Thoracotomy for repair of esophageal atresia: not as bad as they want you to think!

Is it outdated now to do a thoracotomy to repair esophageal atresia (EA)? Our practices and the literature on the subject of thoracoscopic and open thoracotomy repair of EA were reviewed, seeking answers to the following questions: Is it correct to compare the new thoracoscopic approach for the repair of EA against the thoracotomy techniques of 15-30 years ago? Should post-thoracotomy scoliosis/thoracic deformity reported in up to 56% of patients be a significant current concern? Are the clips used to close the fistula in thoracoscopic repairs as safe as open suture closures? Is the leak and stricture rate similar with thoracoscopic surgery? Are the anesthesia, period of ventilation, pain, time to first feeding, and the length of hospital stay significantly different with current thoracotomy techniques compared with thoracoscopic methods? Is the cosmetic result of a thoracoscopic repair significantly better? Is the learning curve for EA thoracoscopic repair harming patients for minimal long-term benefit? These questions were scientifically unanswerable at this time. The limited EA thoracotomies currently performed have a track record of proven safety and minimal morbidity. The results published by surgeons who are pioneers in thoracoscopy may not be generalizable, and the complication rate from teams with less experience is likely underreported. In selected patients and with experienced teams, thoracoscopic EA repair is appropriate. However, EA repair via thoracotomy should, for now, remain as the 'gold standard'. Further registry-based, multicenter, comparative studies on EA repair methodologies and outcomes should provide important answers.

The spectrum of abdominal injuries associated with chance fractures in pediatric patients

INTRODUCTION

With the increased use of seat belts in motor vehicles, the frequency of morbidity and mortality associated with motor vehicle accidents may have decreased but there is an associated rise in injuries. The purpose of this study was to evaluate the risk of intra-abdominal injury in children who sustained Chance-type fractures in a motor vehicle accident.

MATERIALS AND METHODS

A retrospective review was conducted of pediatric patients admitted for injuries sustained in motor vehicle accidents between 1984 and 2001. Patients that sustained lumbar Chance fractures and an abdominal injury were reviewed.

RESULTS

A total of 25 patients with lumbar Chance fractures were seen at our institution; twelve had associated abdominal injuries. The mean age at the time of injury was 10.9 years and the most recent follow-up was a mean of 4.8 years after injury. All patients were involved in high-speed motor vehicle collisions. Eleven patients were restrained using a 2-point restraint and only one was restrained using a 3-point restraint.

CONCLUSIONS

The abdominal injury patients had a significantly higher Chance fracture index than those patients who also suffered Chance fractures but no associated abdominal injuries. Success in the management of intra-abdominal injuries is dependent on the awareness that such an injury exists.

Primary reversed gastric tube reconstruction in long gap esophageal atresia

BACKGROUND/PURPOSE

Esophageal reconstruction in long-gap esophageal atresia (EA) poses a technical challenge with several surgical options. The purpose of this study was to review the authors' experience with the reversed gastric tube (RGT) in esophageal reconstruction.

METHODS

This series describes 7 babies with pure EA treated at 2 centers between 1989 and 2001. Data, gathered by retrospective chart review, included clinical details of the esophageal and associated malformations, technique and timing of repair, early and late complications, and long-term follow-up. Institutional review board (IRB) approval of this study has been obtained.

RESULTS

Seven babies were included. Associated malformations were present in 4: trisomy 21 in 2 and imperforate anus in 2. After gastrostomy tube placement, patients were treated with gastrostomy tube feedings and continuous upper pouch suction. Median gap length was 5.5 vertebral segments (range, 3 to 9). RGT with a posterior mediastinal esophagogastric anastomosis was performed at median age of 62 days (range, 38 to 131). There were no anastomotic leaks. Three patients had strictures, one required resection. Exclusive oral nourishment was achieved in 5 patients by 6 months of age. At last follow-up (mean, 4.5 years), 6 patients were receiving oral nutrition exclusively, and all were maintaining growth curves.

CONCLUSIONS

In long gap EA, early esophageal reconstruction using an RGT can be performed with minimal morbidity and promising short-term results.

Surgical implications of urachal remnants: Presentation and management

BACKGROUND/PURPOSE

The abdominal manifestations of urachal remnants often prompt referral to the pediatric general surgeon. The purpose of this study was to evaluate the authors' management of this anomaly.

METHODS

The authors performed a retrospective review of patients presenting to their institution with urachal remnants between 1984 and 2001. Clinical and radiographic details of presentation, management, and outcomes are described.

RESULTS

Twenty-six patients presented at a median age of 4 years (range, 2 days to 12 years), 16 were boys, and 18 required inpatient care. Eleven (42%) presented with infection, 7 (27%) with clear drainage, 3 (12%) with umbilical polyps/granulation, 3 (12%) with pain, one (4%) with recurrent urinary tract infections, and one (4%) with an asymptomatic punctum. One had an associated anomaly (hypospadias). Urinalysis and urine cultures did not correlate with infection. Ultrasound scan was diagnostic in greater than 90% of cases. Overall, 20 patients underwent primary cyst excision, and 6 underwent incision and drainage (I&D) with delayed excision. Five patients underwent primary excision while infected, and 2 had postoperative complications (wound infection and urine leak). All 6 patients who underwent 2-stage procedure initially presented with infection, and none had complications.

CONCLUSIONS

Persistent urachal remnants can present at any age with a variety of clinical manifestations. Ultrasound scan is a reliable diagnostic tool. Additional diagnostic studies generally are not warranted. Simple excision of noninfected lesions is appropriate. In cases of acute infection, initial I&D with delayed cyst excision may be preferable to avoid unnecessary complications.

Omeprazole maintenance therapy for gastroesophageal reflux disease after failure of fundoplication

BACKGROUND

Recurrence of gastroesophageal reflux (GER) in children after failed fundoplication poses a therapeutic challenge. The authors report the experience with long-term omeprazole for children with severe GER after failed fundoplication.

METHODS

The authors reviewed the charts of all children who were treated with omeprazole for GER subsequent to failed fundoplication from 1990 to 1999. All underwent endoscopic and clinical assessment of the treatment at baseline, at 3-5 months, at 6-9 months, and annually.

RESULTS

Eighteen children presented with GER, after a total of 27 fundoplications. Ten had corrected esophageal atresia, 6 had neurologica impairment, and 2 had hiatal hernia. The mean age of presentation of children with recurrence of GER was 7.8 years, and symptoms of GER occurred 4.9 years (range, 0.6-13) after last fundoplication. Fifteen patients had a mean follow-up of 4.4 years for omeprazole. Ten patients had grade III/IV esophagitis and 5 had grade II esophagitis at presentation after fundoplication. Marked improvement was noted in symptoms of GER and severity of esophagitis while taking omeprazole. Remission of esophagitis was maintained while the patient was taking omeprazole and none had further surgery. There was no recurrence of peptic strictures in eight of nine children on omeprazole, after initial esophageal dilatations. Except for benign gastric polyps in three patients, no clinical adverse effects were observed.

CONCLUSIONS

Omeprazole is an effective long-term drug for gastroesophageal reflux disease after failed fundoplication in children. Omeprazole was well-tolerated by all children and should be tried before subsequent surgical intervention.

Age is the major determinant of recurrence in pediatric differentiated thyroid carcinoma

BACKGROUND

A relationship between young age and increased risk of recurrence of pediatric differentiated thyroid carcinoma has been suggested; however, no attempts have been made to assess the prognostic factors or efficacy of treatment in very young children with this malignancy. The objectives of this study were to evaluate the association of age with outcome in pediatric differentiated thyroid carcinoma and to compare the clinical, pathologic, prognostic, and treatment variables between younger and older children with this disease.

PROCEDURE

A retrospective review of all patients presenting to the British Columbia's Children's Hospital or British Columbia Cancer Agency <17 years of age at diagnosis with differentiated thyroid carcinoma between January, 1955, and December, 1996, was completed.

RESULTS

Thirty-eight patients were identified, 12 of whom were </=10 years of age. The overall and relapse-free survivals at 20 years were 100% and 32.2%, respectively. Age at diagnosis was the only determinant of time to recurrence on univariate and multivariate regression analysis of prognostic factors (P = 0.022). The 20 year relapse-free survival for children < or =10 years of age was 10.1% vs. 48.3% for children >10 years. An association between young age and extrathyroidal tumor invasion was identified (P = 0.016); however, the latter factor did not independently predict outcome. There was a trend for suppressive doses of thyroid hormone to improve outcome, particularly with increasing age at diagnosis, but this was not statistically significant.

CONCLUSIONS

Age is the major determinant of recurrence in pediatric differentiated thyroid carcinoma. The results suggest different tumor biology in young children requiring novel approaches to therapy to decrease recurrence rates.

Presentation of low anorectal malformations beyond the neonatal period

OBJECTIVE

Anorectal malformations are usually diagnosed at birth, but some patients have presented to this institution beyond the early newborn period without recognition of their anorectal malformations. To quantify the extent of this problem, we undertook a review of all patients presenting to this hospital with anorectal malformations.

METHODS

We reviewed all new cases of anorectal malformations treated at British Columbia's Children's Hospital during the past 11 years. We looked specifically at the time of diagnosis, patient age, sex and mode of presentation, the type of anorectal malformations, and any associated anomalies.

RESULTS

One hundred twenty new cases of anorectal malformations were seen here, of whom, 15 patients (9 girls and 6 boys) presented beyond the early newborn period. Of these, 1 male infant was diagnosed at 2 weeks of age and another girl at 14 years of age. The remaining 13 presented between 3 and 11 months of age because of increasing constipation, usually associated with the introduction of solid foods. All had low anorectal malformations. Nine patients had at least 1 other feature of the VACTERL complex.

CONCLUSIONS

Most anorectal malformations are identified at birth, but a significant number of the milder lesions may not be recognized until later. Therefore, this condition must be considered in older infants and children presenting with constipation, particularly if they also have cardiac or genitourinary anomalies. constipation, imperforate anus, VACTERL.

Traumatic intercostal hernia: presentation and diagnostic workup

Intercostal herniation of lung caused by nonpenetrating thoracic trauma is rare in the pediatric population. An 11-year-old boy presented with such a hernia 4 years after the original injury. The hernia was increasing in size and was becoming more difficult to reduce. In view of possible future strangulation, a surgical repair was undertaken with prosthetic mesh closure of the intercostal muscle defect. Intercostal hernias are rare, but familiarity with the proper investigation and treatment to be provided is important.

Cougar attacks on children: injury patterns and treatment

PURPOSE

Cougar attacks on humans appear to be on the rise. A review of all attacks on children was performed to determine the method of attack and injury patterns so that a treatment regimen as well as possible preventative measures could be determined.

METHODS

A review of all attacks, including attacks on children, was performed, including three recent attacks treated at our institution. Situation, adult supervision, patient age, injuries recorded, survival, and mode of attack, if known, were reviewed.

RESULTS

There were 50 documented attacks on children with a 25% fatality rate. Most children were not alone at the time of the attack (92%), and in many instances adult supervision was present or nearby. Severe head and neck lacerations along with puncture wounds were the most common injury. Examples of typical cervical injuries include a nonfatal vertebral artery injury, phrenic nerve injury, a fatal internal carotid artery injury, and a fatal cervical spine injury. The cougar was rabid in two cases. Pasteurella resulted in late infections in two patients.

CONCLUSIONS

Based on the pattern of injuries, the authors recommend aggressive evaluation for occult cervical injuries as well as surgical debridement. Antibiotics should cover oropharyngeal flora including Pasteurella multocida. Rabies prophylaxis is indicated. Adult supervision in wilderness areas is not necessarily protective.

Balloon pyloroplasty in children with delayed gastric emptying

OBJECTIVE

To evaluate initial experience with balloon pyloroplasty for delayed gastric emptying in children.

DESIGN

A retrospective review.

SETTING

A tertiary care pediatric hospital.

PATIENTS

Seven children with scintiscan-proven delayed gastric emptying that was refractory to maximal medical therapy.

INTERVENTIONS

Balloon pyloroplasty under fluoroscopic guidance, mostly on an outpatient basis. For 1 child, the procedure was endoscopically monitored also.

OUTCOME MEASURES

Postoperative symptoms and physical findings, gastric emptying and complications.

RESULTS

Of the 7 children who underwent balloon pyloroplasty, 3 were rendered asymptomatic and 2 more were symptomatically improved. Four of the original 7 patients underwent postdilation scintigraphy, and all 4 showed normalization of the gastric emptying time. There were no complications.

CONCLUSIONS

Initial experience with fluoroscopically-guided balloon pyloroplasty indicates that it is a safe and easily tolerated procedure, worthy of further study.

Tumor karyotype differentiates lipoblastoma from liposarcoma

Lipoblastoma is a rare benign pediatric soft tissue tumor that may be difficult to distinguish from a myxoid liposarcoma clinically or histologically. The authors present a case of a progressively growing, locally invasive soft tissue tumor in a child. Tissue culture for cytogenetic study showed a breakpoint in the long arm of chromosome 8. A review of the literature showed seven case reports of lipoblastoma karyotype, six of which had a similar breakpoint in chromosome 8. This distinguishes it from the histologically alike myxoid liposarcoma, the karyotype of which typically contains the clonal anomaly t(12;16)(q13:p11). The authors recommend that when performing a biopsy of a childhood adipose tumor with unusual features, such as progressive or invasive growth, that fresh tissue be submitted for cell culture. The tumor karyotype will, in most cases, aid in differentiating lipoblastoma from myxoid liposarcoma.

Proximity injury by the ultrasonically activated scalpel during dissection

The ultrasonically activated scalpel is a high-frequency oscillating instrument that is reported to have a decreased dispersion of energy to surrounding tissues during use. To determine if this effect is beneficial and safe to surrounding tissue, it was used on anesthetized adolescent swine to dissect the portal vein from the pancreas, the renal artery and vein from the renal hilum, the ureter from the retroperitoneum, the aorta from the inferior vena cava and the common bile duct from surrounding tissue. Three-second contact to intestine and nerve roots was also performed. Wedge biopsy specimens of liver and spleen were performed. Dissection technique used was as described by the company. Structures were dissected with electrocautery using similar techniques for comparison. Tissues were harvested and placed in formalin for histological analysis. Dissection with the ultrasonically activated scalpel was simple, achieved excellent hemostasis, and did not appear to damage adjacent tissue. Microscopic analysis showed adventicial and media injury to vascular structures. The ureter and common bile duct demonstrated marked injury with regions of transmural coagulation. Nerve and small bowel did not appear to have much injury from the 3-second contact with the instrument. This study indicated that although the ultrasonically activated scalpel can ease dissection with good hemostasis, care must be taken to avoid injury to adjacent structures. Although its lateral energy dispersion may be less than that of cautery, it can still cause transmural necrosis to major structures.

Impact of infection by verotoxigenic Escherichia coli O157:H7 on the use of surgical services in a children's hospital

OBJECTIVES

To determine the impact of Escherichia coli O157:H7 infection in children on the need for surgical assessment in a pediatric surgical practice and whether clinical and bacteriologic variables might contribute to that need.

DESIGN

Examination of a case series.

SETTING

A tertiary-care pediatric hospital.

PATIENTS

Between 1990 and 1994, E. coli O157:H7 gastrointestinal infections were documented among 85 children, 29 of whom suffered from hemolytic-uremic syndrome.

INTERVENTION

Surgical consultation for presumed or proven complications of the infection.

MAIN OUTCOME MEASURES

The frequency of and reasons for surgical consultation, clinical and bacteriologic variables between patients who did or did not require surgical assessment.

RESULTS

Of the 85 children, 17 (20%) were assessed by the surgical service. The majority of these children were inpatients. Two required abdominal surgery. Female gender, older age and progression to hemolytic-uremic syndrome were factors associated in univariate analyses with a likelihood of need for surgical assessment; variation in bacterial genotype was not.

CONCLUSION

There is the potential for verotoxigenic E. coli O157:H7 infection to have a considerable impact on the utilization of pediatric surgical services.

Inguinal herniation with glial implants: possible complication of ventriculoperitoneal shunting

The standard treatment of hydrocephalus is the insertion of a valve-regulated ventriculoperitoneal (VP) shunt, which may result in the development or clinical worsening of an inguinal hernia or hydrocele. A review of the British Columbia's Children's Hospital experience with VP shunt insertion (1983-1994) identified 304 patients who underwent VP shunt placement, 31 of whom subsequently required herniorrhaphy, 5 suffering recurrences. Two cases exhibited areas of glial differentiation (diffusely scattered in one sac from a bilateral repair, focally present in the second unilateral hernia repair) displaying cytoplasmic staining with glial fibrillary acidic protein and S100. At time of surgical repair of case 1 (bilateral hernia repair), the tip of the VP shunt was detected within the hernia sac exhibiting glial differentiation; no glial tissue was identified in the sac from the other side. We conclude that inguinal herniation is a common complication of VP shunt insertion, and the identification of glial tissue within such an inguinal hernia is a rarer complication, possibly occurring when the shunt tip lies in close proximity to the hernial mesothelial tissue.

Internal sphincterotomy in post-pull-through Hirschsprung's disease

Despite proper technique, pull-through operations for Hirschsprung's disease sometimes fail to deliver normal or effective bowel evacuation. Ten patients, described herein, had had a pull-through procedures. The procedures had been performed by various pediatric surgeons. Five cases had been diagnosed in the newborn period and had undergone colostomies. The remainder had been diagnosed later (at 2 months to 2 years of age). They too had undergone colostomy initially, and all had an elective pull-through procedure. The techniques varied; two had Soave procedures, seven had Duhamel procedures, and one had a Kimura-Soave procedure (the only case of total colonic Hirschsprung's disease in the series). All the patients had manifested difficulty in passing stools after the pull-throughs. The problem was described as "severe constipation," "obstipation," or "fecal retention." Four patients had been treated with many laxatives, suppositories, enema routines, and diet regimens for years, with no success. All had been examined radiographically to detect megarectum or megacolon. All had additional biopsies to confirm the presence of ganglia in the pulled-through segments. At 21 months to 12 years of age, these patients underwent full posterior internal sphincterotomies. Nine of the 10 had a good or excellent outcome, with resolution of the megarectum or megacolon. Three patients still require small doses of senna compound, which are being decreased continuously. Therapy failed for a patient with Down's syndrome and a, Duhamel pull-through, and a stoma was required.

Splanchnic artery pseudo-aneurysms secondary to blunt abdominal trauma in children

Traumatic splanchnic artery pseudo-aneurysms are uncommon; only two cases have been reported among the pediatric population. The authors describe their experience with four patients in whom splanchnic artery pseudoaneurysms developed after blunt abdominal trauma. Splenic artery pseudo-aneurysms were found in a 6-year-old boy and an 8-year-old girl after blunt splenic injuries. In both cases, spontaneous thrombosis of the pseudo-aneurysms occurred after a period of observation. Hepatic artery pseudoaneurysms were found in a 7-year-old boy and a 10-year-old girl after major liver lacerations. The boy had successful angiographic embolization of the lesion, but the girl required direct ligation of the pseudo-aneurysm after nearly exsanguinating from acute hemorrhage. All four children have recovered completely, with no long-term sequelae. Traumatic splanchnic artery pseudo-aneurysms are potentially life-threatening complications that can occur after blunt abdominal trauma. The investigation and management of these lesions must be individualized according to the clinical scenario.

Diagnostic laparoscopy in childhood Crohn's disease

In some children, contrast radiography and endoscopy fail to confirm suspected Crohn's disease, or fail to evaluate the extent of disease. This report documents seven cases in which laparoscopy was used to look for creeping mesenteric fat involving the small intestine, a pathological finding reported only for Crohn's disease. One child had extensive Crohn's colitis and possible terminal ileitis that remained clinically disabling despite intensive immunosuppression therapy. The lack of creeping fat in the small intestine was used to justify colon resection and forego further aggressive medical therapy. The patient had complete resolution of her symptoms after the colectomy. Six children had suspected Crohn's disease and underwent diagnostic laparoscopy after other studies were inconclusive. In three, creeping mesenteric fat of the small intestine was found, and all three responded to treatment for Crohn's disease, with resolution of symptoms. The other three children had Crohn's disease excluded based on the absence of creeping mesenteric fat, and subsequently other pathological conditions were identified. The usual radiographic and endoscopic studies will diagnose most cases of Crohn's disease, but this report emphasizes that, in select cases in which other investigations are inconclusive, laparoscopy can be useful to search for creeping mesenteric fat, a finding characteristic of Crohn's disease.

Multiple entero-entero fistulae: an unusual complication of Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP) is an immunologically mediated systemic vasculitis of small blood vessels that frequently involves the gastrointestinal tract. Surgeons often are asked to assess patients with HSP for abdominal pain. Common complications that lead to surgical intervention include intussusception, perforation, necrosis, and massive gastrointestinal bleeding. However, the development of multiple entero-entero fistulae has not been described previously. Herein the authors describe the case of a 10-year-old girl with HSP who had a typical rash, seizures secondary to central nervous vasculitis, and gastrointestinal involvement. The abdominal pain persisted for several days until marked fever and hypotension developed, which necessitated surgical intervention. During laparotomy, multiple entero-entero fistulae of the ileum were found, which required resection and primary anastomosis. Histological examination of the ileum was consistent with HSP vasculitis. The patient made an unremarkable recovery and has had no recurrence of symptoms.

Trans-scrotal intra-abdominal injuries: two case reports

Penetrating injury to the scrotum is uncommon. Usually not serious in itself it may be associated with other more serious conditions. A 15-year-old boy was involved in a tobogganing accident, and a shard of wood penetrated the left scrotum, the anterior abdominal wall and the rectus sheath one-third of the way from umbilicus to xiphisternum. There was also a liver laceration. Removal of the piece of wood and closure of the wounds with drainage resulted in successful recovery. A 45-year-old man, sustained a penetrating straddle-type injury from a broom handle. The handle penetrated Dartos fascia but there was no testicular injury. It also perforated the rectus sheath 6 cm inferior to the costal margin, and both anterior and posterior gastric walls. The tract of the handle extended along the base of the transverse mesocolon and posterior to the pancreas. The perforations were debrided and repaired. The patient received a 5-day course of broad-spectrum antibiotics and recovered fully. As a result of their experience with these two patients the authors recommend that when there is penetration of Dartos fascia, the testicle and cord should be inspected, lavage and débridement should be carried out, and any foreign bodies should be removed and the injuries repaired. Antibiotics should be given perioperatively. In all cases the entire tract should be explored to its terminus to search for other injuries. Even upper abdominal injuries can occur with penetrating scrotal injuries.

Necrotizing fasciitis in childhood

Necrotizing fasciitis is a rare entity in the pediatric population. Five cases of this soft tissue infection were treated at the authors' institution between January and December 1993. Three of the children were profoundly neutropenic secondary to chemotherapy. All five were treated with aggressive surgical debridement, frequent dressing changes, broad-spectrum antibiotics, and nutritional support. In addition, the patients with neutropenia received a combination of granulocyte-colony stimulating factor and granulocyte transfusions. One child died of overwhelming sepsis and bone marrow graft failure. The others eventually made a complete recovery. Necrotizing fasciitis may be becoming a more common problem in children. Aggressive chemotherapeutic regimens and more frequent use of bone marrow transplantation could be a factor in this. Early diagnosis and aggressive surgical therapy is critical. However, mortality may be significant, especially in patients with neutropenia. Leukocyte response to the infection may be a prognostic marker. Pseudomonas and enteric gram-negative organisms are seen frequently in immunocompromised children with necrotizing fasciitis. Antimicrobial selection should supply adequate coverage of these organisms.

Morbidity in neurologically impaired children after percutaneous endoscopic versus Stamm gastrostomy

Neurologically impaired children frequently require a feeding gastrostomy. Few reports are available comparing the incidence of postoperative complications and symptomatic gastroesophageal reflux after endoscopic versus operative Stamm gastrostomy in this group of children. We undertook a retrospective study of 63 consecutive neurologically impaired children requiring a feeding gastrostomy, with an average of 23 months of follow-up. No child had symptomatic gastroesophageal reflux. Thirty children had a percutaneous endoscopic gastrostomy and 33 had a Stamm gastrostomy, depending on the preference of the surgeon. The two groups were comparable in age range, cause of neurologic impairment, and indication for gastrostomy. Minor complications occurred in 30%. All three major complications occurred after Stamm gastrostomy, including two postoperative deaths. Symptomatic gastroesophageal reflux developed in 60%. The incidence of fundoplication after gastrostomy was 10% in the percutaneous endoscopic gastrostomy group and 39% after Stamm gastrostomy (p < .025). Morbidity was lower after percutaneous endoscopic gastrostomy than after Stamm gastrostomy in this group of neurologically impaired children. Fundoplication for symptomatic gastroesophageal reflux was infrequent after percutaneous endoscopic gastrostomy and significantly more common after Stamm gastrostomy. Percutaneous endoscopic gastrostomy is recommended as the initial procedure in neurologically impaired children without symptomatic gastroesophageal reflux who require a feeding gastrostomy.

Obstructive jaundice caused by neuroblastoma managed with temporary cholecystostomy tube

Neuroblastoma presenting as obstructive jaundice is very rare. The authors present two cases of neuroblastoma, one primary and one recurrent, manifesting as a malignant obstruction of the extrahepatic biliary system. Various methods of biliary decompression were considered in these children including transhepatic or retrograde biliary stenting and internal cholecystoenteric bypass. An attempt at percutaneous transhepatic stent placement failed in one case. In each patient, a simple insertion of a cholecystostomy tube proved effective. Immediately postoperatively, both patients had rapid resolution in symptoms and a decrease in bilirubin levels. Transient mild cholangitis in both children was successfully treated with antibiotics. Chemotherapy reduced the tumor size in each case, and the cholecystostomy tubes were removed within 3 weeks, after cholangiography showed patency of the distal common bile ducts. Temporary cholecystostomy tube drainage and systemic chemotherapy proved to be a safe, simple, and effective method for managing obstructive jaundice caused by neuroblastoma in these two cases.

Pilomatrixoma: a common, benign childhood skin tumour

OBJECTIVE

To review recent experience with pilomatrixoma, particularly with respect to diagnosis.

DESIGN

Chart review for an 8-year period.

SETTING

A university-affiliated children's hospital.

PATIENTS

Fifty children with 51 histologically proven pilomatrixomas.

INTERVENTION

Excision of the lesion.

MAIN OUTCOME MEASURES

Clinical presentation, diagnosis and pathological findings.

RESULTS

The clinical presentation was typically that of an asymptomatic superficial mass that increased slowly in size and was located in the head and neck (78%) or chest and upper limbs. In one case the mass increased rapidly over 2 weeks and changed in colour from red to purple with areas of pink and tan. The referring diagnosis was incorrect in 94% of cases, and the preoperative diagnosis was incorrect in 57%. Pathologically the tumours were situated in the dermis or subcutaneous tissue. None were cystic, but several had areas of calcification. None of the tumours recurred after excision, but two patients had multiple lesions at different locations and times.

CONCLUSIONS

Pilomatrixomas in children are simple to treat successfully but have variable clinical presentation. Early diagnosis is important so that unnecessary, aggressive surgery can be avoided.

Implications of Yersinia enterocolitica biotyping

The utility of a simple biotyping scheme to differentiate pathogenic and non-pathogenic strains of Yersinia enterocolitica was determined for 79 patients who were admitted to or attended a reference children's hospital in western Canada. Biotyping defined predominantly two subsets of Y enterocolitica. 'Pathogenic' strains were more likely to have been obtained from younger patients (mean age 61.9 months) who experienced an acute gastrointestinal illness that was occasionally associated with bloody diarrhoea or a surgical procedure. Growth of Y enterocolitica from selective solid bacteriological growth media were often in the moderate to heavy range (82.0%). In contrast, 'non-pathogenic' strains were more often obtained from older patients (mean 116.0 months) who were already recognised to have suffered from a chronic illness and who were likely to have been admitted to hospital. Moderate to heavy growth of bacterium in stool specimens were infrequently (17.4%) obtained from the latter patients. The use of a simple biotyping scheme for the differentiation of Y enterocolitica strains has the potential to improve patient care.

Laparoscopic-guided gastropexy for intermittent gastric volvulus

A 12-year-old girl with acute gastric volvulus associated with severe scoliosis and neurological impairment did well initially with nasogastric tube decompression. To prevent recurrence, anterior gastropexy was performed using percutaneous sutures through the abdominal wall and stomach with the gastroscope in place. Simultaneous laparoscopic guidance was used to ensure that the stomach was fixed in a nonrotated position. One year later, volvulus has not recurred. This method of gastropexy is indicated only in children with intermittent gastric volvulus who do not have an underlying abnormality such as diaphragmatic hernia.

Giant hydatid lung cysts in the Canadian northwest: outcome of conservative treatment in three children

Hydatid lung disease due to Echinococcus granulosus in the Canadian northwest and Alaska is often asymptomatic and usually benign. We reviewed the course and outcome of three children with giant hydatid lung cyst seen over a 2-year period. All were North American Indian children aged 9 to 12 years who presented with cough, fever, and chest pain. One had a rash. There was a history of exposure to domestic dogs who had been fed moose entrails in each case. Chest x-rays showed solitary lung cysts with air-fluid levels, from 6 cm to 12 cm in diameter. Aspiration of each cyst demonstrated Echinococcus hooklets and protoscolices. Serology was unhelpful, being negative in two cases. Transient pneumonitis and pneumothorax were seen as complications of needle aspiration. Two cysts gradually resolved over the following 6 months. One child returned after 9 months with a lung abscess due to superimposed infection of the cyst remnant with Haemophilus influenzae, and eventually required lobectomy. The existence of an endemic benign variant of E granulosus in Canada is not widely known, and it is important to distinguish it from the more aggressive pastoral form of the disease seen in immigrants from sheep-rearing countries. The native Canadian disease usually resolves spontaneously, does not cause anaphylaxis, and does not implant daughter cysts if spilled. Surgical treatment should be avoided except for complications such as secondary bacterial infection.

Rhabdomyosarcoma arising within congenital pulmonary cysts: report of three cases

Over the past 9 months, three cases of primary pulmonary rhabdomyosarcoma have been treated at British Columbia Children's Hospital. Two patients (aged 24 and 37 months) presented with spontaneous pneumothoraces and had cystic changes in the affected lung on chest radiograph. The third patient (aged 42 months) was evaluated for chronic cough, fever, and failure to thrive. Chest x-ray showed a large mass in the left lower lobe as well as mediastinal adenopathy. All three of these lesions originated within congenital lung cysts, one a peripheral bronchogenic cyst and the others cystic adenomatoid malformations. This report suggests that there is a significant risk for the development of rhabdomyosarcoma within malformed pulmonary tissue.

The bowel management tube: an effective means for controlling fecal incontinence

Regular bowel washout enemas have been used as a method of management of fecal incontinence. The effective administration of a washout enema to a child with weak anal sphincters is often a problem. Using a new silastic balloon-tipped enema catheter (bowel management tube [BMT]) of our design, we prospectively studied its effectiveness in a group of children who suffered fecal incontinence. Thirty-one children were studied over a 1-year period. Their diagnoses included meningomyelocele (19), postoperative Hirschsprung's disease or imperforate anus (10), and other (2). Before and after starting the BMT enema system, clinical assessment and a diary, which graded the degree of fecal incontinence and satisfaction with the system, were completed. Five patients failed to benefit because of noncompliance (3) or balloon extrusion (2). Three more patients discontinued the use of the tube system. Twenty-three patients achieved successful results with this system as evidenced by a significant amelioration in their fecal incontinence and their unwillingness to give up the use of the BMT. We conclude that the use of a regular washout enemas with BMT can be an effective method for control of fecal incontinence in children.

The treatment of simultaneous choriocarcinoma in mother and baby

Simultaneous occurrence of choriocarcinoma in mother and child is rare. Such a case is described in which a massive intrahepatic tumor in the infant led to its treatment and that of the mother who showed evidence of the same tumor. Both are alive and well 1 year after treatment, the longest recorded infant survival.

Sirenomelia: case of the surviving mermaid

This report describes a neonate with sirenomelia who was recently treated at British Columbia Children's Hospital. Prenatal diagnosis was made at 29 weeks' gestation. Survival was not anticipated. Cesarean-section at term showed a live 2,375-g infant with excellent Apgar scores. Anomalies noted were fused lower extremities, imperforate anus, colon atresia, bilateral fused pelvic kidneys with renal dysplasia, pelvic and sacral dysplasia, and genital abnormalities. Laparotomy and colostomy were performed. All other anomalies are compatible with life and she is neurologically normal. Eventual separation of the lower extremities is planned. This is the second reported case of survival in a patient born with sirenomelia.

Coagulopathy associated with large sacrococcygeal teratomas

Twelve neonates with sacrococcygeal teratoma (SCT) have been treated at British Columbia Children's Hospital over the past 5 years. Clinically significant coagulopathy developed in four of these neonates and two died, one before surgical intervention could be undertaken. Disseminated intravascular coagulation (DIC) was found in one patient and thrombocytopenia in another on preoperative laboratory studies. Etiology of the coagulopathy is unclear, but appears to be multifactorial. Although several clinical reviews have noted mortalities due to exsanguinating hemorrhage, no study has focused solely on this issue. The diagnosis of SCT in the neonate at high risk for development of coagulopathy is usually made prenatally. Premature labor is often precipitated by associated polyhydramnios and large tumor size. Fetal distress, prematurity, and low birth weight are common. Presence of placentamegaly, hydrops fetalis, and congestive heart failure are ominous prognostic signs. Early identification of patients at increased risk for development of hemorrhagic complications may allow optimization of their management. Cesarean section should minimize trauma to the SCT during delivery. Expeditious resection of the lesion may improve survival.

13-cis-retinoic acid (NSC 122758) in the treatment of children with metastatic neuroblastoma unresponsive to conventional chemotherapy: report from the Childrens Cancer Study Group

The Childrens Cancer Study Group evaluated daily oral 13-cis-retinoic acid to determine its therapeutic efficacy in 28 children with advanced neuroblastoma refractory to conventional therapy. Cheilitis and fissured lips were the most common side effects; however, fewer than 50% of the patients experienced any toxicity. Two of twenty-two evaluable children demonstrated positive response to therapy. In one case, a child received the drug for 11 months. Seventeen patients demonstrated progressive disease within 28 days of the start of treatment. Three other patients with stable disease, or removed from study at day 28, were considered nonresponsive. Our data demonstrate that, when given as a single daily oral dose of 100 mg/m2, 13-cis-retinoic acid does not have significant activity in children with advanced neuroblastoma.

Update on trauma care in Canada. 2. Update on pediatric trauma

Selective conservatism is the key to the rational management of pediatric trauma, realizing that children may harbour severe occult injuries. The modern treatment of childhood abdominal trauma best exemplifies this approach: nonoperative management of splenic trauma is now standard for children, and a selective conservative approach is advised in the handling of childhood liver and pancreatic injuries. Prevention of childhood injuries should be the goal. The development of a national database of childhood trauma should provide the basis for action to educate and legislate for prevention. When prevention fails, however, up-to-date quality pediatric trauma care is the key.

Postoperative intussusception in a premature infant

Intussusception occurs most commonly between the fifth and ninth month of life. Affected infants are usually healthy and born at full gestation age. We describe a case of intussusception occurring in a 10-day-old, 700-g neonate born at 28 weeks' gestation. The diagnosis was made at laparotomy 7 days after colostomy for imperforate anus. There were three associated bowel perforations. This case demonstrates that postoperative intussusception can occur in the premature infant. It also serves to illustrate the difficulty in making the diagnosis preoperatively.

The use of cardiopulmonary bypass and circulatory arrest in the resection of massive tumors

This report describes our experience in five cases, removing a massive soft tissue tumor by means of placing the patient on cardiopulmonary bypass, with profound hypothermia and circulatory arrest. This technique allowed consideration to be given to the resection of tumors previously adjudged "inoperable."

Esophageal atresia--a rabbit model to study anastomotic healing and the use of tissue adhesive fibrin sealant

The problem of bringing together two relatively widely separated, small, and fragile ends of a sick newborn baby's atretic esophagus remains a formidable surgical task, wherein the incidence of anastomotic leakage ranges from 10% to 27%. Recently, a multicomponent tissue adhesive fibrin sealant (Tisseel) has been licensed in Canada and declared useful for sealing gastrointestinal (GI) tract anastomoses. To study whether Tisseel might decrease the leakage rate of esophageal anastomoses in neonatal esophageal atresia and perhaps limit stricture formation, a rabbit model of esophageal atresia was developed. Twenty New Zealand white rabbits weighing 2.8 to 3.7 kg underwent thoracotomy and resection of a segment of esophagus with end-to-end, interrupted silk-sutured anastomosis under tension, to mimic the conditions found in newborn esophageal atresia. Four died immediately following operation. Ten rabbits had their anastomosis sealed with Tisseel, six control animals did not. All animals consumed variable amounts of water and food, starting 24 hours after surgery. Survival averaged 10.5 days (range, 5 to 20 days). Eight animals (five experimental, three control) were evaluated by means of barium esophagograms 1 week postoperatively, and all except one control animal demonstrated radiologic evidence of anastomotic leakage. Autopsy specimens revealed gross leakage in nine animals (seven experimental, two control). However, histology revealed leakage and periesophageal abscess formation in all experimental animals and in four control animals. The remaining two controls revealed only some degree of esophageal stenosis. This experiment showed no demonstrable benefit from the use of a fibrin sealant in preventing esophageal anastomotic leakage, such as that which occurs in repaired esophageal atresia.

The emerging pattern of pediatric day-care surgery

The utilization of short stay surgical facilities is increasing and indications for day-care surgery for children are becoming more diverse. These trends were observed in a review of day-care surgery performed at British Columbia Children's Hospital during the years 1982 to 1986. During 1984 and 1985, 688 hernia repairs were undertaken, as were 76 anorectal procedures such as anal fistulotomy, drainage of abscesses, etc. In addition, 127 orchidopexies were performed, which indicated a 40% increase when compared with earlier years. Further procedures included the excision of 38 branchial cleft anomalies and 17 salivary gland lesions, as well as the performance of 95 tracheobronchial endoscopies including the removal of 25 foreign bodies. Head and neck and endoscopic procedures now represent 21% of all general surgery day care cases, and have increased by 50% since 1982. Thirty-six children (1.6%) initially brought in for day care surgery required actual admission to the hospital for such reasons as (1) the procedure being more complex than initially anticipated (15 patients); (2) hemorrhage (5 patients); or (3) postanesthetic concern (11 patients). Two thirds of the anesthetic complications were in infants less than 3 months of age. A special subgroup of high-risk infants were identified--the previous premature less than 52 weeks conceptual age. In our opinion, infants who are less than 3 months of age, especially if born prematurely, should be admitted to the hospital for surgery.

Neonatal pharyngoesophageal perforation mimicking esophageal atresia: clues to diagnosis

Perforation of the newborn child's esophagus or pharynx can mimic esophageal atresia clinically. Fourteen cases of newborn hypopharyngeal or esophageal perforation are presented. In nine cases, esophageal atresia was the initial diagnosis entertained; seven of these on the first day of life. In four others, the diagnosis of a perforated pharynx or esophagus was evident on plain x-ray. Six patients had esophagograms. Two newborns underwent thoracotomies for repair of their initially diagnosed esophageal atresia. Subsequently, esophageal perforation was diagnosed intraoperatively on each and suture repair was undertaken. The 12 remaining neonates were treated nonoperatively. There were four deaths, all in the nonoperative group and three weighing less than 1,000 g. None of the deaths were directly attributable to the perforations. In retrospect, each child presented with one or more early clues to the diagnosis of pharyngoesophageal perforation, which included a history of difficult tracheal or nasogastric intubation, blood in the nasogastric tube, length and course of nasogastric tube inserted, and subtle chest x-ray changes. In these cases, nonoperative treatment is usually successful.

The prognosis of traumatic asphyxia in childhood

Sixteen children with traumatic asphyxia (TA) over a 10-year period are reported. Follow-up was available in 12 of 14 survivors. Mortality and morbidity are the results of associated injuries or cerebral hypoxia, which are determined by the severity, nature, and duration of the compression force. Associated injuries should be treated in their own right, disregarding the manifestations of TA. The physical findings unique to TA usually resolve spontaneously. Neurologic sequelae such as peripheral nerve injuries or spinal cord injuries may be permanent. The cutaneous lesions uniformly disappear with time. Subconjunctival hemorrhages slowly fade and disappear. Visual defects are rare and usually clear within 24 hours, but may be permanent. No cognitive impairment results in children with uncomplicated TA, and the value of treating cerebral cortical depression with steroids is uncertain.

Treatment of tracheomalacia: eight years' experience

Between 1978 and 1985, 21 patients were treated for tracheomalacia, (group I) and 4 for tracheobronchomalacia (group II). The median age at treatment was 7 months (range 1 to 96 months). Indications for surgery in group I were, "dying spells" (n = 12), recurrent pneumonia (n = 4), intermittent respiratory obstruction (n = 3) and inability to extubate airway (n = 2). 18 had esophageal atresia repair. Treatment in group I was aortopexy (n = 19), three of whom also required an external airway splint; two had an airway splint only. Airway obstruction was relieved in all. Group II patients required surgery because they could not be extubated; none had esophageal atresia. Aortopexy in all and splinting in one failed in 3 of 4 patients. Aortopexy is the primary treatment of tracheomalacia. External airway splinting may be used where aortopexy is inadequate. A satisfactory treatment for tracheobronchomalacia has not yet been devised.

Preoperative home elemental enteral nutrition in complicated Crohn's disease

Home elemental nutrition (HEN) was used in 11 children and adolescents with complicated Crohn's disease to relieve their immediate symptoms and make them more fit for definitive surgery. HEN resulted in symptomatic relief, weight gain from a mean of 47 to 53 kg (P less than .001) and reduction in prednisone requirements from a mean daily dose of 30 to 6 mg (P less than .001). The seven patients who subsequently underwent definitive bowel resection suffered no surgical complications. HEN was well tolerated by all patients. HEN offers a simple, safe, and cost effective means of preparing patients with complicated Crohn's disease for operation.