patient population below 12 months of age.

METHODS

Retrospective analysis of 67 patients under 12 months of age (1969-1995) with a unilateral renal tumour at diagnosis was carried out. Demographics, pathology, staging and treatment variables were analysed.

RESULTS

Of 67 patients, 39 were male and 28 female. Twenty-six (39%) infants were 0-6 months of age (group A) and 41 (61%) were 7-12 months old (group B). In group A there were five patients (19%) with congenital mesoblastic nephroma (CMN), out of which one was still-born and therefore received no treatment, and 21 patients with a unilateral Wilms>> tumour (WT). Fourteen of the 25 patients (56%) were treated with PN, including four patients with CMN. In group B there was one patient (2%) with CMN and 40 patients with WT. Thirteen of the patients (31%) were treated with PN. A total of 15 patients were treated before 1980 and 26 after 1980. Eight of 15 (53%) patients were treated with PN before 1980 and 21/26 (81%) were pre-treated after 1980, according to the protocol.

CONCLUSION

Despite the SIOP recommendations, only 56% of patients </=6 months were treated with PN. The percentage of pre-treated patients in group B increased after changing the protocol in 1980 to 81%. In the age group included in the SIOP studies the protocol had been used significantly more often compared to the group included in the guidelines only. The known excellent survival rate justifies a primary nephrectomy approach in the youngest age group, however, in cases of a large tumour, pre-operative chemotherapy in reduced doses may still be considered. In our study fewer CMN were found (19%) than reported in the SIOP studies (20-70%), most likely due to a low registration rate, as a consequence of excluding this very young age group (0-6 months) from the SIOP protocol.

The hyponatraemic hypertensive syndrome in a 2-year-old child with behavioural symptoms

In this case report we present a 2-year-old girl with the classical signs of the hyponatraemic hypertensive syndrome. She initially presented with a history of behavioural abnormalities and hyponatraemia (126 mmol/l) and her blood pressure was as high as 220/160 mmHg. After admission, somnolence developed. Intravenous anti-hypertensive therapy was started immediately. The hyponatraemia was treated with i.v. sodium supplementation. The cause of this syndrome proved to be fibromuscular dysplasia of the left renal artery. Finally, a left nephrectomy was performed. With this therapy, blood pressure and serum sodium normalised and the girl promptly regained normal consciousness and behaviour.

CONCLUSION

Behavioural abnormalities in the history of a child without any other neurological symptoms might be one of the first signs of hypertensive encephalopathy. In combination with hyponatraemia, these symptoms should alert the physician to consider the hyponatraemic hypertensive syndrome.

The effects of serum depletion and dexamethasone on growth and differentiation of human neuroblastoma cell lines

BACKGROUND/PURPOSE

Neuroblastoma is the most solid common extracranial malignancy in childhood. Despite multimodality treatment, high-risk disease continues to carry a poor prognosis. Glucocorticoids have been shown previously to induce differentiation in murine neuroblastoma cell lines, but no such effect has been documented in human neuroblastoma cells. Glucocorticoids are known to be active in the differentiation process of the neural crest. These studies describe the effects of dexamethasone on 6 human neuroblastoma cell lines.

METHODS

Dexamethasone was added to cultured neuroblastoma cell lines (LA1-5S, LA1-15N, BE[2]S, BE[2]N, SH-EP-1, SH-SY5Y) maintained in media supplemented with either normal serum or charcoal-depleted serum. Proliferation assays were performed, and flow cytometry was used to assess alterations in cell cycle. Cells were closely monitored for morphological changes with serial phase-contrast microscopy. Immunohistochemistry (3F8, NF-1, TRK-A) of cultured cells was used to evaluate differentiation. Glucocorticoid receptor levels was assessed using immunoblotting.

RESULTS

Dexamethasone decreased the rate of cellular proliferation in both standard and charcoal-depleted conditions. Flow cytometry showed a G1 accumulation. Increased expression of the differentiation-associated antigens was found in cells cultured in charcoal-depleted media, and a further augmentation was seen with the addition of dexamethasone. In standard media, dexamethasone had no detectable effect on the expression of these antigens. Glucocorticoid receptor expression was found to be comparable in all cell lines.

CONCLUSIONS

Human neuroblastoma cells are sensitive to the differentiating effects of dexamethasone in an environment of charcoal-depleted serum. This phenomenon may be caused by the existence of growth and mitogenic factors in serum that are inhibiting differentiation.

[Percutaneous endoscopic gastrostomy in children with psychomotor retardation; less complaints and not as stressful]

OBJECTIVE

To evaluate the effects of percutaneous endoscopic gastrostomy (PEG) in children with psychomotor retardation.

DESIGN

Prospective.

METHOD

Data on symptoms, pros and cons and complications were collected by means of questionnaires from the parents of children with psychomotor retardation and severe nutritional problems in whom a PEG tube had been introduced between August 1995 and March 1998 in the department of Children's Gastroenterology and Nutrition of the Emma Children's Hospital/Academic Medical Centre in Amsterdam, the Netherlands, comparing the situations before the introduction and 6 and 18 months afterward.

RESULTS

The patient group consisted of 17 boys and 23 girls with a mean age of 6 years and 3 months (range 8 months-10 years and 1 month). The frequency of vomiting and of airway infections decreased and the general nutritional condition improved. Restlessness and pain occurred less often in over half the children. The disadvantages most often reported were the logistics concerning the feeding (n = 11) and the reduced contact with the child (n = 10). Thirteen children displayed mild side effects such as skin irritation and proud flesh. Technical problems consisted of leakage (n = 11) and obstruction of the tube (n = 2). In one child, introduction of the tube was followed by a major complication.

CONCLUSION

The PEG tube in this patient group reduced the frequency of complaints about nutrition and constituted a patient-friendly alternative to the nasal tube.

Intussusception in a tropical country: comparison among patient populations in Jakarta, Jogyakarta, and Amsterdam

BACKGROUND

Intussusception is the most common cause of intestinal obstruction in young children, and high mortality rates remain a problem in developing countries. The purpose of this study was to describe and elucidate the differences in outcome between groups of children with intussusception in Indonesia, a developing country, and The Netherlands, a developed country.

METHODS

In this retrospective review, 176 patients were studied in three types of hospitals. A comparison was made among children treated at a primary care rural hospital in Indonesia, at a secondary care urban hospital in Indonesia, and at a tertiary care urban hospital in The Netherlands.

RESULTS

Children in the rural community hospital in Indonesia were more severely ill at arrival and had a significantly longer duration of symptoms, an increased incidence of nonviable bowel, and a mortality rate of 20%, in contrast to a mortality rate of 3% in the urban hospital in Indonesia and no deaths in the Dutch hospital.

CONCLUSIONS

The mortality of children with intussusception in rural Indonesia is much higher than in urban Indonesia or in The Netherlands, probably because of delayed treatment, which results in more patients undergoing surgery in worse physical condition.

Homologous bone graft for expansion thoracoplasty in Jeune's asphyxiating thoracic dystrophy

Adult tibial shaft from a bone graft bank was used as a solid homologous bone graft for midsternal expansion thoracoplasty in an infant with Jeune's asphyxiating thoracic dystrophy. The technique appeared successful, but the child grew out of her chest in her second year of life. Expansion thoracoplasty for Jeune's disease probably should only be reserved for children who survive their first year of life without major surgery.

Postoperative intussusception in children

BACKGROUND

Postoperative intussusception is an uncommon and sometimes forgotten cause of postoperative intestinal obstruction in children.

METHODS

Eleven consecutive cases of postoperative intussusception during a period of 16 years (1981-1997) were analysed retrospectively.

RESULTS

Symptoms developed after a median period of 5 days after operation. With one exception, postoperative intussusception was not diagnosed before reoperation. In ten of the 11 cases the intussusception was successfully treated with intraoperative manual reduction.

CONCLUSION

Postoperative intussusception is a rare but typical complication in the paediatric age group and should be kept in mind.

Persistent tachypnea in children: keep pulmonary embolism in mind

PURPOSE

Tachypnea in children is associated with respiratory disorders and nonrespiratory disorders such as cardiac disease, metabolic acidosis, fever, pain, and anxiety. Pulmonary embolism is seldom considered by pediatricians as a cause of tachypnea.

PATIENTS AND METHODS

Three children of various ages with persistent tachypnea are described: a girl after orthopedic surgery for kyphoscoliosis, a boy with nephrotic syndrome, and a neonate with Hirschsprung disease. Other causes of tachypnea were diagnosed and treated before pulmonary embolism was considered.

RESULTS

Ventilation-perfusion scanning appeared to be highly probable for pulmonary embolism in these patients. Anticoagulant therapy was started.

CONCLUSION

Pulmonary embolism should be kept in mind in children with tachypnea, especially when other risk factors for venous thromboembolism are present, to avoid delay in anticoagulant treatment and a fatal outcome.

Oncological implications of RET gene mutations in Hirschsprung's disease

BACKGROUND

Germline mutations of the RET proto-oncogene identical to those found in the tumour predisposition syndrome multiple endocrine neoplasia type 2A (MEN2A), were detected in 2.5-5% of sporadic and familial cases of Hirschsprung's disease. Some patients with Hirschsprung's disease may therefore be exposed to a highly increased risk of tumours.

AIMS

To define clinical use of RET gene testing in Hirschsprung's disease and related patient management from an oncological point of view.

METHODS

Sixty patients with Hirschsprung's disease were screened for RET mutations. In three, MEN2A type RET mutations were detected. Case reports for these three patients are presented.

RESULTS AND CONCLUSIONS

Only 22 families or sporadic patients with Hirschsprung's disease and MEN2A type RET mutations have been reported. Therefore, it is difficult to predict tumour risk for patients with familial or sporadic Hirschsprung's disease, and their relatives, who carry these mutations. For these mutation carriers, periodic screening for tumours as in MEN2A is advised, but prophylactic thyroidectomy is offered hesitantly. RET gene testing in familial or sporadic Hirschsprung's disease is not recommended at present outside a complete clinical research setting. In combined MEN2A/Hirschsprung's disease families RET gene testing, tumour screening, and prophylactic thyroidectomy are indicated as in MEN2A.

[Femoral shaft fracture in children younger than 4 years: shorter hospital stays with the help of at home traction apparatus]

OBJECTIVE

Evaluation of home traction as a treatment as a treatment of femoral shaft fractures in children with the objective to shorten the hospital stay.

DESIGN

Retrospective.

SETTING

Paediatric Surgical Centre Amsterdam (EKZ/AMC and AZVU), the Netherlands.

METHOD

In the period 1991-1995, 18 femoral shaft fractures in children younger then 4 years were treated. In ten of them traction was applied at home (in the other cases the parents refused to co-operate, the home situation was not appropriate, there were additional medical problems or there was a suspicion of child abuse). During follow-up of the group treated at home with traction, angulation, deformity and leg length discrepancy were determined with special attention to complications. The parents' experience of this method was evaluated by telephone (n = 8).

RESULTS

The median age of the children was 2.4 years. The mean hospital stay was 7 days (range: 3-12), the mean follow-up 2.4 years (range: 1.0-4.3). Angulation, rotational deformities and leg length discrepancy > 1 cm did not occur. Oedema and pain were seen in 1 patient as a result of incorrect treatment at home. In one patient a compartment syndrome occurred after a switch from traction to a plaster treatment in another hospital. With exception of some small practical and informational problems, parents were very pleased with this method.

CONCLUSION

Treatment at home of femoral shaft fractures in children with traction is a simple and effective method which reduces the hospital stay to one week with minimal complications. Good patient selection and instructions of the parents are mandatory.