Cystic Biliary Atresia: A Wolf in Sheep's Clothing

Neonatal obstructive jaundice is frequently explained by biliary atresia (BA) or the presence of a choledochal cyst (CC). Cystic biliary atresia (CBA) has been a proposed as a subtype of BA with projected improved outcomes. We aimed to characterize these lesions further. We conducted an Institutional Review Board-approved review of all patients treated for obstructive jaundice at our tertiary children's hospital over 10 years. Over the decade we evaluated 91 children with obstructive jaundice: 13 CBA, 52 BA, and 26 CC. Patients with isolated CBA and BA were diagnosed significantly earlier than those with CC (15.9, 54, and 281 days, respectively; P = 0.0001). There was a significant delay between diagnosis and surgical intervention for patients with CBA compared with BA: 17 days versus 5.7 days ( P = 0.004). There was no difference in rate of transplant between CBA and BA (31 vs 50%; P = 0.35). The time from surgery until transplant was 13.9 and 18.6 months for CBA and BA, respectively ( P = 0.62). Although radiographically similar to CC, CBA behaves similarly to isolated BA. Delay in recognition and surgical treatment may affect outcomes and lead to an increased incidence of liver failure. The presence of a cystic biliary malformation in the setting of neonatal jaundice should be regarded as CBA until proven otherwise.

Indications and outcomes for tunneled central venous line placement via the axillary vein in children

PURPOSE

To assess the indications, safety and outcomes of tunneled central venous catheters (CVCs) placed via a cutdown approach into the axillary vein in children, an approach not well described in this population.

METHODS

A retrospective cohort study was performed on pediatric patients who received CVCs via open cannulation of the axillary vein or one of its tributaries between January 2006 and October 2016 at two hospitals.

RESULTS

A total of 24 axillary CVCs were placed in 20 patients [10 male (42%); mean weight 7.0 kg (SD 2.9); mean age 10 months (SD 6)]. The most common indications for axillary vein access included neck or chest wall challenges (tracheostomies or chest wall wounds) (n = 18). The median duration of line placement was 140 days (IQR 146). The most common indications for removal were completion of therapy (n = 7, 39%) and infection (n = 5, 28%). There were no early complications. Long-term complications included infection (n = 5) or catheter malfunction (n = 3).

CONCLUSIONS

Tunneled CVC placement via a cutdown approach into the axillary vein or its tributary can be an effective alternative approach to obtain long-term vascular access in children. Outcomes may be comparable to lines placed in traditional internal jugular and subclavian vein locations.

Pediatric short bowel syndrome and subsequent development of inflammatory bowel disease: an illustrative case and literature review

Short bowel syndrome (SBS) in neonates is an uncommon but highly morbid condition. As SBS survival increases, physiologic complications become more apparent. Few reports in the literature elucidate outcomes for adults with a pediatric history of SBS. We present a case report of a patient, born with complicated gastroschisis resulting in SBS at birth, who subsequently developed symptoms and pathologic changes of inflammatory bowel disease (IBD) as an adult. The patient lived from age 7, after a Bianchi intestinal lengthening procedure, to age 34 independent of parenteral nutrition (PN), but requiring hydration fluid via G-tube. He was then diagnosed with IBD, after presenting with weight loss, diarrhea, and malabsorption, which required resumption of PN and infliximab treatment. This report adds to a small body of the literature which points to a connection between SBS in neonates and subsequent diagnosis of IBD. Recent evidence suggests that SBS and IBD have shared features of mucosal immune dysfunction and altered intestinal microbiota. We review current treatment options for pediatric SBS as well as multidisciplinary and coordinated transition strategies. We conclude that there may be an etiologic connection between SBS and IBD and that this knowledge may impact outcomes and approaches to care.

Malakoplakia and primary immunodeficiency

Malakoplakia, a rare granulomatous disease caused by impaired macrophage response, has been reported only rarely in children. We report 3 unique cases, with lesions occurring in unusual locations in children with primary immune deficiencies.

Noniatrogenic neonatal gastric perforation: the role of interstitial cells of Cajal

Noniatrogenic neonatal gastric perforation is a rare and life-threatening condition whose etiology is often unclear. Interstitial cells of Cajal act as gastrointestinal pacemaker cells and express the proto-oncogene c-Kit. Six new cases were identified at our institution which presented with no mechanical, pharmacologic, or otherwise medical-related intervention prior to rupture. The number of interstitial cells of Cajal in nonnecrotic muscularis propria from five random high-power fields per specimen was compared using immunohistochemical stains for c-Kit. The authors show that a lack of interstitial cells of Cajal in the stomach musculature may be implicated in the development of noniatrogenic gastric perforation (p = 0.008). Further large-scale studies, including molecular and genetic analysis, may help to better understand this phenomenon.

Cystic biliary atresia: a wolf in sheep's clothing

Neonatal obstructive jaundice is frequently explained by biliary atresia (BA) or the presence of a choledochal cyst (CC). Cystic biliary atresia (CBA) has been a proposed as a subtype of BA with projected improved outcomes. We aimed to characterize these lesions further. We conducted an Institutional Review Board-approved review of all patients treated for obstructive jaundice at our tertiary children's hospital over 10 years. Over the decade we evaluated 91 children with obstructive jaundice: 13 CBA, 52 BA, and 26 CC. Patients with isolated CBA and BA were diagnosed significantly earlier than those with CC (15.9, 54, and 281 days, respectively; P = 0.0001). There was a significant delay between diagnosis and surgical intervention for patients with CBA compared with BA: 17 days versus 5.7 days (P = 0.004). There was no difference in rate of transplant between CBA and BA (31 vs. 50%; P = 0.35). The time from surgery until transplant was 13.9 and 18.6 months for CBA and BA, respectively (P = 0.62). Although radiographically similar to CC, CBA behaves similarly to isolated BA. Delay in recognition and surgical treatment may affect outcomes and lead to an increased incidence of liver failure. The presence of a cystic biliary malformation in the setting of neonatal jaundice should be regarded as CBA until proven otherwise.

Splenic cysts in the pediatric population: a report of 21 cases with review of the literature

Splenic cysts are rare lesions that can occur in parasitic and non-parasitic forms. Because they are uncommon, the classification, pathogenesis, and management techniques are still debated. The continual review of splenic cyst cases in the pediatric population is essential for establishing a clear diagnosis and course of treatment. This report presents 21 cases of pediatric splenic cysts observed at Children's Healthcare of Atlanta over an 18 year period (1993-2011). The cases include both parasitic and and nonparasitic cysts. The current splenic cyst classification and treatment methods are analyzed through a review of the current theories and based on our experiences.

Ciliated hepatic foregut cyst: four case reports with a review of the literature

Ciliated hepatic foregut cysts (CHFCs) are rare congenital legions that arise from the embryonic foregut. The cysts are formed during fetal development by evagination from their respective portions of the foregut, and are characterized by a ciliated epithelial lining. Approximately 100 cases of CHFC have been reported, of which only 13 were in children. Although CHFC is typically benign, malignant transformation to squamous cell carcinoma (SCC) has been reported in 3 cases. Survival rate after progression to malignancy is poor, as SCC in this setting is biologically aggressive. We present 4 new cases of CHFC in children between 5 months and 17 years old. Our cases are unusual, as some of the cysts exhibit multilocularity and biliary communication, and 2 of our patients were diagnosed under the age of 1. Additionally, 1 of the cysts was 19.3 cm in diameter, making it the largest reported CHFC to our knowledge. Ciliated hepatic foregut cysts should be included in the differential diagnosis of hepatic lesions.

Button cholecystostomy for management of progressive familial intrahepatic cholestasis syndromes

BACKGROUND/PURPOSE

Progressive familial intrahepatic cholestasis syndromes are characterized by impaired bile acid secretion resulting in pruritus, coagulopathy, diarrhea, and malnutrition leading to progressive liver failure and death in childhood. Partial internal or external biliary drainage can relieve symptoms and slow the progression of the disease. Objections to partial external biliary drainage include the need for a permanent biliary stoma with all the inherent complications of a stoma. We propose a novel approach to these diseases--placement of a "button" cholecystostomy tube.

METHODS

Under general anesthesia and through a small right subcostal incision, a MIC-KEY button (Kimberly-Clark Worldwide, Inc, Draper, UT) is inserted into the mobilized fundus of the gallbladder and secured with 2 purse-string sutures. Time of drainage is adjusted to relieve pruritus.

RESULTS

Three children with progressive familial intrahepatic cholestasis achieved adequate bile drainage via the cholecystostomy button to relieve pruritus for 1, 2, and 2 ½ years postoperatively, with drainage periods of 12 to 14 hours per day. There were no episodes of cholangitis. Dislodged tubes can be replaced, or stones can be retrieved via the tract that is formed. Patient (parent) acceptance has been excellent.

CONCLUSION

Button cholecystostomy is simple to perform, relieves pruritus with intermittent (nighttime) drainage, avoids complications of a permanent stoma, avoids an enteric anastomosis, and is accepted by parents.

Use of tissue expanders in the repair of complex abdominal wall defects

BACKGROUND/PURPOSE

Closure of abdominal wall defects in children poses a challenge for pediatric surgeons. We describe a technique using tissue expanders placed either intraperitoneally or in the abdominal wall to aid in the reconstruction of a variety of complex abdominal wall defects.

METHODS

The tissue expanders are inserted under general anesthesia. Initial expansion is done in the operating room with attention to peak airway pressure, urine output, and end-tidal carbon dioxide. The expanders are inflated in the outpatient setting via percutaneous access until the calculated inflation volume is achieved. They are then removed; and definitive closure is accomplished using a combination of native tissue flaps, abdominal component separation techniques, biomaterials, and synthetic material.

RESULTS

Six children underwent tissue expansion for treatment of abdominal wall defects (omphalocele, n = 3), trauma (n = 1), and thoracopagus twins (n = 1 pair). One to 4 expanders were used per patient, with all having a successful reconstruction of their abdominal walls. Two to 3 operations were required to restore abdominal domain and consisted of expander insertion, removal with reconstruction, and possible revision of the reconstruction.

CONCLUSIONS

Tissue expanders possess a broad range of applications for abdominal wall reconstruction and can be used in patients of all ages.

NUT midline carcinoma in a newborn with multiorgan disseminated tumor and a 2-year-old with a pancreatic/hepatic primary

NUT midline carcinoma (NMC) is a rare and aggressive malignant epithelial tumor defined by rearrangement of the NUT gene on chromosome 15. In two thirds of cases, NUT is involved in a balanced translocation with BDR4 on chromosome 19, while in the remaining cases, NUT is rearranged with variant fusion partners such as BRD3. These undifferentiated tumors primarily affect midline structures, usually in the upper aerodigestive tract and mediastinum. Most reported cases have followed a rapidly lethal clinical course. We report the clinical and pathological findings of NMC in the youngest patients identified so far. The 1st case involves a newborn who presented with a supraorbital mass and extensive multiorgan involvement, including the spine, lungs, liver, pancreas, adrenal glands, and subcutaneous tissue. The 2nd patient was a 2-year-old male with an abdominal mass involving the liver and pancreas with pulmonary metastasis. Histopathological analysis of both tumors showed undifferentiated malignant neoplasms, and immunohistochemistry showed positivity for epithelial markers. Both tumors demonstrated t(15;19), and immunohistochemistry with NUT monoclonal antibodies and fluorescent in situ hybridization confirmed NUT rearrangement. The patients died from disease at 1 and 2 months postpresentation. Thus far, 25 cases have been reported, including our 2 current cases. Presentation ages range from 0 to 78 years (mean, 23 years). Herein, we report the 2 youngest reported cases of NMC, including the 1st congenital case and the 1st case arising within the liver/pancreas. Increased awareness and further molecular studies are required for a better understanding of NMC pathobiology and improved therapeutic outcomes.

Role of hepatic portocholecystostomy ('gallbladder Kasai') in treating infants with biliary atresia

The aim of this study is to compare liver function and cholangitis episodes during the first year postoperatively between patients who undergo hepatic portocholecystostomy (HPC) and patients who undergo hepatic portoenterostomy (HPE). Records of six patients who underwent HPC for biliary atresia (BA) and 27 patients who underwent HPE for BA were reviewed retrospectively. Comparison was done of the patient's total bilirubin, albumin, and international normalized ratio values preoperatively and at 3 months, 6 months, and 1 year postoperatively. Comparison was also done of the occurrence of ascending cholangitis during the first year postoperatively and in rates of transplant and mortality during long-term follow-up. Preoperative laboratory values between the two groups were not significantly different. At 6 months, the patients who underwent HPC had significantly lower total bilirubin levels compared with those who underwent HPE (HPC 0.8 +/- 0.96, n = 4; HPE 4.93 +/- 7.73, n = 21; P < 0.05). No other laboratory values or rates of ascending cholangitis, transplant, or mortality showed a significant difference. Those patients who underwent HPC had significantly lower total bilirubin levels at 6 months postoperatively. This may suggest that HPC may be a superior operative technique for patients who are candidates for the operation.

Role of Hepatic Portocholecystostomy (‘Gallbladder Kasai’) in Treating Infants with Biliary Atresia

The aim of this study is to compare liver function and cholangitis episodes during the first year postoperatively between patients who undergo hepatic portocholecystostomy (HPC) and patients who undergo hepatic portoenterostomy (HPE). Records of six patients who underwent HPC for biliary atresia (BA) and 27 patients who underwent HPE for BA were reviewed retrospectively Comparison was done of the patient's total bilirubin, albumin, and international normalized ratio values preoperatively and at 3 months, 6 months, and 1 year postoperatively. Comparison was also done of the occurrence of ascending cholangitis during the first year postoperatively and in rates of transplant and mortality during long-term follow-up. Preoperative laboratory values between the two groups were not significantly different. At 6 months, the patients who underwent HPC had significantly lower total bilirubin levels compared with those who underwent HPE (HPC 0.8 ± 0.96, n = 4; HPE 4.93 ± 7.73, n = 21; P < 0.05). No other laboratory values or rates of ascending cholangitis, transplant, or mortality showed a significant difference. Those patients who underwent HPC had significantly lower total bilirubin levels at 6 months postoperatively. This may suggest that HPC may be a superior operative technique for patients who are candidates for the operation.

Bedside placement of an aortic occlusion balloon to control a ruptured aorto-esophageal fistula in a small child

A child had a percutaneous endoscopic gastrostomy tube removed by transecting it at skin level. The internal portion ("the bolster") was allowed to pass in the GI tract. She subsequently had odynophagia. Magnetic resonance imaging identified a foreign body within the lower thoracic esophagus. During esophagoscopy, the bolster was removed. The following morning, she had massive hematemesis with cardiovascular collapse. As an emergent maneuver, an intra-aortic balloon was percutaneously deployed at the bedside without fluoroscopic guidance. This temporized the exsanguination. Subsequent intraoperative aortography confirmed an aortoesophageal fistula. A stent-graft was deployed with immediate hemodynamic stabilization. She later underwent esophageal resection and recovered well.

Pseudoangiomatous stromal hyperplasia of the breast in pediatric patients: an underrecognized entity

Pseudoangiomatous stromal hyperplasia (PASH) is a benign lesion consisting of mammary stromal proliferation with anastomosing slits mimicking vascular spaces. Grossly, it most often resembles fibroadenoma, but may commonly be confused with angiosarcoma and other types of benign vascular proliferations. While PASH has been described in female and male adults since the mid-1980s, there have been only a few accounts in the pediatric population. We present a series of 12 pediatric patients with PASH, including a 3-year-old male, who we believe to be the youngest patient to present with this entity. In our study, PASH was found in 12% of tumors diagnosed preoperatively as fibroadenomas and in 12% of cases diagnosed preoperatively as gynecomastia. Our series documents that PASH is not uncommon in pediatric breast pathology and delineates important differences between adult and pediatric presentations of this entity.

Unusual presentation of ovarian cellular fibroma coexisting with nodular sclerosing Hodgkin's disease: a case report and review of the literature

A case of a nonfunctioning, noncalcified ovarian cellular fibroma in a 15-year-old adolescent girl is described. The fibroma was found incidentally in a patient who was later found to have nodular sclerosing Hodgkin's disease. The patient presented with symptoms suggestive of lymphoma but on exam was found to have a mobile and nontender abdominal mass. Laparotomy exposed a smooth, well-circumscribed left ovarian mass. A left salpingoophorectomy was performed. The mass weighed 2390 g and measured 19 x 15 x 8.5 cm. Approximately 15% of the tumor was composed of large cellular nodules identified as spindle cells having a storiform pattern. Mild nuclear atypia with 2 mitosis per 10 high-power fields was noted. An ovarian fibroma in a 15-year-old is an unexpected diagnosis. Less than 1% of ovarian stromal tumors are found in patients 19 years and younger. The uncommon histology and additional classification as a cellular fibroma as well as the simultaneous diagnosis of 2 neoplasms in this case are remarkable.

Primary ovarian rhabdomyosarcoma in children

Although rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children, primary rhabdomyosarcomas of the ovary are extremely rare, with only eight well-documented pediatric cases previously reported in the literature. We present two additional cases: an alveolar RMS originating in the right ovary with metastatic spread to the splenic flexure of the colon and to both lungs in a 13-year-old African American girl, and an embryonal RMS arising in the right ovary of a 6-year-old Caucasian girl with pre-operative intra-abdominal rupture and a malignant right pleural effusion. Both patients had complete resection of their primary tumors and received chemotherapy including vincristine, doxorubicin and cyclophosphamide with good response to therapy. Both are alive 8 and 9 months post-operatively.

Congenital spigelian hernias and cryptorchidism

PURPOSE

Spigelian hernias in childhood are rare. Only 24 infants in the English literature have been identified to have spigelian hernias, and 12 of these have been associated with cryptorchidism. Spigelian hernias are more commonly seen in the adult population and are considered to be acquired because they are typically associated with trauma or other etiologies of increased intraabdominal pressure. In the infant however, the etiology remains unclear, but a congenital defect in abdominal wall development is suspected.

METHODS

We discuss the presentation and treatment of 4 additional patients with spigelian hernias (2 siblings included) associated with cryptorchidism.

RESULTS

The hernias occurred within the well-described spigelian hernia belt in the semilunar line at the level of the semicircular fold of Douglas. Of the 6 repaired spigelian hernias, 5 were closed primarily with absorbable suture similar to previously reported cases; the sixth hernia required a patch closure because of its large size. All cryptorchid testes (7) were repaired in single-stage orchiopexies.

CONCLUSIONS

Spigelian hernias are rare entities in infants. We present 4 new cases of spigelian hernias associated with cryptorchidism and, with previously reported cases, discuss the probability of a congenital origin of these hernias in infants.

Antireflux surgery outcomes in pediatric gastroesophageal reflux disease

OBJECTIVES

Antireflux surgery is performed frequently in children with gastroesophageal reflux disease (GERD). Few comparative studies exist which assess the indications for and short- or long-term outcome of open Nissen fundoplication (ONF) and laparoscopic Nissen fundoplication (LNF) for pediatric GERD. We investigated the frequency of reoperation and factors that might influence its occurrence.

METHODS

We performed a retrospective, follow up cohort study of all children </=5 years, who underwent LNF or ONF at our institution from January 1, 1997 to December 31, 2002, where five pediatric surgeons perform fundoplication. Mean follow up time was 36.2 months. The following information was obtained: surgical indications, hospital course data, and long-term surgical outcomes. Data were analyzed using univariate and multiple logistic regressions.

RESULTS

Overall, 456 (150 [32.9%] ONF vs. 306 [67.1%] LNF) cases were analyzed. Reoperation was performed in 55 (12.06%), LNF 43 (14.05%), and ONF 12 (8%). The mean interim to reoperation for LNF was 11 months compared to 17 months for ONF (p= 0.007). The reoperation rate at 12 and 24 months were 10.5%, 13.4% and 4%, 6.7% respectively, when LNF was compared to ONF (p= 0.01). The multivariate analysis showed that initial LNF and prematurity were the main predictors for reoperation.

CONCLUSIONS

The majority of reoperations for both LNF and ONF occurred in the first year after initial operation; LNF had a significantly higher reoperation rate than ONF. The probability of reoperation for LNF and ONF increases with the presence of comorbidities, especially prematurity and chronic respiratory conditions.

Postoperative outcomes of extremely low birth-weight infants with necrotizing enterocolitis or isolated intestinal perforation: a prospective cohort study by the NICHD Neonatal Research Network

OBJECTIVE

Purposes of this study were: 1) to compare mortality and postoperative morbidities (intra-abdominal abscess, wound dehiscence, and intestinal stricture) in extremely low birth weight (ELBW) infants who underwent initial laparotomy or drainage for necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP); 2) to determine the ability to distinguish NEC from IP preoperatively and the importance of this distinction on outcome measures; and 3) to evaluate the association between extent of intestinal disease determined at operation and outcome measures.

BACKGROUND

ELBW infants who undergo operation for NEC or IP have a postoperative, in-hospital mortality rate of approximately 50%. Whether to perform laparotomy or drainage initially is controversial. Also unknown is the importance of distinguishing NEC from IP and the current ability to make this distinction based on objective data available prior to operation.

METHODS

A prospective, multicenter cohort study of 156 ELBW infants at 16 neonatal intensive care units (NICU) within the NICHD Neonatal Research Network.

RESULTS

Among the 156 enrolled infants, 80 underwent initial peritoneal drainage and 76 initial laparotomy. Mortality rate was 49% (76 of 156). Ninety-six patients had a preoperative diagnosis of NEC and 60 had presumed IP. There was a high level of agreement between the presumed preoperative diagnosis and intraoperative diagnosis in patients undergoing initial laparotomy (kappa = 0.85). The relative risk for death with a preoperative diagnosis of NEC (versus IP) was 1.4 (95% confidence interval, 0.99-2.1, P = 0.052). The overall incidence of postoperative intestinal stricture was 10.3%, wound dehiscence 4.4%, and intra-abdominal abscess 5.8%, and did not significantly differ between groups undergoing initial laparotomy versus initial drainage.

CONCLUSIONS

Survival to hospital discharge after operation for NEC or IP in ELBW neonates remains poor (51%). Patients with a preoperative diagnosis of NEC have a relative risk for death of 1.4 compared with those with a preoperative diagnosis of IP. A distinction can be made preoperatively between NEC and IP based on abdominal radiographic findings and the patient's age at operation. Future randomized trials that compare laparotomy versus drainage would likely benefit from stratification of treatment assignment based on preoperative diagnosis.

Gastrointestinal stromal tumors arising from the stomach: a report of three children

BACKGROUND

Gastrointestinal stromal tumors (GIST) are a unique subset of intestinal mesenchymal tumors that behave in an aggressive fashion. They have been commonly described in adults but have been rarely observed in children.

METHODS

The authors review the presentation, diagnostic workup, operative records, pathologic specimens, and outcomes of 3 children with GISTs that originated from the stomach.

RESULTS

All 3 children presented after upper gastrointestinal bleeding from the gastric tumor. The first was a 10-year-old girl who underwent partial gastrectomy but had recurrence 8 years later requiring a second resection. She subsequently had a hepatic metastasis 8 years later requiring a third resection. The second patient was a 9-year-old girl who had an antrectomy with a Bilroth I reconstruction and was noted to have a synchronous liver metastasis that was also resected. Despite Imatinib Mesylate, she had further hepatic metastases. The third child was a 4-year-old boy who recently underwent a partial gastrectomy and has no signs of metastatic disease at this time.

CONCLUSIONS

GISTs are unusual tumors that have been rarely described in children. When they arise in the stomach, they often present after upper gastrointestinal bleeding. Diagnosis can be made by endoscopy and biopsy. GISTs require resection and close observation for hepatic metastases. Current studies are ongoing for the potential role of Imatinib Mesylate for GISTs in children.

Lymphangioma of the falciform ligament--a case report

A rare case of a lymphangioma of the falciform ligament in a child is described. He presented with abdominal pain and was found to have an unusual intraabdominal mass. Resection was curative.

Pediatric blunt trauma resulting in major arterial injuries

Ten children, aged 4 to 14 years, sustaining blunt arterial trauma from motor vehicle collisions (6), bicycle accidents (2), and falls (2) were identified over a 10-year period. The arteries injured included the common iliac (3), abdominal aorta (2), carotid (2), brachial (2), and the subclavian, renal, and femoral artery (1 each). One patient had three arterial injuries. Six patients had associated injuries including a pelvic and lumbar spine fracture, Horner's syndrome, liver laceration, skull fracture, open humerus fracture, small bowel serosal tear, and a brachial plexus injury. Definitive diagnosis was made using arteriography (6), computed tomography (CT) scan (2), and physical examination (2). The types of arterial injuries found included incomplete transection, complete transection with pseudo-aneurysm formation, traumatic arteriovenous (AV) fistulas, complete occlusion, and dissection. Repair was accomplished by hypogastric artery interposition or bypass grafting, synthetic grafting with polytetrafluoroethylene (PTFE), reverse saphenous vein grafting, or primary repair, depending on the circumstances. An AV fistula between the carotid artery and cavernous sinus was embolized. All grafts remained patent with exception of the aorto-renal bypass graft at follow-up ranging from 1 month to 3 years. The principles for repairing vascular injuries in children are slightly different than those in adults. Every effort should be made to use autogenous tissue such as the hypogastric artery or saphenous vein for repair if possible. If not, PTFE grafts can be used, although the long-term patency of these grafts in growing children is not known.

Pediatric Blunt Trauma Resulting in Major Arterial Injuries

Ten children, aged 4 to 14 years, sustaining blunt arterial trauma from motor vehicle collisions (6), bicycle accidents (2), and falls (2) were identified over a 10-year period. The arteries injured included the common iliac (3), abdominal aorta (2), carotid (2), brachial (2), and the subclavian, renal, and femoral artery (1 each). One patient had three arterial injuries. Six patients had associated injuries including a pelvic and lumbar spine fracture, Horner's syndrome, liver laceration, skull fracture, open humerus fracture, small bowel serosal tear, and a brachial plexus injury. Definitive diagnosis was made using arteriography (6), computed tomography (CT) scan (2), and physical examination (2). The types of arterial injuries found included incomplete transection, complete transection with pseudo-aneurysm formation, traumatic arteriovenous (AV) fistulas, complete occlusion, and dissection. Repair was accomplished by hypogastric artery interposition or bypass grafting, synthetic grafting with polytetrafluoroethylene (PTFE), reverse saphenous vein grafting, or primary repair, depending on the circumstances. An AV fistula between the carotid artery and cavernous sinus was embolized. All grafts remained patent with exception of the aorto-renal bypass graft at follow-up ranging from 1 month to 3 years. The principles for repairing vascular injuries in children are slightly different than those in adults. Every effort should be made to use autogenous tissue such as the hypogastric artery or saphenous vein for repair if possible. If not, PTFE grafts can be used, although the long-term patency of these grafts in growing children is not known.

Surgical complications of inguinal and abdominal wall hernias

Inguinal and other abdominal wall hernias are some of the most commonly encountered problems in the pediatric population that require surgical intervention. Surgical repair is straightforward in most cases and can be performed on an outpatient basis. Complications are unusual, but potentially devastating. This article focuses specifically on incidence and risk factors of these complications, reviews the currently accepted treatment options, and points out strategies to avoid them.

Management of congenital esophageal stenosis

BACKGROUND/PURPOSE

The authors report the incidence, diagnosis, and treatment methods of congenital esophageal stenosis (CES) at their institution.

METHODS

A retrospective analysis of 123 patients with tracheoesophageal anomalies in a pediatric hospital between 1980 and 1999 was performed. Charts were reviewed for patient demographics, presence of true CES, associated congenital anomalies, method of diagnosis, methods of treatment, and histopathology.

RESULTS

Six of the 123 patients (4.9%) had true CES (one patient had 2 separate stenoses). Two patients had isolated CES, one patient had CES with isolated tracheoesophageal fistula (TEF), one patient had CES with isolated esophageal atresia (EA), and 2 patients had CES with EA/TEF. Diagnoses were made with an upper gastrointestinal (GI) contrast study in 5 patients, and one patient had one of 2 stenoses diagnosed by prenatal ultrasound and the other diagnosed intraoperatively. Four of the 7 stenoses were treated with surgical resection, and the remainder was treated with esophageal dilatation. Histopathology from the 4 resected stenoses showed tracheobronchial remnants in 3 specimens and submucosal thickening in 1 specimen.

CONCLUSIONS

Although isolated CES is rare (2 of 123 = 1.6%), CES associated with other tracheoesophageal anomalies has a higher incidence (4 of 123 = 3.25%). Patients with this lesion should be treated first with dilatation. If ineffective, resection is required.

Leiomyoma at the site of esophageal atresia repair

Esophageal leiomyomas are rare in the pediatric population. They frequently occur in association with other anomalies, such as Alport's syndrome, osteoarthropathy, and leiomyomas elsewhere in the body. The authors describe the case of a focal esophageal leiomyoma in a 12-month-old girl with a history of long-gap esophageal atresia. The patient initially underwent bouginage of the proximal pouch while awaiting definitive repair. After esophageal repair, the patient required multiple dilatations for anastomotic strictures. A segmental resection of the esophagus was performed because of recurrent strictures. A leiomyoma, arising from the site of the previous esophageal atresia repair, was noted on histologic evaluation. Esophageal leiomyomas have not been reported previously in a child with esophageal atresia. J Pediatr Surg 36:1832-1833.

Clinical management of anterior mediastinal tumors in children

The majority of anterior mediastinal tumors in children are malignant. The most common tumors in this location are lymphomas, germ cell tumors, and thymic masses. Most require an operation, either a biopsy or a resection, for cure. Because of their size and location, patients with these masses are at significant risk for cardiopulmonary complications when general anesthesia is administered. Of the many clinical, functional, and radiologic criteria used to identify the children at greatest risk for anesthetic complications, the peak expiratory flow rate (PEFR) and the tracheal cross-section area seem to be the most reliable. General anesthesia should not be administered to children if the PEFR and a tracheal cross section area are both less than 50% of predicted values. If both are greater than 50% of predicted values, general anesthesia can be administered safely. An algorithm is proposed for the preoperative evaluation and management of children with anterior mediastinal tumors.

Kasai portoenterostomy: differences related to race

PURPOSE

The aim of this study was to evaluate the Kasai portoenterostomy in African-American and white children with respect to differences in presentation and outcome.

METHODS

A retrospective review of all children with biliary atresia who underwent a portoenterostomy at our institution over the last 15 years (n = 63) was performed. Sex, age at the time of Kasai, preoperative laboratory tests, success rates (defined as postoperative total serum bilirubin < or = 2.0 mg/dL), and survival rate were recorded. Differences between African-American (AA; n = 30) and white (W; n = 33) children were analyzed. Long-term follow-up was available on 59 of 63 patients.

RESULTS

Sixty-three percent of all patients (40 of 65) were girls, and 48% were AA (30 of 63). A higher percentage of AA children (73%) were girls than were white children (55%), although this difference did not achieve statistical significance. African-Americans underwent portoenterostomy at a later age, had higher alkaline phosphatase levels, and higher AST. These differences were statistically significant. Preoperative ALT, total bilirubin level, and GGTP levels all were greater in African-Americans, although these differences did not achieve statistical significance. There was a trend toward decreased success and survival rate, although these results also were not statistically significant.

CONCLUSIONS

African-Americans underwent primary therapeutic intervention for biliary atresia at an older age than white children with a trend toward less favorable results. These differences related to race may be attributed to greater difficulty in diagnosing jaundice or poorer access to health care in this patient population. Increased effort at identifying biliary atresia in AA children may lead to earlier diagnosis and treatment and improved outcomes.

Statistical models to predict the need for postoperative intensive care and hospitalization in pediatric surgical patients

OBJECTIVE

To develop statistical models for predicting postoperative hospital and ICU stay in pediatric surgical patients based on preoperative clinical characteristics and operative factors related to the degree of surgical stress. We hypothesized that preoperative and operative factors will predict the need for ICU admission and may be used to forecast the length of ICU stay or postoperative hospital stay.

DESIGN

Prospective data collection from 1,763 patients.

SETTING

Tertiary care children's hospital.

PATIENTS AND PARTICIPANTS

All pediatric surgical patients, including those undergoing day surgery. Patients undergoing dental or ophthalmologic surgical procedures were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

A logistic regression model predicting ICU admission was developed from all patients. Poissonregression models were developed from 1,161 randomly selected patients and validated from the remaining 602 patients. The logistic regression model for ICU admission was highlypredictive (area under the receiver operating characteristics (ROC) curve = 0.981). In the data set used for development of Poisson regression models, significant correlations occurred between the observed and predicted ICU stay (Pearson r = 0.468, p < 0.0001, n = 131) and between the observed and predicted hospital stay for patients undergoing general (r = 0.695, p < 0.0001), orthopedic (r = 0.717, p < 0.0001), cardiothoracic (r = 0.746, p < 0.0001), urologic (r = 0.458, p < 0.0001), otorhinolaryngologic (r = 0.962, p < 0.0001), neurosurgical (r = 0.7084, p < 0.0001) and plastic surgical (r = 0.854, p < 0.0001) procedures. In the validation data set, correlations between predicted and observed hospital stay were significant for general (p < 0.0001), orthopedic (p < 0.0001), cardiothoracic (p = 0.0321) and urologic surgery (p = 0.0383). The Poisson models for length of ICU stay, otorhinolaryngology, neurosurgery or plastic surgery could not be validated because of small numbers of patients.

CONCLUSIONS

Preoperative and operative factors may be used to develop statistical models predicting the need for ICU admission in pediatric surgical patients, and hospital stay following general surgical, orthopedic, cardiothoracic and urologic procedures. These statistical models need to be refined and validatedfurther, perhaps using data collection from multiple institutions.

An unusual case of meconium peritonitis associated with perforated hydrocolpos

Meconium peritonitis results from intestinal wall perforation with meconium spillage into the peritoneum during intrauterine life. Anal atresia is associated with meconium peritonitis and is also associated with cloacal malformation. A female neonate presented with a distended abdomen, anal atresia, and meconium peritonitis as diagnosed by calcification in the peritoneal cavity on abdominal radiograph. Sonography and cystography demonstrated a cloacal malformation with perforation of the hydrocolpos and resultant spillage of meconium into the peritoneum. There was no evidence of further perforation of bowel at surgery. This unusual case of meconium peritonitis is reported.

The Kasai portoenterostomy: when is it too late?

BACKGROUND/PURPOSE

Kasai portoenterostomy is recommended as the primary initial therapy for extrahepatic biliary atresia if the procedure can be performed within 10 to 12 weeks of life. The optimal management for infants with delayed presentation of biliary atresia remains controversial. The purpose of this study was to determine the success rate and outcome for patients who underwent a "late" Kasai portoenterostomy.

METHODS

The authors conducted a retrospective review of the medical records of all patients with biliary atresia who underwent a Kasai portoenterostomy at their institution from 1986 to 1999 (n = 31). The authors analyzed success rates compared with age at the time of the Kasai procedure and the association with patient demographics. Surgical success was defined as achievement of a total serum bilirubin < or = 2 mg/dL. Long-term follow-up assessments included the need for liver transplantation and patient survival rate.

RESULTS

The demographics of this study cohort showed a predominance of African-Americans, 19 of 31 (61%), and girls, 23 of 31 (74%). Assessment of success compared with subject age at the time of the initial portoenterostomy showed that 52% (13 of 25) had successful Kasai procedure at 0 to 75 days, compared with 83% success rate (5 of 6) at age 76 days or older (P = .359). Liver transplantation was performed in 16 of 31 patients (45%). Overall survival rate for the entire cohort is 23 of 31 (74%), whereas 12 of 31 (39%) are currently alive without a liver transplant.

CONCLUSION

These data suggest that there is no contraindication to performing a Kasai portoenterostomy for biliary atresia in children over 75 days of age.

Esophageal atresia in infants with very low birth weight

Infants with esophageal atresia (EA), with or without a tracheoesophageal fistula (TEF) frequently are of low birth weight. With advances in neonatal, respiratory, surgical, and anesthetic care, more infants with very low birth weight (VLBW; birth weight less than 1.5 kg) are surviving. The therapy of the VLBW neonate with EA is not longer automatically staged. Primary or delayed primary anastomosis can be performed safely if the patient is stable. This report will review the epidemiology, pathophysiology, treatment, and prognosis of EA in VLBW infants. The authors present their own experience in dealing with the VLBW with EA and review the world literature.

Resuscitation of the surgical neonate

This article reviews the general principles of resuscitation of a neonate with a surgical disorder. These principles include careful attention to critical management issues of the airway, ventilation, perfusion, nutritional support and thermogenesis. In addition, a variety of surgical disorders in the neonatal period are discussed. For each disorder, early recognition of presentation patterns, efficient work-up strategy, initial management steps, and basic surgical principles are stressed. This framework can provide a basis for successful cooperation between the neonatologist and the pediatric surgeon for the initial care of the neonate requiring surgery.

Use of the aortic homograft in the reconstruction of complex tracheobronchial tree injuries

BACKGROUND/PURPOSE

The repair of complex tracheobronchial tree injuries often is associated with complications including stenosis and excessive granulation tissue formation. Patch reconstruction using pericardium or synthetic material decreases the incidence of stenosis. The authors report on the use of the ascending aorta cryopreserved homograft in reconstructing the tracheobronchial tree of three children.

RESULTS

A 10 year old had a through-and-through gun shot wound to the left main stem bronchus with cartilaginous loss. A 12 year old double lung transplant recipient had a breakdown of one bronchial anastomosis after stent placement. A 1 year old had an acquired tracheoesophageal fistula secondary to a long standing foreign body. In all three patients, the aortic patches were secured with interrupted sutures. All three had uneventful recoveries, and postoperative bronchoscopy showed the patches to be completely covered with epithelium without stenosis or granulation tissue.

CONCLUSIONS

This is the first report of the use of the cryopreserved ascending aorta homograft in the reconstruction of the tracheobronchial tree. The homograft is strong yet malleable. It gets completely covered with epithelium and results in no stenosis because of the lack of tension. These characteristics make it an attractive alternative for the patch reconstruction of complex tracheobronchial tree injuries.

Neonatal gastric perforation and necrosis with Hunt-Lawrence pouch reconstruction

This report describes a newborn infant girl who presented with abdominal distension and pneumoperitoneum. At operation, near total necrosis of the stomach was observed. The esophagus was ligated, the stomach resected. The baby was fed by an transpyloric feeding tube. At 8 weeks, an esophagojejunal anastomosis was performed with a Hunt-Lawrence Pouch. A good outcome was achieved.

Mesenchymal hamartoma of the liver

Mesenchymal hamartomas of the liver are the second most common benign liver tumor of childhood. The experience with this tumor at Egleston's Children Hospital at Emory University from 1989 to 1994 is reviewed. Eight patients presented with abdominal distention or an upper abdominal mass. Six patients presented at a mean age of 8 months, and two patients presented at 17 and 23 years of age, respectively. Four patients displayed normal alpha-fetoprotein levels, whereas one patient had an elevated level. Liver function studies were normal in all patients. Abdominal ultrasonography and CT scans revealed a cystic, septated mass within the liver or on a pedicle in all patients. Five patients had simple excision of the tumor, and two had major hepatic resections. The cysts were multiloculated and lined with cuboidal bile duct epithelium surrounded by stroma containing proliferating bile ducts, blood vessels, and compressed liver tissue with no calcifications. In one patient, some pathologists favored the diagnosis of malignant myxoid fibrous histiocytoma because of similar-appearing stroma. Follow-up (mean, 35 months) revealed one symptomatic recurrence after initial resection was incomplete. There were no other recurrences and no malignant transformations. A septated, noncalcified, cystic hepatic mass in an infant with normal liver function studies and characteristic ultrasound or CT is likely a benign mesenchymal hamartoma that can be cured by total local excision.

Presacral neuroenteric fistula presenting with meningitis and vaginal fistula: a case report

Neuroenteric fistulas are rare congenital malformations arising from a persistent connection between the embryonic neural and intestinal tissues; they are extremely rare in the lumbosacral area. Neuroenteric fistulas should be suspected whenever children present with anaerobic meningitis in the absence of brain abscesses or respiratory infections. This patient is the first patient who presented with a presacral cyst that separately connected to the nervous system and the vagina. It is thought that the rape of this 12-year-old patient resulted in soilage of the spinal fluid through dual fistulae, causing anaerobic meningitis without an abscess.

A modification of the Bianchi intestinal lengthening procedure with a single anastomosis

BACKGROUND/PURPOSE

Intestinal lengthening, as described by Bianchi, is the most commonly used method of gastrointestinal reconstruction for the therapy of short bowel syndrome. It divides the bowel in two longitudinal halves based on the bifurcated mesenteric blood supply, then reconnects the two halves in series with the rest of the small intestine. This requires three end-to-end narrow anastomoses in addition to the two longitudinal sutures lines. The authors describe a modification of the Bianchi procedure that lengthens the small intestine with a single wide end-to-end anastomosis thus avoiding two suture lines and their potential complications.

METHODS

The anatomic principle used in this modification is the same as that described by Bianchi. The mesentery is separated based on the bifurcated vessels. With sequential firings of the stapler, the division of the intestine begins obliquely, proceeds longitudinally as in the Bianchi procedure, then ends obliquely at the other end of the intestine. This results in two divided segments that remain attached to the proximal and distal intestine and end in tapered staple lines. The two ends are sewn into a wide tapered anastomosis, reestablishing intestinal continuity with a single anastomosis instead of three.

CONCLUSIONS

This simple modification, which we have used on two patients so far, decreases the number of anastomoses in an intestinal lengthening procedure from three narrow ones to one that is wider and tapered, thus reducing the risk of leaks and strictures. Because the end result is a lengthened intestinal segment similar to the Bianchi procedure, it should be equally effective in the therapy of short bowel syndrome.

Prosthetic patch stabilization of crural repair in antireflux surgery in children

Nissen fundoplication is a frequently performed procedure by pediatric surgeons for the treatment of gastroesophageal reflux. Reoperation for failed fundoplication is necessary in 10 per cent of children and in 25 per cent of neurologically impaired children. In an attempt to reduce the postoperative recurrence of gastroesophageal reflux and wrap herniation, we have modified our Nissen fundoplication by reinforcing the crural repair with a horseshoe-shaped prosthetic patch. Between 1993 and 1995, 38 children underwent a Nissen fundoplication with prosthetic patch crural repair. Tension-free crural repair was performed over an esophageal dilator by suturing a horseshoe-shaped Dacron patch posterior to the esophagus. After crural repair, the standard Nissen 360 degrees wrap was constructed. Of the 38 children, 56 per cent (n = 21) were neurologically impaired. In 18 per cent of patients, the operation was performed for recurrent reflux due to wrap herniation after a Nissen fundoplication without prosthetic patch repair. One child required esophageal dilatation postoperatively for dysphagia related to esophageal stenosis. After a mean follow-up of 15 months, all patients were without symptomatic reflux or had no radiographic evidence of recurrent reflux or wrap herniation. Tension-free crural repair with a prosthetic patch may decrease postoperative reflux and wrap herniation, particularly in neurologically impaired children and in children requiring reoperation for recurrent reflux.

Fetus-in-fetu with malignant recurrence

Fetus-in-fetu is an unusual condition in which a vertebrate fetus is enclosed within the abdomen of another fetus. These occurrences are usually benign. This report describes an instance of malignant recurrence after resection of a fetus-in-fetu.

Inflammatory pseudotumor of the spleen in a young child

We describe a case of an inflammatory pseudotumor of the spleen in a 5-year-old boy, found incidentally during a physical examination. The boy underwent a hemisplenectomy. The problems in differentiating this disease from lymphoma of the spleen before surgery and the advantages of hemisplenectomy are discussed. This rare disease has previously been described in the spleen in only 28 cases, the youngest being a 16-year-old patient.

Mesenteric and omental cysts in children

Mesenteric and omental cysts are rare intra-abdominal lesions. The rarity of these lesions, with an incidence of only about 1 in 140,000 hospital admissions, and the absence of characteristic clinical findings makes diagnosis difficult. Fourteen patients were treated for either mesenteric and/or omental cysts between 1965 and 1994 at Egleston Children's Hospital at Emory University. Of the 14 patients, 6 were female, 8 male; 3 were non-Caucasian, and 11 were Caucasian. They ranged in age from in-utero to 12 years old, with the most common presenting symptoms being abdominal distention (71%), pain (50%), vomiting (50%), and pain and distention (43%). Ultrasonography was the diagnostic method of choice. Other diagnostic modalities included intravenous pyelogram, barium enema, upper gastrointestinal series, CT scan, and MRI in selected patients. A single mesenteric cyst (79%) was most common, with only one patient (7%) having multiple mesenteric cysts as well as an omental cyst. The remaining two patients (14%) had single omental cysts. On gross examination, most (64%) were single, multilocular cysts. On pathological examination, the cysts ranged in size from 3.5 x 1 x 0.2 cm to 30 x 40 x 10 cm, with a mean of 14.9 x 11.5 x 4.7 cm. Six of the 14 contained fluid consistent with hemorrhage into the cysts. The most common treatment was simple excision (71%) followed by excision with partial bowel resection (29%). None received drainage alone as a treatment. There were no major postoperative complications and no reported recurrences of the cysts.

Current urologic management of cloacal exstrophy: experience with 11 patients

PURPOSE

Since 1980 the authors have treated 12 infants with cloacal exstrophy (10 classical and 2 variants). Eleven patients had repair, and are all surviving. The initial phases of management that led to improved survival have previously been reported. Quality of life is now a major focus for the cloacal exstrophy patient. During the past 10 years, nine of the 11 patients had lower urinary tract reconstructive procedures. This review evaluates experience with reconstructive efforts to achieve bowel and bladder control and to improve the quality of life in this complex group of patients.

METHODS

Through review of patient charts and by patient interviews, data were collected to evaluate the ability to provide urinary and bowel control. A continence score was applied to provide a measure of success: voluntary control, 3; control with an enema program or intermittent catheterization, 2; incontinence with a well-functioning stoma, 1; and incontinence without a stoma, 0. The best continence score is 6 (genitourinary and gastrointestinal). Surgical complications, urodynamic and metabolic sequelae of continent urinary diversion were reviewed.

RESULTS

At the time of the authors' previous report, eight of 11 patients had a continence score of 2 or less. Currently, eight of 11 patients have a score of 3 or better (five with enteric stoma and continent urinary diversion, two with enema program and continent urinary diversion, and one with enema program and continent bladder). Urinary-diversion procedures have included two gastric augmentations and five gastric reservoirs, two of which have required subsequent bowel augmentation. Gastric augmentations carry a definite risk of metabolic problems with three of our patients demonstrating significant episodes of metabolic alkalosis. In addition, results of urodynamic monitoring suggests that gastric reservoirs may be less compliant than reservoirs formed using other bowel segments.

CONCLUSIONS

Modern principles of continent urinary diversion have been successfully applied to the cloacal exstrophy patient further improving their quality of life. Use of gastric flaps with preservation of intestinal length has been central to urologic reconstructive efforts. Use of stomach alone for formation of urinary reservoirs may produce suboptimal compliance, and composite ileogastric construction should be considered if the gastric flap is of marginal size.

Management of biliary tract stones in heart transplant patients

OBJECTIVE

The authors report their experience with biliary tract stones in adult and pediatric heart transplant patients, and review the current literature relative to this problem.

SUMMARY BACKGROUND DATA

Prior studies in adults have noted that heart transplant patients frequently have cholelithiasis, but offer no consensus about treatment strategy. Few studies exist for pediatric heart transplant patients. A higher rate of hemolysis and cyclosporine-induced changes in bile metabolism may contribute to lithogenesis in this population.

METHODS

A chart review was conducted for 211 patients who had heart transplants between January 1988 and September 1994 to determine prevalence of biliary tract stones, management strategies used, and outcome.

RESULTS

Of 175 long-term heart transplant survivors, 52 (29.7%) had stones detected: 32.8% of adults (47/143) and 15.6% of children (5/32). The majority of patients (31) were diagnosed 4 months (mean) after transplantation; cholelithiasis developed in 10 of these patients (32%) within 11 months (median) after a negative ultrasound. Symptoms developed in 45% of patients. All patients underwent either elective (36) or urgent (6) cholecystectomy via an open (32) or laparoscopic (10) approach, or endoscopy for common bile duct stones (2). There were no deaths or complications during a follow-up period of up to 7 years.

CONCLUSION

Heart transplant patients have a high prevalence of symptomatic biliary tract stone disease. They can be treated safely via an open or laparoscopic approach after transplantation. The authors recommend routine gallbladder ultrasound screening and elective cholecystectomy in the post-transplant period if stones are detected.

Idiopathic fibrosing pancreatitis: a rare cause of obstructive jaundice in children

Idiopathic fibrosing pancreatitis is a rare cause of obstructive jaundice in children and young adults. Only 30 cases have been previously reported. Four children with this entity have been treated at Egleston Children's Hospital at Emory University since 1970. Diagnosis was established by imaging studies and open pancreatic biopsy. Treatment was by bilioenteric bypass, and excellent results have been achieved with follow-up periods up to 25 years.

Choledochal cysts: a ten year experience

Choledochal cyst (CC) is a rare disorder that usually presents in childhood. Prognosis depends on early diagnosis, complete excision of the cyst, and reconstruction by hepaticojejunostomy. This report details our 10-year experience and emphasizes innovations in our management. Sixteen patients presented with CC at a mean age of 3 years. (Range, newborn to 21 years, with a M:F ratio 1:4). Two groups could be identified on the basis of age at presentation. Group I (N = 7), presented in the neonatal period, three with obstructive jaundice and four without symptoms. In Group II (N = 9), all patients presented with ascending cholangitis at a mean age of 6 years. Thirteen patients had a type 1 CC, one patient had a type 3 CC, and two had type 4 CC. The patients with type 1 and type 4 CC underwent primary cyst excision with Roux-en-Y hepaticojejunostomy, whereas the patient with type 3 CC underwent cyst excision with sphincteroplasty of the ampulla. There was only one complication of postop cholangitis that cleared with antibiotic therapy. All patients have remained free from symptoms in the follow-up period (6 months-10 years). Our four most recent cases were diagnosed in utero by prenatal ultrasonography. This led to appropriate antenatal counseling and prospectively planned neonatal surgery. These infants were asymptomatic, with no clinical signs at birth, and antenatal ultrasonography prevented diagnostic delay. Excision of the choledochal cyst and primary hepatico-enteric anastomosis is confirmed as the therapy of choice. Antenatal sonography is a sensitive method in the diagnosis of CC and offers the opportunity for early diagnosis and planned surgery before the onset of complications.

Thoracoscopy in the management of pediatric empyema

The surgical management of empyema consists of (1) aggressive therapy with thoracotomy and decortication or (2) conservative treatment with chest tube drainage and intravenous antibiotics. Recently, Kern and Rodgers introduced thoracoscopic debridement as an adjunct to the management of children with empyema, with promising results. Hence, the authors report their experience with thoracoscopy in the management of pediatric patients with empyema. In the last years, 10 children have undergone thoracoscopic debridement (TD) for empyema. The average age was 6.9 years (range, 2 to 16). Children underwent TD an average of 14 days (range, 8 to 16) after initial presentation and 4 days (range, 2 to 6) after admission to the authors' hospital. Indications for TD were persistent requirement of supplemental oxygen and failure of conservative medical management that consisted of antibiotics and tube thoracostomy. Three children had positive pleural fluid cultures for Streptococcus pneumoniae. In all cases, preoperative ultrasound or chest computed tomography examination showed dense pleural fluid with septation. During surgery, TD allowed for lung expansion and precise chest tube placement in all patients except one who required conversion to minithoracotomy and decortication for persistent encasement with a thick pleural peel. There were no postoperative complications related to the procedure. After TD, all children had prompt clinical improvement. The patients were weaned from supplemental oxygen by postoperative day 2, and following early chest tube removal, nine children were discharged home by postoperative day 7 (range, 3 to 10). One child required further hospitalization for underlying renal failure. In the authors' hands, TD was effective in producing prompt clinical improvement in children with empyema.(ABSTRACT TRUNCATED AT 250 WORDS)