Emotional considerations and attending involvement ameliorates organ donation in brain dead pediatric trauma victims

PURPOSE

The purpose of this study was to ascertain a strategy for maximizing parental consent for organ donation in traumatically injured children suffering from brain death. Our hypothesis was that appropriate attending surgeon involvement and delay in evaluating children for brain death leads to an increased percentage of organ donors.

METHODS

From January 1993 to August 1999, the records of all children who died in a Level I trauma center were evaluated. Those children suffering brain death that were suitable for organ donation were entered into the study. Cases were reviewed for patient demographics, time to entry into brain death protocol (measured from time of admission), time to parent notification about brain death (measured from time of admission), specific attending involved in the case (with level of involvement), and success of organ donation request. In all, 43 charts were reviewed.

RESULTS

Of 43 deaths, 33 were deemed suitable for donation. Age of suitable donors ranged from 1 month to 18 years. In all, 11 attending physicians were involved in the care of these children. Overall, 20 of 33 were organ donors (60%). When the attending surgeon was involved, donation success for organ retrieval was 86%, whereas if the attending was not involved personally, the success rate dropped to 23% (p < 0.04). One senior pediatric surgeon obtained a success rate of 12 of 12 children. It was this surgeon's policy to not initiate brain death protocols in children immediately on entry into the emergency room, but rather to delay initiation until family could be gathered and spend time with the affected child in order that the family could recover from the initial shock of trauma (always at least overnight). When time to initiation of brain death protocol was examined, success was obtained when a delay of 15.5 hours was respected, versus 7.0 hours when donation was requested but denied (p < 0.03).

CONCLUSION

These data indicate that attending involvement is important when parents of brain dead children are asked about organ retrieval (p < 0.04). Delay in initiating brain death protocols in order for family members to deal with the shock of the initial trauma appears to increase willingness to participate in organ donation.

Mandatory admission after isolated mild closed head injury in children: is it necessary?

BACKGROUND/PURPOSE

Children with closed head injuries diagnosed as concussion alone or concussion with brief loss of consciousness are admitted routinely for observation despite a normal central nervous system finding, negative computed tomography (CT) scan, and a Glasgow Coma Score (GCS) of 15. Recent studies have questioned the necessity of such an admission. The purpose of this study was to review a large pediatric database and study the length of stay as well as any required procedures or complications in these children. The hypothesis was that routine admission is unnecessary in this population.

METHODS

The National Pediatric Trauma Registry-Phase II was reviewed for the period from October 1988 to January 1996. Entry criteria included age less than 18 and an isolated closed head injury after blunt trauma with an admission GCS of 15. Variables studied included age, gender, mechanism of injury, length of stay, procedures, and outcome.

RESULTS

A total of 1,033 children met criteria for this study. The average age was 8.3 years. Males predominated at 61.9%. Falls, sports, and motor vehicle crashes were the most common mechanisms of injury. The average length of stay was 1.19 days, and 60 children were not admitted. A total of 583 children had no procedures performed, whereas 386 received a CT scan, and 148 had x-rays. None required neurosurgical intervention, and all were discharged alive.

CONCLUSION

These findings indicate that routine admission may not be necessary for children with isolated mild closed head injuries with a negative CT scan and a normal neurologic finding and allows for a prospective randomized trial to confirm this.

Do pediatric trauma centers have better survival rates than adult trauma centers? An examination of the National Pediatric Trauma Registry

BACKGROUND

Pediatric trauma centers (PTCs) were developed to improve the survival of injured children, but it is currently unknown if children admitted to PTCs are more likely to survive than those admitted to adult trauma centers (ATCs).

METHODS

Fifty-three thousand one hundred thirteen pediatric trauma cases from 22 PTCs and 31 ATCs included in the National Pediatric Trauma Registry were reviewed to evaluate survival rates at PTCs and ATCs.

RESULTS

Overall, 1,259 children died. The raw mortality rate was lower at PTCs (1.81% of 32,554 children) than at ATCs (3.88% of 18,368 children). However, patients admitted to ATCs were more severely injured. When Injury Severity Score, Pediatric Trauma Score, mechanism (blunt or penetrating), gender, age, clustering, and American College of Surgeons (ACS) verification status were controlled for using a single logistic regression model, there was no statistically significant difference in survival between PTCs and ATCs (odds ratio, 1.02; 95% confidence interval, 0.83-1.26; p = 0.587). A similar comparison of the 12 ACS-verified trauma centers with the 41 nonverified centers showed verification to be associated with improved survival (odds ratio, 0.75; 95% confidence interval, 0.58-0.97; p = 0.013).

CONCLUSION

Although PTCs have higher overall survival rates than ATCs, this difference disappears when the analysis controls for Injury Severity Score, Pediatric Trauma Score, age, mechanism, and ACS verification status. ACS-verified centers have significantly higher survival rates than do unverified centers.

Changing patterns of treatment for blunt splenic injuries: an 11-year experience in a rural state

PURPOSE

The aim of this study was to perform a population-based study evaluating the trend in management of pediatric blunt splenic injuries in a rural state and assess differences in the management of those injuries at a level I pediatric trauma center (PTC) and regional hospitals (RH) from 1985 through 1995.

METHODS

ICD-9-CM diagnosis and procedure codes for children (age less than 19) discharged from all hospitals in a rural state with splenic injuries from 1985 through 1995 were reviewed. Hospital charges, age, and nonoperative management (NOM) rates were calculated for PTC and RH and compared using chi2 and linear regression. (P < .05 is statistically significant.) Patients were divided into 2 groups; G1, 1985 through 1989 (127 children); G2, 1990 through 1995 (140 children).

RESULTS

The overall NOM rate increased from 21% (G1) to 64.2% (G2), P < .001. A total of 114 patients were treated at PTC and 153 patients received care at RH. PTC had a NOM rate of 54.3% versus 35.9% at RH (P = .003). There was no statistical difference in ages or ISS within the groups or between PTC and RH. NOM in RH rose from 7.7% in G1 to 56.9% in G2 (P < .000), and from 35.5% in G1 to 76.9% in G2 (P < .001) for PTC. Hospital charges were lower for patients receiving NOM versus those with surgical treatment of their injury, $8,094 versus $10,862 (P = .018). However, a higher percentage of children were treated at RH than PTC in G2 versus G1 (68.2% v 51.2%, P = .0541).

CONCLUSIONS

Over the 10-year period studied, the NOM rate for splenic injuries significantly decreased. This trend was seen at both the PTC and RH, but the PTC maintained a higher rate of NOM. Unfortunately, more children were treated at RH in G2. Educational programs increased NOM in RH but not to a level equal to PTC. These programs had the negative effect of allowing more children to be treated at RH, actually increasing the splenic operation rate for this population.

Receptor tyrosine kinase inhibition suppresses growth of pediatric renal tumor cells in vitro

PURPOSE

Children who undergo standard therapy for renal tumors are at an increased risk for treatment sequelae such as congestive heart failure, abnormal trunk development, and secondary malignancies. Therefore, research on the use of novel chemotherapeutic agents with fewer side effects is justified. Recent experimental evidence suggests that growth factor receptors such as epidermal growth factor receptor (EGFR) and platelet-derived growth factor receptor (PDGFR) play an important role in growth and development of pediatric renal tumors especially that of Wilms' tumor. In this study we investigated the effects of genistein, AG1478, and AG1295, from the class of growth factor receptor tyrosine kinase (GFR-TK) inhibitors, on proliferation and colonigenic growth of 2 pediatric renal tumor cell lines.

METHODS

The authors studied the effect of genistein (broad-spectrum GFR-TK inhibitor), AG1478 (EGFR-specific GFR-TK inhibitor), and AG1295 (PDGFR-specific GFR-TK inhibitor) on proliferation and colonigenic growth of rhabdoid tumor of the kidney and Wilms' tumor cell lines: G-401 and SK-NEP-1, respectively. The effect of genistein at concentrations of 0 to 200 micromol/L, and AG1478 and AG1295 at 0 to 10,000 nmol/L were tested on proliferation by using a growth inhibition assay. Viable cell counts at each concentration were obtained by hemocytometer and trypan blue exclusion, and percent growth inhibition was calculated based on control cultures at the same time-point. As a measure of colonigenic survival, the percent inhibition of colony formation in drug-treated dishes was calculated based on the number of colonies (>50 cells) in control dishes.

RESULTS

Genistein at concentrations of 25 and 50 micromol/L inhibited the colonigenic growth of G-401 by 37% and 79% (P = .01 and 5E-06, 2-tailed t test, respectively) and that of SK-NEP-1 by 44% and 74% (P = .0001 and 9.9E-07). The mean percent growth inhibition at the above doses was 57% +/- 7.9% and 96% +/- 0.2% for G-401, and 47% +/- 11.2% and 60% +/- 2.7% for SK-NEP-1. AG1478 at concentrations of 1,000 and 5,000 nmol/L inhibited the colonigenic growth of G401 by 75% and 78% (P = .0005 and 7.38E-06, respectively) and that of SK-NEP-1 by 19% and 40% (P = .02 and .0001). The percent growth inhibition at the mentioned concentrations for G-401 were 53% +/- 9.3% and 63% +/- 6.3%, and for SK-NEP-1 were 55% +/- 14.5% and 65% +/- 20.1%, respectively. AG1295 did not appear to be as effective as AG1478.

CONCLUSIONS

This is the first experimental study on the use of GFR-TK inhibitors as a potential treatment for pediatric renal tumors. GFR-TK inhibitors such as genistein occur naturally in soybean foods and have been shown to reach therapeutic levels in blood after consuming a soybean-based diet. Considering the significance of growth factor receptor activity in Wilms' tumor development, inhibition of GFR-TKs should be investigated as effective and potentially nontoxic adjunctive treatment for this childhood tumor. Furthermore, GFR-TK inhibitors may offer an effective alternative to the treatment of commonly fatal rhabdoid tumor of the kidney in children.

Complications of intrauterine intervention for treatment of fetal obstructive uropathy

The intrauterine surgical placement of vesicoamniotic shunts in the treatment of fetal obstructive uropathy associated with prune-belly syndrome to avoid such complications as renal damage and oligohydramnios remains controversial. We present a case of an infant born with prune-belly syndrome at 33 weeks and 5 days of estimated gestational age to a mother of two by vaginal delivery after a pregnancy complicated by fetal obstructive uropathy with attempted intrauterine intervention. After sonographic and laboratory diagnostic and prognostic evaluations, an intrauterine procedure was performed in which a vesicoamniotic shunt was placed under ultrasound guidance. Complications included dislodgment of the initial shunt, with a failed subsequent attempt at placement, oligohydramnios, preterm labor and delivery, and traumatic gastroschisis through the surgical abdominal wall defect. His hospital stay was further complicated by chronic renal insufficiency, prematurity, respiratory distress, bowel malrotation, an episode of gram-negative sepsis with Enterobacter cloacae, signs of liver failure, an exploratory laparotomy for severe enterocolitis, and orchiopexy for bilateral undescended testes. At present, it is unclear whether vesicoamniotic shunt placement can provide any significant improvement in the morbidity or mortality for patients with prune-belly syndrome. A large, prospective, randomized trial is needed to determine its efficacy.

Spinal anesthesia for preterm infants undergoing inguinal hernia repair

HYPOTHESES

Use of spinal anesthesia is safe and effective in an outpatient population of preterm infants undergoing inguinal hernia repair (IHR) and eliminates routine postoperative hospital admission for apnea monitoring.

METHODS

From October 1982 through October 1997, all preterm (gestational age [GA], < or =37 weeks), high-risk (preterm infants whose postconceptual age at surgery [PCAS] is <60 weeks) infants undergoing IHR with spinal anesthesia were studied prospectively. No exclusions were made for preexisting conditions. Elective IHRs and incarcerated hernias were both considered. A postoperative apnea rate was calculated and compared with published postoperative apnea rates in preterm infants after receiving general anesthesia.

RESULTS

For 269 IHRs performed, 262 spinal anesthetic placements (97.3%) were successful in 259 infants; 246 placements were achieved on the first attempt and 16 on the second. The mean GA was 32 weeks (GA range, 24-37 weeks); mean PCAS, 43.7 weeks (PCAS range, 33.4-59.3 weeks); and mean birth weight, 1688 g (weight range, 540-3950 g). Two hundred six patients (78.6 %) did not require supplemental anesthesia; 56 (21.4%) did: 34 received intravenous anesthesia; 6, general; 12, local; and 4, other regional. One hundred fifty-three infants had a history of apnea. Thirteen episodes of apnea were noted in 13 infants (4.9%) following the 262 procedures; all 13 were inpatients undergoing concomitant therapy for apnea (mean GA, 28 weeks; PCAS, 42.9 weeks). Four of these infants received supplemental anesthesia. This apnea rate is significantly lower than the published rate (10%-30%) (P = .01). One hundred three infants underwent IHR on an outpatient basis, 39 of whom had a history of apnea. None of these developed apnea postoperatively. The mean birth weight of this group was 2091 g (weight range, 710-3693 g); mean GA, 33 weeks (GA range, 25-37 weeks); and mean PCAS, 44.3 weeks (PCAS range, 35.4-59.2 weeks). All 103 patients were discharged home the day of surgery. Average time from room entry to incision was 26.3 minutes, which is similar to anesthesia induction time for patients receiving general anesthesia. Average time from bandaging to leaving room was 1 minute, less than usual time for patients receiving general anesthesia.

CONCLUSIONS

Spinal anesthesia is safe, effective, and eliminates the need for postoperative hospital admission in an outpatient population of preterm infants undergoing IHR. This results in considerable cost savings without compromising quality of care.

Rural trauma: the challenge for the next decade

Improving the care of trauma patients in a rural environment requires that several important issues be addressed. First, a universal definition of what constitutes "rural" must be established. We propose that a combined effort of the Federal Government and the Committee on Trauma of the American College of Surgeons develop this definition. Second, data on rural trauma demographics and outcome must be collected in a national database. We propose that this database be incorporated in the "TRACS" database of the Committee on Trauma of the American College of Surgeons. Such a database will allow a "needs assessment analysis of existing care in rural environments and facilitate planning and implementation of efficient systems of care. Funding for the rural database should come from the federal government. Finally, increased public awareness of problems unique to rural trauma care is necessary. The rural trauma subcommittee of the ACSCOT should go from an ad hoc committee to a standing committee with the American College of Surgeons Committee on Trauma. We propose a national conference on rural trauma care hosted by the federal government for the purpose of addressing these issues and simultaneously increasing public awareness.

Focused abdominal sonogram for trauma: the learning curve of nonradiologist clinicians in detecting hemoperitoneum

BACKGROUND

The focused abdominal sonogram for trauma (FAST) has been used by surgeons and emergency physicians (CLIN) to screen reliably for hemoperitoneum after trauma. Despite recommendations for "appropriate training," ranging from 50 to 400 proctored examinations, there are no supporting data.

METHODS

We prospectively examined the initial FAST experience of CLIN in detecting hemoperitoneum by using diagnostic peritoneal lavage, computed tomography, and clinical findings as the diagnostic "gold standard."

RESULTS

241 patients had FAST performed by 12 CLIN (average, 20/CLIN; range, 2-43); 51 patients (21.2%) had hemoperitoneum and 17 patients (7.1%) required laparotomy. Initial experience with FAST by CLIN produced 35 true positives, 180 true negatives, 16 false negatives, and 3 false positives; sensitivity, 68%; specificity, 98%. Initial error rate was 17%, which fell to 5% after 10 examinations (chi2; p < 0.05).

CONCLUSION

Previous recommendations for the number of proctored examinations for individual nonradiologist clinician sonographers to develop competence are excessive.

Financial aspects of providing trauma care at the extremes of life

BACKGROUND

Children and the elderly are more likely to be underinsured compared with the general population of trauma patients. We performed financial analysis on all trauma patients admitted during an 18-month period to a Level I adult and pediatric trauma center to evaluate the financial impact of providing trauma care for children and the elderly.

METHODS

Patients were categorized by age: PEDI<17 years, GERI>64 years and MID = 17 to 64 years. Reimbursement ratio (RR = reimbursement/cost; RR>1 = profit, RR<1 = loss), length of stay (LOS), and Injury Severity Score (ISS) were calculated for each age group.

RESULTS

RR for GERI (RR = 0.99) was significantly lower than for PEDI (RR = 1.15) and MID (RR = 1.16). There was no difference in ISS, but the LOS of GERI was greater than that of PEDI and MID (p<0.05). Cost per patient and LOS were less in PEDI versus MID and GERI (p<0.05).

CONCLUSION

Trauma care reimbursement for the elderly is inadequate, whereas pediatric trauma care costs less to deliver and is profitable to the trauma center.

Perforation of the intrathoracic esophagus from blunt trauma in a child: case report and review of the literature

Rupture of the intrathoracic esophagus from blunt trauma is an exceedingly rare injury in children and often presents on a delayed basis. The authors encountered a case of this unusual injury and review six additional cases found in the literature.

Allogeneic fetal intestinal transplantation with FK506 immunosuppression

PURPOSE

Small intestinal transplantation remains a significant clinical problem. Allogeneic fetal intestinal (AFI) transplantation shows promise, particularly regarding procurement; however, no studiesto date have evaluated the potential success of true allogeneic loci implantation. The authors hypothesized that isolated segments of AFI could be heterotopically transplanted but would require immunosuppression to survive.

METHODS

Donor tissue was obtained from late-gestation Brown Norway rat fetuses with a histo-locus RTN and Fischer fetuses with a histo-locus RT1L. The recipients were adolescent male Fischer rats with a histo-locus RT1L. A 1.2-cm segment of fetal small bowel was implanted in the omentum of the recipient rat and allowed to mature for 5 weeks. Animals were then separated into five groups. Group A served as controls with syngeneic fetal intestinal (SFI) transplant. Group B received AFI with no immunosuppression; group C, AFI transplant with five days of FK506; group D, AFI with 10 days of FK506; and Group E, AFI with daily FK506 for the entire 5-week maturation period. Animals were killed on day 35.

RESULTS

All animals gained weight over the maturation period. Groups B, C, and D had no viable transplant segments at day 35. Groups A and E both had well-developed viable segments confirmed by gross and histological evaluation.

CONCLUSIONS

FK506 allows for normal intestinal development for use in allogeneic fetal bowel transplantation. With this observation, the use of fetal intestine transplanted into the portal circulation emerges as a potentially viable alternative to present intestinal transplant models.

Evaluation of alpine skiing and snowboarding injury in a northeastern state

BACKGROUND

To demonstrate the injury patterns of Alpine skiing and snowboarding in a northeastern state and evaluate potential risk factors.

METHODS

The medical records of a single pediatric and adult Level I trauma center were evaluated from January 1, 1990, through December 31, 1995. All admissions with injuries caused by Alpine skiing or snowboarding were reviewed. Those patients arriving from two local ski resorts, all of whose injuries are referred to the institution for care, were separated out for consideration. Age, sex, type of injury, date of injury, Injury Severity Score, operations performed, and outcome (including mortality) were evaluated. In addition, resort utilization for the study period was obtained from the two resorts included in the evaluation. Mortality data was obtained from the Vermont office of the Chief Medical Examiner for the same time period.

RESULTS

For the 6-year period of the study approximately 2,978,000 skier and snowboarder days were recorded at the study sites. Approximately 447,000 of those days were attributed to snowboarders (15%). In all, 279 patients were admitted for injuries (0.01%), 238 were related to Alpine skiing (incidence 0.01%) and 40 to snowboarding (incidence 0.01%). Snowboarders were statistically younger (20 years; range, 4-44 years) than skiers (29 years; range, 6-70 years) (p < 0.001) and had a significantly lower Injury Severity Score (15 in snowboarders vs. 27 in skiers, p < 0.03). Two female patients were injured snowboarding and 68 female patients were injured skiing. Eight percent of injured snowboarders and 16% of injured skiers sustained multiple injuries (p < 0.01). Injury patterns were significantly different. Upper extremity injuries were almost exclusively found in snowboarders (24% vs. 7%, p < 0.003), whereas cruciate ligament injuries occurred far more commonly in skiers (45% vs. 4%, p < 0.001 Lower extremity injuries in general were more common in skiers (78% vs. 38%, p < 0.001). Central nervous system injuries, including head and spine, were evenly distributed over the two groups, although the snowboarders with central nervous system injuries were younger. In addition, splenic injuries were more common in snowboarders (13% vs. 2%, p < 0.01). Snowboarding accidents were far more common in December, March, and April than other months. Fifty-one patients sustained abdominal or chest injuries and only two of these required operative intervention (two splenectomies). Other operative interventions were limited to extremity injuries, injuries of the spine, or placement of an intracranial pressure monitor. There were no fatalities recorded in this population, although over the 6.5 years, there were 25 deaths related to alpine skiing and one to snowboarding in the State (incidence 0.0000009 skier days). Victims tended to be male: 96% of the skiers and the one snowboarder. The predominant cause of death was blunt head trauma followed by blunt chest trauma. Helmets were not worn by those sustaining head injuries or fatalities. Spine injuries were recorded only in extremely young snowboarders and skiers out of control.

CONCLUSION

Snowboarders and Alpine skiers are equally prone to injury. Snowboarding accidents are typically less severe and show significantly different injury patterns than skiing accidents. Abdominal and chest injuries in this population are generally amenable to nonoperative management. Prevention programs are best targeted at safe skiing and snowboarding practices, not skiing or snowboarding in poor conditions, use of helmets for skiers, and restraint of snowboard use in very young children.

Graft length affects outcome in fetal small bowel transplants

Multiple studies have demonstrated the ability of the fetal rat small intestine to be transplanted successfully as a free graft, devoid of its mesentery. While maintaining normal histologic architecture, portal circulation, and digestive and absorptive properties, the initial myeloelectric activity is delayed. The purpose of this study was to investigate how abnormal early motility affects functional outcome and survival. Using a syngeneic model, fetal rat small intestine segments were transplanted into adolescent rat recipients as free grafts into the omentum. After a maturation period, viable segments measuring 1 or 2 cm were placed into continuity with the native intestine after a standardized resection of either jejunum-ileum, ileum-cecum, or cecum. Control animals had native intestinal resection without graft interposition. Survival, daily weight gain, oral intake, and fecal output were monitored. In this model, overall survival was improved with the use of the shorter 1-cm graft segment compared with the 2-cm and more distal interpositions. No animals survived with proximal graft placement after jejunal-ileal resection. Nutrient use was improved in the transplant recipients compared with nontransplant controls but did not differ between the two graft lengths. These data suggest that outcome in this model is improved using shorter fetal intestine graft lengths. The use of multiple segments in multistaged procedures and early defunctionalization may improve results.

Conservative management of pancreatic trauma in children

Many adults and most children with a solid-organ abdominal injury can be managed nonoperatively. To date, however, little is known about the outcome of nonoperative management of pancreatic injury. To analyze current treatment patterns of pancreatic injury in children, all children (age < 19 years) identified in the National Pediatric Trauma Registry (49,540 patients) and admitted to two level I pediatric trauma centers with a diagnosis of injury to the pancreas (International Classification of Disease-9 codes 863.81-863.84 and 863.91-863.94) were reviewed. Over a 7-year period, 154 children were identified with pancreatic injury. Thirty-one (20%) sustained severe injuries (grades III, IV, or V) and 123 (80%) sustained lower-grade injuries (grades I and II). Sixteen (52%) of the children sustaining grades III, IV, or V injury required pancreatic procedures (9 distal resections, 3 simple repairs, 2 enteric anastomoses, 2 others). Only 26 (21%) of the grades I and II injuries required surgical intervention specific to the pancreas (11 resections, 9 catheter drainage of pseudocysts, 2 enteric anastomoses, 4 others). Ninety-seven (79%) grades I and II injuries were successfully managed conservatively. Overall, 15 (10%) children required drainage procedures for pseudocyst. The frequency of operative intervention decreased during the last 4 years of the study (18 vs. 26%, p > 0.05), coinciding with a decrease in the frequency of drainage procedures for pseudocysts. The need for surgical intervention was not influenced by age, Injury Severity Score, or Pediatric Trauma Score (p > 0.05). Associated abdominal injuries were common but did not influence operations on the pancreas (p > 0.05). No deaths were attributed to the pancreatic injury. These data indicate that early intervention for pancreatic injury, in the absence of clinical deterioration or major ductal injury (grades III, IV, or V), is unwarranted, and careful observation may supplant the conventional surgical therapy recommended for adults.

Associated head injury should not prevent nonoperative management of spleen or liver injury in children

The appropriate management of children with liver or spleen injuries and associated head injury after blunt trauma remains controversial. To evaluate the success rates for nonoperative management and the impact this approach has on both abdominal and head injury outcome, children recorded in the National Pediatric Trauma Registry were reviewed. From January 1, 1994 to April 1, 1995, 107 children (aged < 19) were identified with liver, spleen, and associated head injury from blunt trauma. Forty-five (42%) children had combined head and spleen injury, 51 (48%) had head and liver injury, and 11 (10%) had head, liver, and spleen injury. Only 18 (17%) required laparotomy (head and spleen injury, 9 (8%); head and liver injury, 5 (5%); and head, liver, and spleen injury, 4 (4%)). Overall, there were no differences in Glasgow Coma Scale scores for children requiring laparotomy compared with those managed conservatively (13 vs. 14, p > 0.05). For all groups, the mean Injury Severity Score was significantly higher for children requiring laparotomy (19 vs. 31, p < 0.05). However, when comparison of the groups was stratified for type of injury and severity, the transfusion requirements, mortality, and abdominal and neurologic morbidity were all improved in children managed nonoperatively. Contrary to previous guidelines in the literature for selection of patients for nonoperative management of blunt solid organ abdominal injury, the association of altered mental status from head injury with liver and spleen injuries should not impact the decision for observational management.

Penetrating hepatic trauma in children: operating room or not?

Nonoperative management has become widely accepted as the standard of care for patients with blunt hepatic trauma. Recent studies among adults have supported the use of nonoperative management of selective penetrating wounds to the hepatic bed in stable patients. The therapeutic management of children with penetrating injuries to the hepatic bed were evaluated to ascertain whether nonoperative management was a reasonable consideration in their care. The database of the National Pediatric Trauma Registry (NPTR) was reviewed for the period 1985-1994. ICD-9 codes 864.00 to 864.10 were used to select injury site, diagnosis, and, combined with Current Procedural Terminology (CPT) code data, to ascertain therapeutic interventions. The NPTR is a compilation of data from 61 pediatric trauma centers, currently held at Tufts University. The charts of 29,000 children were reviewed; of these, 1,147 sustained hepatic injuries, 132 (12%) of whom had a penetrating injury. The mechanism of injury was gunshot wound in 100 patients (76%) and stab wound in 32 (24%). The mean age of the children who had a penetrating injury was 12.7 years (range, in utero to 19 years). Six children were managed nonoperatively (5%), and 20 (15%) had negative laparotomy findings. Overall, 106 children sustained additional injuries that required surgical repair. There were 50 hollow viscous injury repair, 19 diaphragmatic repairs, 5 nephrectomies, 4 splenectomies, 4 pancreatic resections, and 43 significant hepatic repairs. The overall mortality rate was 9.8% (13 deaths). Nine of these patients died within 24 hours of injury. These data indicate that penetrating injury to the hepatic bed in children is associated with a high percentage of other organ injuries that require surgical intervention. This seems to be in direct contrast with the findings for adults, for whom the hepatic mass appears protective because of its larger size. The close anatomic proximity of the organs in a child's abdomen appears to make surgical intervention necessary for the majority of children with penetrating injury to the hepatic bed, and indicates that this approach should remain the standard of care for pediatric patients.

Management of complicated appendicitis. A rational approach based on clinical course

OBJECTIVE

To better define the appropriate management of children with complicated appendicitis, using an outcome approach based on clinical parameters.

DESIGN

Retrospective study.

SETTING

A 500-bed tertiary care university-based hospital.

PATIENTS

Fifty-six consecutively admitted children (age <19 years) with a diagnosis of complicated appendicitis (gangrenous or perforated) confirmed at laparotomy.

INTERVENTION

All children were managed postoperatively using an institutionally established protocol requiring hospitalization and broad-spectrum intravenous antibiotics until three criteria were met permitting discharge: (1) resolution of fever for 24 hours; (2) normalization of white blood cell count; and (3) normal results of clinical examination.

MAIN OUTCOME MEASURES

Length of stay, costs, and infectious complications.

RESULTS

Overall, infectious complications occurred in only two patients (3.5%). No complications occurred in any patient who met the criteria for discharge. The average length of stay for all patients was 5.1+/-3.0 days (range, 3 to 18 days). Using this approach instead of current standards reported in the literature resulted in an estimated savings of over $4000 per patient and $224000 for the entire cohort.

CONCLUSIONS

Postoperative management of complicated appendicitis can be safely based on a defined clinical algorithm that should replace empirical therapy as the "gold standard."

Continuous thoracic epidural infusions for postoperative analgesia after pectus deformity repair

PURPOSE

To determine whether continuous epidural analgesia after repair of a pectus deformity is a viable and safe alternative to high-dose narcotics in children.

METHODS

Data were collected prospectively for 19 children (4 to 17 years of age; 15 boys, 4 girls) who underwent pectus excavatum (14) or carinatum (5) repair between June 1, 1991 and July 1, 1994. Seventeen had a thoracic epidural catheter placed for postoperative pain control and two did not. The epidural catheter was routinely plead preoperatively by the anesthesiologist at the T3-T8 level, after induction of general anesthesia. Epidural catheters were test-dosed with local anesthesia alone or in combination with fentanyl, and afterward a continuous epidural infusion was maintained on the floor. Postoperative pain was assessed by nursing and house staff on the Wong-Baker scale, with adjustment of the dose rate or analgesic medication as appropriate.

RESULTS

All patients had extubation before leaving the operating room and were sent to the general pediatrics ward after leaving the recovery room. The average duration of the epidural was 69 hours (range, 20 to 116 hours). Sixteen patients received their test epidural dose preoperatively, and one patient had his in the recovery room. Fifteen epidural initially were dosed with bupivicaine (1 to 2 mg/kg) alone or in combination with fentanyl (1 to 2 micrograms/kg). Two patients received initial doses of lidocaine (1 to 1.5 micrograms/kg). Ten of 17 patients received fentanyl (1 microgram/kg/h) with bupivicaine (0.5 to 1.0 mg/kg/h) in the epidural as their maintenance medication, and the remainder received bupivicaine alone at the same dosage rate. Eight of 17 patients required additional intermittent supplemental narcotics, with an average of two doses of intravenous morphine per day (0.1 mg/kg) over the first 3 postoperative days. In contrast, the two patients who did not have an epidural catheter for pain control required high-dose intravenous morphine (0.2 mg/kg) every 2 to 3 hours for the first 3 to 4 postoperative days. No catheter-related complications occurred.

CONCLUSION

Thoracic epidural analgesia was completely successful in nine (53%) children who underwent repair of pectus deformity, and effectively reduced the intravenous narcotic demand in the other eight. Pain control was excellent, and no catheter-related complications were encountered. The data show that this method of analgesia in children is a safe and attractive alternative to intravenous narcotics, and eliminates the potential disadvantages of sedation and respiratory compromise.

Epidemiology of rural traumatic death in children: a population-based study

To determine the epidemiology of traumatic death in pediatric patients in a rural state, we reviewed all deaths caused by injury in victims < 19 years old between 1985 and 1990. We hypothesized that mortality would be higher than equivalent populations in urban areas. During the study period, 5,322 children were hospitalized for trauma (14% of total admissions for children in the state) and 36 died (0.67%). For this subgroup, head injury was the most common cause of death (72%). When compared with data from the National Pediatric Trauma Registry from urban centers, the mortality rate for hospitalized children in this rural state was lower (0.67% vs. 2.7%, p < 0.001). On review of the population-based statistics for the entire state, we found that these numbers were deceivingly low. In all, 731 children died during the study period, of which 283 were determined by autopsy or coroner's report to have died of trauma (38.7%). Eighty-seven percent of children who died never reached the hospital. Mortality (age-adjusted) was highest in the 15- to 18-year-olds (68.5 of 100,000), then < 1-year-old (26.8 of 100,000), 1- to 5-year-olds (15.6 of 100,000), and 5- to 14-year-olds (11.8 of 100,000), which significantly exceeds the predicted national averages for these age groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonoperative treatment of a major hepatic injury in a hemophiliac

Selective nonoperative management of hepatic injuries from blunt trauma has become an accepted practice over the past 10 years. A case of nonoperative management of a major hepatic injury in a person with Hemophilia A is reported. Treatment with aggressive blood component therapy resulted in a successful outcome.

Management of pediatric blunt splenic injury: comparison of pediatric and adult trauma surgeons

The majority of injured children requiring hospitalization in the United States are cared for by nonpediatric surgeons. To determine whether there are differences in the management strategies (frequency of operative intervention) of pediatric and nonpediatric surgeons caring for children with blunt splenic injury, the data for children with this injury from the entire state of Vermont and the National Pediatric Trauma Registry were compared. From January 1, 1985 through December 31, 1991, 817 children (aged < 19 years) were entered into the study. There was operative intervention for splenic injury in 21% of the children managed by pediatric surgeons and in 52% of those managed by "adult" trauma surgeons (P < .05). This significance was maintained when operative rates were analyzed with control for injury severity score and age. The overall splenectomy rate was higher among cases treated by nonpediatric surgeons (24% v 13%; P < .05). In addition, previously reported factors (transfusion requirements, length of stay, hospital costs) used by opponents to nonoperative management were studied to determine management influence. Both transfusion requirement and hospital cost were lower for patients managed nonoperatively (P < .05). Length of hospital stay did not differ between the groups. Acute mortality rates were similar. The management of children with splenic injury must take into consideration the long-term morbidity associated with splenectomy as well as the acute operative morbidity. Today, adult trauma surgeons appear to manage children with blunt splenic injury with practice standards more appropriate for adult patients. Outcome analysis must include methods of care and their long- and short-term consequences to be considered valid.

Pulmonary embolism in pediatric trauma patients

Recent articles in the literature on adults have recommended prophylaxis for pulmonary embolism (PE) in selected trauma patients; however, to date no information is available regarding pediatric patients. We decided to investigate whether the incidence of PE in pediatric trauma patients is as high as that reported in adults, and identify those children who might be at high risk and benefit from prophylactic treatment. Utilizing the data from the National Pediatric Trauma Registry (NPTR), records were reviewed of all pediatric trauma patients (age < 19 years) admitted to the participating institutions between December 1987 and February 1993. Patients with documented PE were identified as well as those having associated risk factors as identified in adult trauma patients (deep venous thrombosis, extremity injury, spinal cord injury, and head injury). A total of 28,692 pediatric trauma patients were reviewed from the NPTR. The mean age was 9 years and the mean Injury Severity Score for the group was 11. Two thousand one children (7%) had serious head injuries (Glasgow Coma Scale score < 8), over 5700 (20%) had an isolated extremity injury, 290 had an identified spinal cord injury (108 with associated paralysis), and deep venous thrombosis was identified in 6 patients. Pulmonary embolism occurred in only two of the children in this series. Both patients with PE had spinal cord injuries with associated paraplegia, significant pulmonary injury, and high ISSs (25 and 27). The overall incidence of PE in the group was 0.000069%, and for those children with paralysis from spinal cord injury 1.85%.(ABSTRACT TRUNCATED AT 250 WORDS)

Spinal anesthesia for primary repair of gastroschisis: a new and safe technique for selected patients

Spinal anesthesia has been described for infants and premature babies undergoing minor operative procedures. The advantages of shorter operating time, avoidance of intubation, and shorter hospital stay have made this the gold standard for premature and other high-risk infants requiring minor procedures. However, little is known about this technique for major interventions in newborns and preterm infants. Recently, four infants born with gastroschisis underwent repair under spinal anesthesia. Two had accompanying intestinal atresia (one with a prenatal perforation and pan-hypopituitarism), and two had intact gastrointestinal systems. The gestational ages were 39, 33, 36, and 36 weeks, respectively. All had primary closure of the defect; one had no repair of the atresia because the bowel was thick and matted with a significant peel, and the defect was not identified. In the second case with atresia, necrosis and perforation of a localized segment of intestine was identified proximal to the intestinal atresia, and was exteriorized with the primary repair. When they arrived in the operating room, all four infants were breathing spontaneously, on room air, after appropriate fluid resuscitation. All underwent spinal anesthesia, which was the only agent used for the operation. The operative time was 45, 25, 30, and 25 minutes, respectively (mean, 31.25 minutes). The duration of anesthesia was 170 to 230 minutes (mean, 205 minutes). All infants were returned to the neonatal intensive care unit on room air and breathing spontaneously. One was given morphine postoperatively and suffered significant respiratory depression, requiring intubation. It appears that spinal anesthesia is safe and effective for major operative procedures in high-risk infants. (ABSTRACT TRUNCATED AT 250 WORDS)

Prompt fixation of isolated femur fractures in a rural trauma center: a study examining the timing of fixation and resource allocation

Early fixation is defined by most authors as fracture fixation within 24 hours of admission. This definition of early is arbitrary and may not be achievable in a rural environment where interhospital transfer is often required and operating room resources are constrained. A review of isolated femur fractures was performed to determine if prompt fixation (24-72 hours, Early) was more effective than late fixation (> 72 hours, Late) and similar to immediate fixation (< 24 hours, Immediate) with regard to complications, mortality, and resource utilization. Between October 1, 1987 and December 31, 1990, 67 patients were admitted and stratified into one of the three groups based on the timing of fixation. The number of emergency operations was significantly greater in the Immediate group and the surgery took significantly longer to perform than in either the Early or Late groups (p < 0.004; ANOVA). There were significantly fewer pulmonary and infectious complications in the Immediate and Early groups compared with the Late group (p < 0.05, chi 2). Fixation of isolated femur fractures after 24 hours but before 72 hours had morbidity similar to fixation within the first 24 hours, but utilized operating room resources more efficiently.

The epidemiology of injury in a rural state: 5,322 cases over 6 years

Presently, descriptions of rural trauma are complications of national sample statistics and local data from states projected to rural areas. This study reviews all hospital discharges (36,866) for children (aged 0 to 18 years) from January 1985 through December 1990 in an entirely rural state. Fourteen percent of admissions (5,322) were due to traumatic injury and 63% of these occurred in boys. Injury rates were age dependent with children 15 to 18 years experiencing an incidence of 110/10,000; 10 to 14 years 55/10,000; 5 to 9 years 39/10,000; 1 to 4 years 35/10,000; and < 1 year 39.5/10,000. Mean age for the entire population was 11.4 +/- 5.7 years. Thirty-five percent of children had more than one major site of injury. Sixty-three percent of admissions were for blunt trauma and only 4.8% were penetrating. The remainder were due to burns, hanging, ingestion, and other toxic agents. Falls constituted the most prevalent cause of injury in this population occurring in 25.9%, motor vehicle accidents 22.9%, struck by an object 9.6%, suicide attempts 8.5%, poisoning 4.7%, fire 1.2%, drowning 0.7%, and farm machinery 0.3%. The vast majority of motor vehicle accidents involved the child as an operator or occupant of the vehicle. Less than 10% involved a pedestrian being struck and less than 5% involved a child being struck while on a bicycle. Less than 6% of all injuries involved a bicycle. Child maltreatment was recorded in less than 2% of this population. Only 3.3% of injured children required transfer to another acute care facility (1/3 because of a motor vehicle accident and 1/4 because of a fall).(ABSTRACT TRUNCATED AT 250 WORDS)

Regional anesthesia in pediatric surgery: complications and postoperative comfort level in 174 children

Postoperative pain control (PPC) in children is a difficult management problem. Systemic narcotics often result in respiratory depression, while nonnarcotic analgesics are associated with inconsistent PPC. This report reviews a 29-month (January 1989 through July 1991) experience with 174 children (aged < 18 years) who received regional PPC through indwelling catheters. There were 105 males and 69 females. Patient age ranged from 1 day to 17 years 10 months (mean age, 97 months). All catheters were placed using introduction needles ranging from 24 to 16 gauge. Agents were delivered as either continuous infusion (151 patients, 87%) or bolus injections (23 patients, 13%). Analgesics were age- and weight-determined dosages of bupivacaine with or without narcotic supplementation. All patients had surgical procedures except two who had catheters placed for pain control after trauma and one who had a catheter for intractable abdominal pain of unknown etiology. Twenty-five (15%) children had thoracic incisions, 76 (43%) abdominal, 16 (9%) flank, and 54 (31%) extremity. Catheter placement included 40 thoracic epidurals (23%), 100 lumbar (57%), 27 caudal (16%), and 7 pleural (4%). Catheters were utilized for a duration of 0.5 to 8 days (mean, 2.1 +/- 1.2 days). One hundred forty-four children required no additional pain medications (83%). Thirty (17%) patients required supplemental medications. Acetaminophen was used in 6 (3%), acetaminophen with codeine in 4(2%), morphine in 18 (10%), and Percocet in 1(1%). Minor complications occurred 21 times in 16 children (9%).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of hypotension and hypoxia on children with severe head injuries

Survival of children (< 17 years) with severe head injuries (Glascow Coma Scale [GCS] score < 8) has been shown to be better than that of adults. The addition of hypotension (HT) or hypoxia (H) has a deleterious effect on outcome in adults but no information is currently available about their effects in children. Over a 5-year period, 58 children with GCS scores < 8 were admitted and prospectively evaluated at this institution. Patients were divided into two groups on the basis of systolic blood pressure (SBP) and arterial blood gasses. Patients exhibiting HT, defined as a SBP < 90 mm Hg, and patients demonstrating H with a PaO2 < 60 mm Hg were compared with normoxic, normotensive children. Survival was increased fourfold in patients with neither H nor HT as compared with children with either H or HT (P < .001). To validate these observations we reviewed the data from the National Pediatric Trauma Registry for similar patients and included our cohort in the analysis. In total, 509 children had sufficient data for analysis and were studied. Hypoxia alone was not associated with increased mortality in normotensive patients (P = .34). Hypotension significantly increased mortality in these children even without concomitant H (P < .00001). If both HT and H were found together, mortality was only slightly increased over those children with HT alone (P = .056). These data confirm that HT with or without H causes significantly increased mortality in head-injured children to those levels normally found in adults (P = .9), alleviating any age-related protective mechanisms normally afforded.(ABSTRACT TRUNCATED AT 250 WORDS)

Improved outcome utilizing spinal anesthesia in high-risk infants

The development of apnea following general anesthesia in high-risk infants (less than 60 weeks postconceptual age) has been reported up to 37%, prompting the routine admission of these children following minor surgical procedures. One hundred forty high-risk infants (American Society of Anesthesiologists category greater than or equal to 2) were prospectively evaluated after undergoing surgical procedures normally performed as outpatients in low-risk babies. All patients had spinal anesthesia for their operations. The mean gestational age for these infants was 30.8 +/- 3.7 weeks (minimum, 24 weeks) with a mean birth weight of 1,466.0 +/- 638.8 g. The mean postconceptual age and weight at the time of surgery were 44.8 +/- 7.8 weeks and 3,336 +/- 1,242 g, respectively. Difficulty in administering the spinal anesthetic occurred in 6 cases (4.2%). Postoperative complications occurred in 5 children (3.8%). They were: postoperative fever (2), transient bradycardia (2), and apnea (1). The four cases of postoperative fever and bradycardia were insignificant and required no medical intervention. The single case of apnea occurred in a premature infant who received a supplemental dose of intravenous midazolam. Length of operation in these cases ranged from 15 minutes to 95 minutes (mean, 53 minutes), with two incidents of inadequate anesthesia occurring in this cohort. Mean duration of anesthesia was 146 minutes (range, 50 to 240 minutes) and was directly dependent on dosage administration of the agents. These data indicate that the use of spinal anesthesia in high-risk infants is safe and effective for surgical procedures generally performed as outpatients (3.0% minor complication rate, 0.8% major complication rate).(ABSTRACT TRUNCATED AT 250 WORDS)

Inguinal hernia in children: factors affecting recurrence in 62 cases

This report analyzes factors associated with 71 recurrent inguinal hernias in 62 children treated between 1976 and 1988. Cases were evaluated for sex, age, type of initial repair, interval to recurrence, the presence of comorbid conditions, and type of reoperation. There were 57 boys and 5 girls. Sixty percent of patients were less than 6 months old and 72% were less than 1 year of age at the time of the initial repair. Recurrence was on the right in 74%, left in 24%, and bilateral in 2%. Recurrence was noted by 6 months in 50%, by 2 years in 76%, and by 5 years in 96%. Comorbid conditions were present in 60% of cases, including increased intraabdominal pressure (ventriculoperitoneal [VP] shunts), growth failure, prematurity, chronic pulmonary disease, bladder exstrophy, connective tissue disorders, cryptorchism, seizure disorder, and malnutrition. Incarceration was a factor in four of the 62 cases. Seven patients had multiple recurrences. Fifty-one recurrences were indirect, whereas 20 were direct inguinal hernias. Inadequate high ligation (three with chromic catgut), wound infection, and groin hematoma were other findings. The direct hernias may be related to injury to the floor of the canal during initial repair. Recurrent repair included high ligation of the sac alone (20), high ligation plus snugging of a large internal ring (11), and high ligation with repair of the iliopubic tract in patients with VP shunts, connective tissue disorder, or weak floor (20). All direct hernias had a Cooper's ligament (McVay) repair. Two direct hernias recurred again and were successfully repaired using a preperitoneal approach.(ABSTRACT TRUNCATED AT 250 WORDS)

Pancreatic tumors in childhood: analysis of 13 cases

Pancreatic tumors are rare in children. Over a 20-year period we have treated 13 children with pancreatic neoplasms. There were eight boys and five girls (age range, 4 months to 12 years). Seven tumors were benign, including five insulinomas, and two cystadenomas. Six lesions were malignant (rhabdomyosarcoma, 2; pancreatic carcinoma, 4). Children with insulinoma presented with hypoglycemia and irrational behavior. Three had abnormal insulin:glucose ratios ( greater than 1.0). The tumor was detected by computed tomography scan in three cases, at the time of surgery in one, and with intraoperative ultrasound in one. Surgical treatment included tumor enucleation in four cases and 80% pancreatectomy in one. Mucinous cystadenomas were observed in two patients, ages 4 months and 10 months. Tha latter infant underwent cyst excision alone, resulting in malignant recurrence at 18 months of age and death. The 4-month-old child had a distal pancreatectomy and is alive at 6 years. Two of the four children with pancreatic cancer had unresectable tumors at diagnosis, and were treated by biopsy (ductal adenocarcinoma), irradiation, and chemotherapy. Length of survival was 6 months and 9 months. Two others (ages 4 and 12 years) underwent 85% distal pancreatic resection for pancreatoblastoma and a pancreatoduodenectomy for papillary carcinoma, respectively. The latter is alive and tumor-free at 20 years of follow-up. The former underwent hepatic lobectomy for a 3.0 x 3.0 cm solitary liver metastases and is alive at 6 years with no evidence of disease. One child with rhabdomyosarcoma died of progressive disease, the other is alive with residual disease despite resection and chemotherapy. Most insulinomas can be treated by enucleation.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure of percutaneous drainage in children with traumatic pancreatic pseudocysts

Recent reports have documented the successful use of percutaneous drainage (PD) in the management of traumatic pancreatic pseudocysts in children. This study presents four cases of pancreatic pseudocyst in which percutaneous catheter drainage was performed. In one instance, no operative therapy was required. However, in the other three cases PD failed to resolve the problem and distal pancreatectomy with splenic salvage was performed when contrast studies (endoscopic retrograde cholangiopancreatography or catheter injection) demonstrated disruption of the main pancreatic duct. This report suggests that children with pancreatic pseudocysts unresponsive to PD require prompt investigation of ductal anatomy to rule out transection or other major injury.

Anomalies of intestinal rotation in childhood: analysis of 447 cases

This report concerns 447 infants and children with anomalies of rotation and fixation. Patients were placed in four groups based on initial symptoms. Group A involved 18 patients with acute midgut volvulus. At laparotomy, midgut volvulus was noted and reduction of midgut volvulus and a Ladd procedure were performed in 10 cases and resection was required in 8. There were five deaths (28%). Group B included 54 children with chronic symptoms of intermittent volvulus or duodenal obstruction. Group C involved 44 cases of malrotation observed during exploration for other disorders. Patients in groups B and C underwent a Ladd procedure and appendectomy. There were five unrelated deaths. Group D included 331 neonates with malrotation caused by either diaphragmatic hernia (n = 111) or abdominal wall defects (n = 220). A Ladd procedure was performed on 48 patients with abdominal wall defects and 29 surviving children with diaphragmatic hernia. Only 2 of 172 (1.2%) patients with abdominal wall defects and 1 of 34 (2.9%) patients with diaphragmatic hernia not treated for malrotation had midgut volvulus. Midgut volvulus is more common in infants and is associated with a high mortality rate (28%). Patients with malrotation and chronic obstructive symptoms or those observed during other elective procedures should undergo a Ladd procedure because of the risk of midgut volvulus. The risk of midgut volvulus is low in patients with abdominal wall defects and, probably as a result of adhesions from previous neonatal operations.

Pulmonary hypertension in neonatal cystic lung disease: survival following lobectomy and ECMO in two cases

Extracorporeal membrane oxygenation (ECMO) is an accepted form of therapy in the treatment of neonates with otherwise lethal persistent pulmonary hypertension related to meconium aspiration, congenital diaphragmatic hernia, and sepsis. This report concerns two neonates with congenital cystic lesions of the lung who developed severe pulmonary hypertension and were salvaged with lobectomy and ECMO. These cases present an additional group of patients in whom ECMO may be a life-saving measure.

Delayed onset of intestinal obstruction in children after unrecognized seat belt injury

The increased use of child safety seats and seat belt restraints has significantly reduced the incidence of severe head injuries associated with motor vehicular accidents. However, an increase in the number of both acutely recognized intestinal perforations and delayed obstructions due to ischemic strictures has been noted. This report describes two children with delayed onset of intestinal obstruction related to the "seat belt syndrome" who presented with bilious emesis 3 to 6 weeks following an unrecognized lap belt injury. At laparotomy, a volvulus around an omental band adherent to a resolving traumatic mesenteric hematoma was the basis of the obstruction in both cases. The volvulus resulted in a stricture in each instance that required resection and end-to-end anastomosis. The diagnosis of posttraumatic intestinal obstruction should be suspected in children who develop nausea and bilious emesis following motor vehicular accidents in which they were wearing lap belts.

The effect of chloroquine and hyperthermia on murine neuroblastoma

A number of reports suggest that hyperthermia is an effective adjunctive treatment modality in management of neural crest tumors. Recent studies have demonstrated a synergistic effect of induced hyperthermia when coupled with chloroquine in an in vitro model. This study examines the effect of chloroquine and hyperthermia in an in vivo murine neuroblastoma model. Forty-seven Ajax white mice (weighing 20 to 30 g) received a subaxillary tumor burden (C-1300 murine neuroblastoma) per trochar (1.25 x 10(6) cells). The tumor was then incubated for 9 days. Mice were then divided into four groups: group 1, controls (n = 15); group 2, hyperthermia (n = 12); group 3, chloroquine (n = 10); and group 4, chloroquine with hyperthermia (n = 10). Hyperthermia was induced with 40 to 69 mW/cm2 at 2,450 MHz microwave radiation for 4 minutes to achieve a temperature of 41.5 degrees C for 10 of 14 treatment days. Chloroquine was administered intraperitoneally at a dose of 40 mg/kg body weight for 10 of 14 treatment days. Mice were weighed and tumor size was determined daily. Animals were killed on day 21 and postmortem examination was performed, with tumors graded histologically. Animal weight, tumor weight, and tumor size were similar for all groups (P greater than .05). Mortality was 6% in group 1, 25% in group 2, 50% in group 3, and 40% in group 4 (P less than .05). Rate of tumor metastases was also statistically different from controls: group 1, 0%; group 2, 60%; group 3, 90%; and group 4, 90% (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Peritoneal dialysis in the first 60 days of life

This report describes a 7-year experience with acute peritoneal dialysis in 31 neonates and infants less than 60 days of age. There were 20 boys and 11 girls, ages 3 to 60 days. Tenckhoff catheters of modified length were placed in the newborn intensive care unit (ICU), pediatric ICU, or surgery suites, and hourly exchanges (20 cc/kg) were started immediately postoperatively. Diagnoses included congenital metabolic disorders (11), acute tubular necrosis (6), postcardiopulmonary bypass with renal failure (5), renal cortical necrosis (5), obstructive uropathy (2), renal agenesis (1), and bilateral renal dysplasia (1). Complications included: peritonitis (4), bowel perforation (1), exit site infection (3), leaking dialysate (4), catheter obstruction (2), inguinal hernias (3), umbilical hernia (1), and retroperitoneal hemorrhage (1). There were 19 deaths (61.3%) from 1 to 90 days postinsertion in this high risk group. The (1), and post liver transplant (1). Effective dialysis (lowering of blood urea nitrogen (BUN) or ammonia, correction of acidosis, decrease in fluid overload) was possible in all cases. Five of the 12 survivors remain on chronic dialysis awaiting renal transplantation. Peritoneal dialysis is effective in the newborn period in the management of metabolic disturbances as well as renal failure. Morbidity and mortality (61.3%) is related to the near-morbid condition of the baby at the time of insertion and the severity of the complex underlying diagnosis often associated with multiorgan failure.

Acquired aganglionosis: a rare occurrence following pull-through procedures for Hirschsprung's disease

Hirschsprung's disease (HD) is a neurogenic form of intestinal obstruction characterized by a congenital absence of ganglion cells in the submucosal and myenteric plexuses. Acquired aganglionosis (AAG) is a rare condition that may occur following various pull-through procedures for HD. This report describes five boys with acquired aganglionosis. In all cases, the presence of normal ganglion cells was confirmed on review of biopsies of the pull-through segments at the initial operation. The original pull-through procedure included Soave (2), Duhamel (2), and Swenson (1) operations. Three procedures were initially performed at other institutions. Recurrent symptoms including abdominal distention, obstipation, enterocolitis, and failure to thrive developed 7, 11, 12, 18, and 30 months postoperatively (mean, 15.6 months). The diagnosis of AAG was delayed 1.5 to 9 years after the onset of recurrent symptoms. Full column barium enema studies revealed a transition zone or narrow area in the rectosigmoid or descending colon in four children. Repeat full thickness rectal biopsies at 3.0 cm above the anal verge in the pull-through segment confirmed the absence of ganglion cells in each case. Two children (post Swenson and Duhamel) were successfully revised with a Swenson procedure. Two additional children (post Soave and Duhamel) were successfully treated with extended posterior anomyomectomy procedures. The remaining boy now has a preliminary colostomy and is awaiting a second procedure. Vascular compromise of the distal bowel segment at the time of the initial pull-through procedure may contribute to the selective loss of ganglion cells postoperatively as neural tissues are most sensitive to hypoxia.(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy of hepatoportoenterostomy in biliary atresia

This report describes the treatment and outcome of 66 infants with biliary atresia. Mean age was 79.8 +/- 33.2 days. Diagnosis was achieved by 99mTc DISIDA scanning. Hepatoportoenterostomy (HPE) was performed in 48 cases and hepatoportocholecystostomy in four, with microscopic ducts at the porta hepatis. Fourteen infants without microscopic ducts did not undergo HPE. Patients were staged according to the postoperative result. HPE was successful in 25% of patients (group A), resulted in improvement in 19% (group B), failed in 43% (group C), and was short-term in 13% (group D). In patients less than 90 days of age, the HPE success rate was 31%; 23% improved, and 33% showed no improvement. Age (less than 90 days) and bile clearance were prognostic determinants of success. Reoperation was useful only in patients with a previously successful HPE. Ten of 20 patients referred for liver transplantation survived (50%) (7/11) survived after liver transplantation and 3/9 on the waiting list). Fourteen of 15 patients in group A remain anicteric and well without liver transplantation. Patients in group B have had extended survival (greater than 3 years) but eventually required transplantation. Patients in group C and children more than 90 days old at diagnosis require early liver transplantation. HPE is a useful procedure when performed in infants less than 90 days of age who have biliary atresia.

Impaired bowel motility following small intestinal transplantation

Little information is available concerning motility following bowel transplantation and the appropriate timing of offering enteral feedings. Eight Lewis rats (300 g) underwent small bowel transplant as described by R. P. Harmel, Jr., and H. Stanley (J. Pediatr. Surg. 21:214, 1986). Silver oxide electrodes were placed in the native proximal ileum and in the distal segment of the homograft. Four control rats underwent laparotomy and placement of silver oxide electrodes in the jejunum and proximal ileum. Leads were brought out through a stab wound and the abdominal incision was closed. The electrodes were connected to a continuous recorder. Basal electrical rhythm (BER) was recorded periodically and was evaluated daily as the average of three readings per animal per day. Homograft electrical activity was not observed until at least 40 hr post-transplant and never attained the level of BER of the native intestine (P less than 0.05). Myoelectric complex potentials were not observed in the transplanted rats until post-operative day 11. These data suggest that basal electrical activity is significantly impaired following bowel transplantation. This study indicates that intestinal activity can be monitored for extended periods of time and may be a useful method of evaluating recovery of motility post bowel transplant prior to initiating enteral intake.

Pancreatic disorders in infancy and childhood: experience with 92 cases

Ninety-two children with pancreatic disorders were treated over a 10-year period. Thirty-three had blunt trauma, while 69 had medical, metabolic, or neoplastic diseases. Children with trauma had either duct disruption (3), gland fracture (4), or pseudocysts formation (26). Operation was required in 30. Pseudocysts were treated with observation alone in three cases, ultrasound-guided percutaneous aspiration in three, surgical external drainage in two, distal pancreatectomy in four, cyst gastrostomy in ten, and cyst-Roux-en-Y jejunostomy in six. Other disorders included pancreatitis (44), neoplasms (10), nesidioblastosis (4), and pancreaticosplenic abscess (2). Treatment for neoplasms included surgical excision in nine and biopsy in one (adenocarcinoma). Patients with nesidioblastosis underwent 95% (near total) pancreatic resection (two after previous unsuccessful 80% resection). Pancreatitis was familial in two cases, necrotizing in two, idiopathic in 11, and secondary to medications in six cases (steroids, 2; L-asparaginase, 4), gallstones in 17, and choledochal cysts in 6. Pancreatitis resolved after observation and conservative therapy in ten idiopathic cases, 4/6 medication-related cases, and following correction of biliary tract disease (15/17) or choledochal cysts (6). Pancreatic resection or drainage was required in the remaining cases. Pancreatic disorders can be accurately detected with computed tomography (CT) scan in most cases (excluding insulinoma). Ultrasound (US) is useful in cases of biliary tract disease and pseudocyst formation. Traumatic pseudocysts can resolve spontaneously or with US-guided percutaneous drainage (in the presence of normal ducts). Children with neoplasms, abnormal pancreatic ducts, or recurrent pancreatitis require resection or appropriate drainage procedures. Overall survival was 95%.

Pneumatosis intestinalis in children beyond the neonatal period

Pneumatosis intestinalis (PI) is a well-recognized manifestation of necrotizing enterocolitis (NEC) in the newborn--a condition that often requires surgical intervention for infarcted bowel. However, little information is available concerning PI in older children or its management. Sixteen older infants and children (greater than 2 months) had x-ray findings of PI (intramural air). There were eight girls and eight boys ranging in age from 2 months to 8 years. Associated conditions included short bowel syndrome (SBS) (8), congenital heart disease (2), iron ingestion (1), nesidioblastosis (1), hemolytic anemia (1), rheumatoid arthritis (1), bronchopulmonary dysplasia (BPD) (1), and malrotation (1). Clinical presentation included abdominal distension (13), bloody diarrhea (12), bilious emesis (5), and lethargy (5). Two patients on steroids had unsuspected PI identified as an incidental operative finding during pancreatectomy for nesidioblastosis (1) and splenectomy for hemolytic anemia (1), respectively. Only four other children (iron toxicity, postcardiac catheterization, rheumatoid arthritis, and BPD required surgical intervention. Each manifested peritioneal irritation, acidosis, and hypotension or had pneumoperitoneum on abdominal x-ray. In ten of 14 patients, PI was managed nonoperatively with nasogastric suction, fluid resuscitation, intravenous (IV) antibiotics (seven to ten days), and repeated abdominal x-ray and physical examinations. Children with SBS comprised 50% of the total number of patients and eight of ten treated by observation. All had associated viral syndromes (rotavirus) or rhotozyme-positive stools and developed bloody diarrhea. There were two deaths (12.5%) in patients with iron toxicity and congenital heart disease who required resection of gangrenous bowel. All of the other patients survived.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased incidence of delayed gastric emptying in children with gastroesophageal reflux. A prospective evaluation

Symptomatic gastroesophageal reflux is a common cause of failure to thrive, aspiration, and chronic pulmonary infection in infants. Gastric emptying was prospectively evaluated in 99 infants and children with symptomatic gastroesophageal reflux. Twenty-eight (28.2%) of 99 patients with gastroesophageal reflux had delayed gastric emptying. Twenty-one (75%) of the 28 patients underwent a concomitant gastric drainage procedure at the time of fundoplication. Seven had fundoplication alone and developed symptoms of early satiety, gas bloat, gagging, and pain postoperatively. Medical therapy was ineffective in these patients, and 5 improved after pyloroplasty. Delayed gastric emptying is common in patients with gastroesophageal reflux. These findings suggest that after fundoplication, symptoms of gagging, early satiety, and gas-bloat syndrome may be related to delayed gastric emptying. This implies that a gastric emptying study should be performed preoperatively.

Changing patterns of treatment and survival in neonates with meconium ileus

This report describes 51 neonates with meconium ileus and emphasizes a changing pattern of treatment and improved survival. Twenty-four neonates had uncomplicated meconium ileus due to inspissated meconium obstructing the distal ileum. Twenty-seven neonates had 41 complications of meconium ileus including volvulus (18), bowel atresia (13), perforation (5), and giant cystic meconium peritonitis (5). Nine patients with uncomplicated cases responded to nonoperative clearing of meconium using a meglumine diatrizoate (Gastrografin) enema. Six of 7 patients with enema failures underwent laparotomy, purse-string enterotomy, and intraluminal irrigation. The remaining 9 patients with uncomplicated meconium ileus had resection and enterostomy. Complicated cases were managed by resection and anastomosis (13) or enterostomy (14). Survival at 1 year was 92% in patients with uncomplicated meconium ileus and 85% for those with complicated meconium ileus. Nonoperative Gastrografin enema or enterotomy-irrigation can relieve obstruction in uncomplicated meconium ileus and avoid an enterostomy in most cases.

Gastrointestinal injuries in childhood: analysis of 53 patients

Gastrointestinal injuries were noted in 53 children. Blunt trauma was responsible for 51 cases, and penetrating wounds in two. There were 42 boys and 11 girls (mean age, 8.1 years). The site of injury was the stomach (2), duodenum (17), jejunum (19), and ileum (15). Types of injury included two gastric perforations, 16 duodenal hematomas, one duodenal laceration, 27 jejunoileal perforations, five mesenteric avulsions, one abdominal wall laceration and evisceration, and one entrapment necrosis between lumbar vertebrae. Diagnosis was accomplished by observing free air on x-ray, with contrast (duodenal haematoma), computed tomography, and frequent examination (noting peritoneal irritation). Thirty-four associated injuries occurred in 21 patients (40%) including the liver (6), pancreas (6), skeletal injury (6), head trauma (5), diaphragm (4), lung (3), spleen (2), and kidney (2). Nine of 16 duodenal hematomas resolved non-operatively, while seven were evacuated during other procedures. Twenty-three of 30 perforations had simple closure, while seven (jejunoileal) were resected. Mesenteric avulsions required resection in five cases--the eviscerated bowel was replaced and the entrapped bowel resected. Twenty complications occurred in 13 patients, including atelectases (6), pseudocyst (5), sepsis (4), wound infection (2), subhepatic abscess (1), subglottic stenosis (1), and short bowel syndrome (1). One infant (aged 2 months) with a duodenal laceration died of head injuries (1/53 = 1.8% mortality). Prompt recognition and appropriate treatment result in improved survival.

Evaluation of high-intensity therapeutic ultrasound irradiation in the treatment of experimental hepatoma

A study evaluating the efficacy of high-intensity therapeutic ultrasound (HITU) as a treatment modality in experimental hepatoma is reported. Morris hepatoma (3924) 1 x 10(6) cells were transferred subcutaneously into 40 male ACI rats (weight, 150 to 200 g). Animals were divided into four experimental groups: group 1 (n = 10) consisted of untreated controls; group 2 (n = 10) received intraperitoneal cyclophosphamide 50 mg/kg as a single dose; group 3 (n = 10) underwent HITU only; and group 4 (n = 10) received both chemotherapy (as in group 2) and HITU (as in group 3). HITU was administered with a 5.5-cm diameter 4-MHz quartz transducer creating a continuous wave with 400 W/cm2 focal intensity. The entire tumor was irradiated in 1-mm increments (horizontal and vertical) using treatment cycles of 4 seconds on and 11 seconds off. Total body weight and tumor volume were measured on the day of treatment, and 4 weeks later. At 4 weeks, the animals were killed, the tumor was excised and weighed, and tumor volume was determined. Tumor volume in all treated animals (groups 2, 3 and 4) was significantly smaller than in controls (P less than .001) at 4 weeks, and tumor volume for animals in group 4 was significantly smaller than for those in groups 2 and 3 (P less than .01). These data indicate that HITU significantly reduces tumor size when compared with control rats with Morris hepatoma. A synergistic effect of chemotherapy and HITU was observed and resulted in an enhanced tumor response and reduction of tumor size.(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative intussusception: experience with 36 cases in children

Intestinal obstruction is a common postoperative complication and is usually related to peritoneal adhesion formation. A less well-recognized cause is postoperative intussusception (POI). Thirty-six instances of POI in children (aged 1 month to 18 years) were treated between 1970 and 1987. POI followed Nissen fundoplication in 9 patients, neuroblastoma resection in 5, small-bowel procedures in 4, inguinal herniorrhaphy in 3, pull-through procedures in 3, ureterostomy in 2, thoracic procedures in 2, ventral hernia in 1, nephrectomy in 1, hepatic resection in 1, Heller myotomy in 1, ventriculo-atrial shunt in 1, and gastrocystoplasty in 1. Initial symptoms included bilious vomiting or increased nasogastric drainage (after initial return of gut function) in 26 patients, abdominal distension in 24, irritability in 10, intermittent pain in 7, palpable abdominal mass in 2, rectal bleeding in 2, and lethargy in 1. The symptoms occurred 1 to 24 days (mean, 8 days) after the initial surgery. Plain abdominal radiographs revealed multiple air-fluid levels in 31 and an "adynamic ileus" in five patients. Barium contrast techniques could successfully reduce two ileocolic and one distal ileo-ileal lesions. The remainder necessitated operative management. Manual reduction was possible in 29 cases, and four children with diagnostic delay required bowel resection and an anastomosis for intestinal necrosis. The site of intussusception was ileo-ileal in 23 patients, jejunojejunal in 6, ileocolic in 5, and jejuno-ileal in 2. The diagnosis of POI should be considered in children with signs of bowel dysfunction in the early postoperative period. Contrast studies are of limited value, since most cases are confined to the small bowel. A high index of suspicion and prompt laparotomy will usually allow manual reduction of the lesion. Diagnostic delay may result in bowel necrosis.

Impaired immune function in obstructive jaundice

Sepsis is a common and occasionally lethal complication of obstructive jaundice. The reasons for this increased susceptibility to infection are unknown. This study examines lymphocyte and reticuloendothelial (RES) function in animals with obstructive jaundice. Twelve New Zealand white rabbits (3-4 kg) were studied. Lymphocyte function was evaluated in six rabbits by phytohemagglutinin (PHA), concanavalin A (Con A), and pokeweed mitogen (PWM) stimulation. In six animals, hepatic RES function was assessed by calculating the phagocytic index (PI) using the disappearance of 99Tc sulfacolloid (5 mg/kg) iv. After baseline studies, the common bile duct was divided and ligated. The above studies and serum bilirubin were repeated at 3 weeks. Obstruction was then relieved by cholecystojejunostomy (CJ) and RES studies repeated monthly x 6. Preobstructive lymphocyte function showed a stimulation index ratio (log) of 0.85 +/- 0.25 for PHA, 0.75 +/- 0.3 for Con A, and 0.71 +/- 0.25 for PWM. With biliary obstruction, the values fell to -0.23 +/- 15 (P less than 0.006), -0.31 +/- 0.12 (P less than 0.006), and -0.29 (P less than 0.006), demonstrating impaired lymphocyte function. When tested lymphocytes were mixed with control pooled rabbit serum, however, no lymphocyte impairment was noted. Baseline hepatic PI was 6.02 +/- 0.18 and fell to 3.79 +/- 0.33 with obstruction (P less than .01) and remained low at (3.20 +/- 0.14) 1 month (P less than 0.01) and (3.33 +/- 0.23) at 3 months (P less than .01), after CJ but returned to normal (8.04 +/- 0.97) at 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Chest wall resection and reconstruction for malignant conditions in childhood

This report evaluates the efficacy of extensive chest wall resection and prosthetic reconstruction in 15 children with chest wall malignancies. There were nine boys and six girls, with a mean age of 9.6 years. Eleven patients had primary chest wall tumors including Ewing's sarcoma (ES), six; rhabdomyosarcoma (RH), two; chondrosarcoma (CS), one; Askin's malignant neuroectodermal tumor, one; and mesenchymal sarcoma, one. Four children had metastases to chest wall and lung from Wilms' tumor (WT), two; osteogenic sarcoma (OS), one; and neuroblastoma (NB), one. Chest wall resection of two to six ribs and reconstruction with Marlex mesh (seven), lattisimus flap (two), prolene mesh (one), and more recently, a Gortex patch (five), was performed. Eight of the patients required concomitant en-bloc pulmonary resection (wedge, five; lobectomy, two; pneumonectomy, one) and two required resection of diaphragm. Fourteen received adjunctive therapy (chemotherapy, 14; irradiation, eight [preoperative, five; postoperative, three]. Six patients had second-look resections after chemotherapy. There was no operative mortality. Early pulmonary function was normal; however, pulmonary restrictive disease and scoliosis occurred with growth. One ES patient developed a radiation-induced second malignant tumor at age 10 and one ES child died at age 6 (no evidence of disease) of meningitis. Average survival length for ES patients was 77 months (range, 18 to 132 months.) Currently, eight patients are alive and five are free of disease. Extensive chest wall resection and reconstruction is useful in the treatment of primary chest wall tumors, but is palliative in metastatic cases. The Gortex patch is the current prosthetic of choice.