Foreign body aspiration in children: value of radiography and complications of bronchoscopy

PURPOSE

The authors undertook a 10-year review of bronchoscopies for airway foreign bodies in children to test assertions in previous reports that (1) characteristic abnormalities in chest radiographs are important indicators of the need for bronchoscopy and (2) experienced operators incur negligible complications.

METHODS

The medical records of 293 children who underwent bronchoscopies by experienced pediatric surgeons for suspected airway foreign bodies were reviewed for patient age, symptoms, duration of symptoms before bronchoscopy, prebronchoscopy radiographs, type of foreign body, anatomic location of foreign body, success of bronchoscopic removal, length of hospital stay, and complications.

RESULTS

Of the 293 bronchoscopies, 265 showed airway foreign bodies. A choking episode was recorded in 228 of the 265 patients with foreign bodies and 5 of the 28 with negative bronchoscopy. The surgeon thought that radiographs were normal at the time of bronchoscopy in 110 patients who had foreign bodies. Nine patients with foreign bodies had atypical radiographs; three had bilateral emphysema and six had upper lobe or bilateral atelectasis or pneumonia. There were three complications: one vocal cord injury requiring temporary tracheostomy, one tracheal laceration from removal of an aspirated tooth, and one severe postoperative subglottic edema requiring a 4-day hospital stay. The age of the patients, symptoms, types of foreign bodies, locations of foreign bodies, management, and outcomes were similar to those of previous reports.

CONCLUSIONS

In children with airway foreign bodies, chest radiograph findings are frequently normal and can display abnormalities uncharacteristic for foreign body aspiration. Children witnessed to choke while having small particles in their mouths and noted subsequently to have raspy respiration, wheezing, or coughing should undergo prompt bronchoscopy regardless of radiographic findings. Complications of bronchoscopy for foreign body aspiration are uncommon but occur even in experienced hands.

Peripheral arterial missile embolization: a case report and 22-year literature review

The present case report is that of an air pistol missile injury with perforation of a common femoral artery and subsequent arterioarterial embolization to the anterior tibial artery. Included in this report is a review and analysis of a 22-year experience in the vascular trauma literature with missile injuries resulting in cardioarterial or arterioarterial embolization. In-depth analysis of this collective literature review revealed small weapon caliber (79%), usually .22. Soft tissue tamponade at the injury site in the form of mediastinal hematoma, retroperitoneal hematoma, or hemopericardium preventing exsanguination occurred in 37% of cases. Cardiac and thoracic aortic entry sites represented 70% of the series with distinct patterns of peripheral vascular embolization found resulting from anatomic relationships and laminar flow. Diagnostic evaluation by means of remote x-ray screening documented 86% of the emboli and was supplemented with arteriographic studies in 36%. Direct transverse arteriotomy overlying the projectile was favored; most of the delayed embolectomies stemmed from a failure to recognize those patients with peripheral embolization and a compensated asymptomatic limb. An appropriate management plan and diagnostic algorithm for this rare vascular phenomenon have been generated by this study.

Gastric teratoma with gastrointestinal bleeding

Gastric teratoma is a rare lesion seen most often in infant males. This case report and review of the literature indicate that an endophytic subtype can be associated with gastrointestinal (GI) bleeding. Neither the age of the patient, the gross appearance of the tumor, nor the presence of intestinal bleeding is evidence of malignancy in this benign condition and simple excision of the lesion is satisfactory treatment.

The current management of choledochal cyst

The diagnosis and treatment of choledochal cysts have changed dramatically in the past decade. Although history and physical exam remain paramount in arousing clinical suspicions, the classic triad of abdominal pain, jaundice, and a palpable mass is present infrequently. Ultrasonography can readily identify and precisely locate upper abdominal masses and distinguish between intrahepatic, extrahepatic, renal, and gastrointestinal cystic and solid masses. Use of the new iminodiacetic acid tracers then allows visualization of these cysts even in the presence of significant jaundice or abnormal liver function tests. For many years choledochal cystenterostomy was considered the treatment of choice because of the high morbidity and mortality originally associated with attempts at total excision. Over the years, evaluation of cystenterostomy has revealed an unacceptable rate of recurrent jaundice, ascending cholangitis, stone formation, and anastamotic stricture. In addition, a disturbing incidence of highly malignant biliary duct carcinoma that increases with the passage of time has been reported. Total excision of choledochal cysts has been reported in the English and Japanese literature with minimal morbidity and mortality and has become the treatment of choice. The authors' recent experience of two patients with this relatively rare condition confirms these changing trends and will be reported here.

The posterior sagittal approach to repair of vaginal atresia and imperforate anus

In 1982 deVries and Peña reintroduced the posterior sagittal approach for the repair of high imperforate anus, and it is already being utilized by many pediatric surgeons worldwide. This approach, the so-called "Kraske approach," has been used in the past for access to difficult rectal lesions, and has been applied to cloacal anomalies, again by Peña and deVries. We have recently applied this technique to repair a mid-vaginal atresia in a 12-year-old girl who also had chronic constipation and fecal incontinence following neonatal imperforate anus repair. The posterior sagittal approach allowed simultaneous reconstruction of the anus and vagina and may have application to the primary repair of ano-vaginal anomalies in infancy. The case history and a discussion of the technique form the basis of this report.

A modification of the MAGPI procedure

Since its description in 1981, the MAGPI procedure has rapidly assumed a major role in the repair of coronal and subcoronal hypospadias without chordee. Success with this procedure depends upon careful attention to detail and proper patient selection. Despite heeding these caveats the authors have noted occasional patients who, following completion of a MAGPI, have a disturbing "fishmouth" quality to the meatus. Herein is described a simple modification that seems to improve the cosmetic results when this situation is encountered.