Pharyngeal perforation masquerading as esophageal atresia

We present a case of pharyngeal perforation from a nasogastric tube mistakenly diagnosed as esophageal atresia with tracheoesophageal fistula in a full term infant female. The correct diagnosis was identified with rigid bronchoscopy and esophagoscopy immediately prior to the planned thoracotomy which was aborted. After one week of oral restriction and antibiotics, the healed perforation did not demonstrate leakage on a contrasted pharyngoesophagogram and bottle feeds were initiated. The infant was discharged to home on day of life 13 without any further complications.

A 22-year experience in global transport extracorporeal membrane oxygenation

BACKGROUND/PURPOSE

Transport extracorporeal membrane oxygenation (ECMO) is currently available at 12 centers. We report a 22-year experience from the only facility providing global transport ECMO. Indications for transport ECMO include lack of ECMO services, inability to transport conventionally, inability to wean from cardiopulmonary bypass, extracorporeal cardiopulmonary resuscitation, and need to move a patient on ECMO for specialized services such as organ transplantation.

METHODS

Retrospective database review of children undergoing inhouse and transport ECMO from 1985 to 2007.

RESULTS

Sixty-eight children underwent transport ECMO. Fifty-six were transported on ECMO into our facility. The remaining 12 were moved between 2 outside locations. Ground vehicles and fixed-wing aircraft were used. Distance transported was 8 to 7500 miles (13-12070 km), mean 1380 miles (2220 km). There were 116 inhouse ECMO runs. No child died during transport. Survival to discharge after transport ECMO was 65% (44/68) and, for inhouse ECMO, was 70% (81/116).

CONCLUSIONS

Transport ECMO is feasible and effective, with survival rates comparable to inhouse ECMO. We have used transport ECMO to help children at non-ECMO centers with pulmonary failure who have not improved with inhaled nitric oxide and high-frequency ventilation. We have also transported a child after extracorporeal cardiopulmonary resuscitation, which may represent an emerging indication for transport ECMO. Transport ECMO often is the only option for children too unstable for conventional transport or those already on ECMO and requiring a specialized service at another facility, such as organ transplantation.

Superior mesenteric artery syndrome in a basic military trainee

We present the case of a 19-year-old woman with feeding intolerance, due to superior mesenteric artery (SMA) syndrome, after weight loss experienced during basic military training. She had previous good health and presented with vomiting 8 weeks after starting military training. She had experienced a 16-pound (7 kg) weight loss during the course of training and was increasingly unable to tolerate meals, solids worse than liquids. Computed tomography of the abdomen with oral contrast revealed gastric and duodenal distention, with narrowing of the second portion of the duodenum at the SMA. A nasojejunal feeding tube was placed and she was given tube feedings. Weight increased and she eventually tolerated oral feedings. She completed military training and remains in good health. SMA syndrome is a rare cause of feeding intolerance, but can follow periods of acute weight loss, as is experienced by some basic military trainees.

Intercostal hernia and spontaneous pneumothorax in a liver transplant recipient: a case report

Intercostal hernia can occur after blunt trauma and can also complicate thoracotomy. This report describes a 13-year-old liver transplant recipient with chronic asymptomatic intercostal hernia at site of thoracotomy. This hernia became manifest upon development of spontaneous pneumothorax. She presented with pleuritic pain and radiographic evidence of spontaneous pneumothorax. Her history included liver transplantation at age 19 months for tyrosinemia, posttransplant lymphoproliferative disorder at age 7 years with thoracotomy for lung biopsy, and prolonged corticosteroid administration. Examination and computed tomography revealed an intercostal hernia. She underwent repair of hernia, stapled resection of apical blebs, and pleurodesis. Reconstruction of chest wall involved rib fracture and intercostal approximation with nonabsorbable sutures covered by serratus muscle advancement. She is symptom free with intact repair 2 years and 9 months after surgery and is able to participate in vigorous physical activity. This is the first report of an intercostal hernia detected upon development of spontaneous pneumothorax. The hernia occurred at the site of a prior thoracotomy, possibly because of impaired healing from corticosteroid administration. This case suggests that nonabsorbable sutures should be used for intercostal approximation after thoracotomy in patients with impaired wound healing.

Prophylactic bilateral salpingo-oopherectomy in a 17-year-old with Frasier syndrome reveals gonadoblastoma and seminoma: a case report

Mutations in the Wilms' tumor gene are present in children with Frasier syndrome, Denys-Drash syndrome, WAGR syndrome, and some cases of Wilms' tumor. The Wilms' tumor gene product, WT1, is necessary for normal urogenital development. Frasier syndrome is an association between focal segmental glomerulosclerosis, beginning in the second and third decade, male to female sex reversal, and dysgenetic gonads. We report a case of Frasier syndrome in a 17-year-old adolescent girl with renal failure, kidney transplant, and dysgenetic gonads, with development of gonadoblastoma and dysgerminoma (seminoma). The diagnosis of Frasier syndrome was based on nephrotic syndrome with diffuse mesangial sclerosis leading to chronic renal failure, dysgenetic gonads, 46 XY karyotype in a phenotypic female, and a mutation in the Wilms' tumor gene. Prophylactic laparoscopic bilateral salpingo-oopherectomy revealed gonadoblastoma and seminoma in opposite atrophic ovaries as well as a hypoplastic uterus. Early prophylactic resection of dysgenetic gonads is indicated in children with Frasier syndrome to prevent the development of germ cell malignancy.

Children Treated at an Expeditionary Military Hospital in Iraq

OBJECTIVE

To describe the treatment of children at an expeditionary military hospital in wartime Iraq.

DESIGN

Descriptive, retrospective study.

SETTING

The 332nd Air Force Theater Hospital in Balad, Iraq, January 1, 2004, to May 31, 2005.

PATIENTS

All 85 children (of 1626 total patients) evaluated and treated at the hospital during the study period.

INTERVENTIONS

Indicated surgical procedures performed on children.

MAIN OUTCOME MEASURES

Age, sex, diagnosis, injury, operations, and complications for children during the study period.

RESULTS

The 85 children (age range, 1 day to 17 years; mean, 8 years) represented 5.2% of all patients. Thirty-four (61%) of the 56 children for whom sex was recorded were male. Injury was the diagnosis for 48 children (56%). Of these, the cause was fragmentation wound in 25 children (52%), penetrating trauma in 11 (23%), burn in 9 (19%), and blunt trauma in 3 (6%). The site of injury was the lower extremity in 18 children (38%), head in 11 (23%), upper extremity in 8 (17%), abdomen in 8 (17%), and chest in 3 (6%). Nontraumatic conditions had congenital, infectious, gastrointestinal, and neoplastic causes. During the study, 134 operations were performed on 63 children. There were 5 deaths.

CONCLUSIONS

Expeditionary military hospitals will encounter both injured and noninjured children seeking medical care. To optimize the care of these children, it will be necessary to provide the proper personnel, training, and equipment.

A surgeon in your corner

The surgical emergencies presented in this article encompass the vast majority of the nontraumatic emergencies seen by a pediatric surgeon but represent only a small proportion of surgical disease in children. Most children seeking outpatient medical care do not need a surgeon, but those who do need one quickly. When one of the processes detailed above is suspected, it is always best to avail oneself of the opinion of a surgeon in a timely manner.

Nitrovasodilator responses in pulmonary arterioles from rats with nitrofen-induced congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Many infants with congenital diaphragmatic hernias (CDHs) experience persistent pulmonary hypertension that is refractory to treatment with inhaled nitric oxide (NO). We have examined the responses of isolated pulmonary arterioles from prenatal and postnatal rats with and without nitrofen (2,4-dichlorophenyl-p-nitrophenyl ether)-induced CDH to a variety of activators of the NO-cyclic guanosine monophosphate (cGMP) pathway.

METHODS

Right-sided CDH was induced in fetal rats by feeding nitrofen to pregnant rats on day 12 of gestation. Control rats were fed olive oil (vehicle). Third-generation pulmonary arterioles were isolated from the right lung of prenatal rats at term and from newborn rats within 8 hours after birth. Responses to increasing concentrations of sodium nitroprusside (SNP), atrial natriuretic peptide, or 8-bromo-cGMP were measured in pulmonary arterioles from control rats and from rats with nitrofen-induced CDH. Postnatal responses to 8-bromo-cGMP were also recorded in the presence of zaprinast, a type V phosphodiesterase inhibitor.

RESULTS

Pulmonary arterioles from prenatal rats did not dilate in response to SNP, atrial natriuretic peptide, or 8-bromo-cGMP. Vasodilatory responses of postnatal pulmonary arterioles from control rats to SNP and 8-bromo-cGMP were significantly greater than for arterioles from rats with CDH. Zaprinast pretreatment resulted in similar responses for postnatal CDH and control arterioles to 8-bromo-cGMP.

CONCLUSIONS

Postnatal pulmonary arterioles from CDH rats exhibit altered nitrovasodilator responsiveness, which may be due to rapid degradation of cGMP.

Repetitive deformation and pressure activate small bowel and colonic mucosal tyrosine kinase activity in vivo

Physical forces like deformation and pressure modulate signaling and phenotype in cultured cells. However, it is more difficult to establish that such phenomena occur in vivo. We studied the effects of 0 to 10 minutes of rhythmic distension with an isotonic electrolyte and polyethylene glycol solution to 30 cm H(2)O pressure on defunctionalized small and large bowel segments in adult male Sprague Dawley rats. Mucosa was harvested at 0, 1, and 10 minutes and assayed for tyrosine kinase activity. Rhythmic distension caused a time-dependent increase in colonic mucosal tyrosine kinase activity, which was statistically significant at 10 minutes (140% +/- 41% increase, n = 5, P <.05). Small bowel tyrosine kinase activity was markedly lower than that observed in the colon, but achieved a statistically significant increase at 5 minutes after initiation of rhythmic distension. (115% +/- 44% increase, n = 5, P <.05).

Oxygen-induced vasodilation is blunted in pulmonary arterioles from fetal rats with nitrofen-induced congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Persistent pulmonary hypertension contributes to the high mortality rate associated with congenital diaphragmatic hernia (CDH). Oxygen is an important stimulus for pulmonary vasodilation in the perinatal period. The authors have investigated the responses of isolated pulmonary arterioles from fetal rats with and without CDH to an increase in oxygen tension.

METHODS

CDHs were induced in fetal rats by feeding nitrofen to timed-pregnant rats at midgestation. A third-generation pulmonary arteriole was isolated from the right lung at term. Isolated arterioles were pressurized at their "optimal distending pressure." Diameter changes in response to an increase in oxygen tension from 25 to 40 mm Hg ("hypoxic" conditions) to 90 to 150 mm Hg ("normoxic" conditions) were recorded for K(+) preconstricted arterioles from control rats, from rats with nitrofen-induced CDH, and from rats that were nitrofen exposed but did not have a CDH.

RESULTS

"Normoxic" exposure reversed the K(+) preconstriction in control arterioles by 124 +/- 26%. In contrast, arterioles from rats with nitrofen-induced CDH dilated significantly less than controls (20 +/- 15% of the K(+) preconstriction). The responses of arterioles from rats that were nitrofen exposed but did not get a CDH were not different (P >.05) from controls.

CONCLUSIONS

Oxygen-induced vasodilation is blunted in pulmonary arterioles from rats with nitrofen-induced CDH. Blunted oxygen-induced vasodilation may contribute to persistent pulmonary hypertension in CDH. J Pediatr Surg 36:593-597.

Oxygen-induced vasodilation in pulmonary arterioles from fetal rats

BACKGROUND

Oxygen is a potent stimulus for pulmonary vasodilation in the perinatal period. Little information is available regarding mediators of oxygen-induced pulmonary vasodilation in fetal rats. We have investigated the effect of blocking several proposed mediators of oxygen-induced vasodilation on the responses of isolated, third-generation pulmonary arterioles from term fetal rats to an increase in oxygen tension.

MATERIALS AND METHODS

Third-generation pulmonary arterioles were isolated from fetal rats at term. Arterioles were preconstricted by suffusion with "hypoxic" (pO(2) 25-40 mm Hg) solution containing 40 mM KCl. The vasodilation induced by suffusion with "normoxic" (pO(2) 90-150 mm Hg) 40 mM KCl solution was recorded for control pulmonary arterioles and for arterioles pretreated with inhibitors of nitric oxide synthase and cyclooxygenase, and blockers of bradykinin receptors and purinergic receptors. Responses to oxygen suffusion were also recorded for pulmonary arterioles denuded of endothelium.

RESULTS

Control arterioles dilated 113 +/- 28% of the potassium-induced preconstriction after 60 min of normoxic suffusion. Pretreatment with indomethacin completely blocked oxygen-induced vasodilation. Inhibitors of nitric oxide synthase, blockers of bradykinin and purinergic receptors, and removal of the endothelium did not significantly change normoxic vasodilation.

CONCLUSIONS

Our results are most consistent with a vasodilator product of cyclooxygenase metabolism as a primary stimulus for oxygen-induced vasodilation in isolated, third-generation pulmonary arterioles from fetal rats.

Molecular analysis of the adaptive response of intestinal bile acid transport after ileal resection in the rat

BACKGROUND & AIMS

The apical sodium-dependent bile acid transporter is critical for intestinal reclamation of bile salts. Its expression and activity, along with the ileal lipid-binding protein, were studied before and after intestinal resection in the rat.

METHODS

The effects of surgical resection and bile acid feeding on the expression of ileal bile acid transport were assessed by a combination of functional (taurocholate uptake into crude brush border membrane vesicles) and molecular assays (Northern and Western blotting).

RESULTS

Transport, apical sodium-dependent bile acid transporter and ileal lipid-binding protein messenger RNA and protein expression were restricted to the distal 30 cm of ileum. After resection, transport and expression were limited to the remaining portions of this segment. Limited ileal resection increased protein mass and, therefore, transport in the terminal 5 cm of ileum without a specific increase in transporter gene expression. Increased bile acid presentation to the terminal ileum did not induce ileal hyperplasia. Eighty-five percent intestinal resection led to ileal hypertrophy and a specific repression in bile acid transport activity.

CONCLUSIONS

Native and compensatory bile acid transporter gene expression occur predominantly in the terminal 30 cm of ileum. The specific ileal responses to intestinal resection are dependent on the extent of resection.

Hypoxic pulmonary vasoconstriction is impaired in rats with nitrofen-induced congenital diaphragmatic hernia

BACKGROUND

Pulmonary hypertension and persistent fetal circulation contribute to the high mortality rate associated with congenital diaphragmatic hernia (CDH). Morphological alterations of the pulmonary vasculature in infants with CDH are thought to contribute to exaggerated vasoconstrictor responses to normal vasoconstrictor stimuli. In the pulmonary circulation, hypoxia is a potent vasoconstrictor. Under pathological conditions, hypoxia-induced vasoconstriction may contribute to the development of pulmonary hypertension.

METHODS

The authors have used the nitrofen-induced model of congenital diaphragmatic hernia in rats to investigate the magnitude of the hypoxic vasoconstrictor response. Congenital diaphragmatic hernias were induced in fetal rats by feeding nitrofen (2,4-dichlorophenyl-p-nitrophenyl ether) to pregnant Sprague-Dawley rats at midgestation. Hypoxia-induced vasoconstriction was measured in isolated, perfused third-generation pulmonary arterioles from normal rats and from rats with nitrofen-induced CDH.

RESULTS

The hypoxic vasoconstrictor response was significantly blunted in the pulmonary arterioles of fetal rats with nitrofen-induced (2% +/- 1% vasoconstriction), as compared with the responses observed in normal fetal rats (15% +/- 3% vasoconstriction, P = .004).

CONCLUSION

Blunting of the hypoxic pulmonary vasoconstrictor response may contribute to ventilation-perfusion mismatching in infants with CDH.

Endothelin-1 pulmonary vasoconstriction in rats with diaphragmatic hernia

BACKGROUND

Pulmonary hypertension is an important cause of mortality in infants with congenital diaphragmatic hernia (CDH). Endothelin-1 has been implicated as a mediator of pulmonary hypertension. ET-A receptors are increased in the nitrofen model of CDH in rats. We hypothesized that vasoconstrictor responses to endothelin-1 are increased in pulmonary arterioles of rats with nitrofen-induced CDH.

MATERIALS AND METHODS

CDH was induced in fetal rats by feeding nitrofen (2,4-dichlorophenyl-p-nitrophenyl ether) to pregnant rats at midgestation. Third-generation pulmonary arterioles were isolated on the final day of gestation. Arterioles were cannulated and perfused at constant pressure with a physiologic salt solution. Diameters of arterioles from control animals (n = 8), CDH animals (n = 5), and animals exposed to nitrofen but without CDH (n = 4) were measured. Responses to endothelin-1 concentrations of 10(-12) to 10(-8) M were compared by Student's t test.

RESULTS

CDH arterioles constricted more than controls in response to endothelin-1 at concentrations of 10(-11) M (29 +/- 11% vs 5 +/- 3%, P = 0.02) and 10(-10) M (40 +/- 14% vs 9 +/- 6%, P = 0.04). The log concentration of endothelin-1 that induced half-maximal response (ED50) was lower for CDH arterioles than for control arterioles (-10.3 +/- 0.6 vs -9.1 +/- 0.2, P = 0.03). Responses of arterioles from animals exposed to nitrofen but without CDH were not different from controls (P > or = 0.05).

CONCLUSIONS

Exaggerated vasoconstrictor responses to endothelin-1 may contribute to pulmonary hypertension in CDH.

Inhibitory effects of Candida albicans extracellular polysaccharides on mouse sarcoma 180

Extracellular glycoprotein produced by Candida albicans in chemically defined medium was used to treat solid Sarcoma 180 tumor cells implanted subcutaneously in Swiss female mice. Neither toxicity nor skin ulcerations surrounding the tumors was observed. Significant tumor inhibition was obtained using different methods to evaluate treatment effectiveness. Comparison of tumor weights after a single treatment (400 mg/kg, ip) on various days after transplantation indicated significant inhibition with a 10--80% regression rate. Multiple doses (800--2,000 mg/kg, ip) regressed 60--90% of all tumors. Subsequent dosage experiments showed an increase percentage of survivors for all treated groups and a significant decrease in tumor size. Studies of the glycoprotein material indicated that it was immunologically active.

Influence of visible light on organ weights of mice

Hau:ICR mice separated by sex, were reared for 30 days under various fluorescent lamps: pink, blue, black UV, cool white and full spectrum. Body weights and absolute organ weights were compared. After light exposure, female body weights were not significantly different between any groups; however, a difference in male body weights was observed. Light affected the weights of the pituitary, adrenals, kidneys and prostate in male mice and the adrenals, thyroid and pineal glands in females. The weight of adrenal glands of both males and females were most sensitive to changes in lighting.