Talc pleurodesis during videothoracoscopy for Pneumocystis carinii pneumonia-related pneumothorax. A new technique

Pneumocystis carinii pneumonia in AIDS patients represents a growing problem for chest physicians. For thoracic surgeons, spontaneous pneumothorax and recurrent or persistent pneumothoraces can complicate this disease, requiring surgical intervention. Minimally invasive videothoracoscopy has now become a standard form of surgery for these patients, and we present a technique of talc insufflation that we believe is safe, simple, cost-effective, and reliable.

Recombinant human granulocyte colony-stimulating factor promotes wound healing in a patient with congenital neutropenia

We report a patient with congenital neutropenia or Kostmann's Syndrome who suffered many complications after presenting with Clostridium septicum enterocolitis, including absence of wound healing. Because of several reports of the use of granulocyte colony-stimulating factor (G-CSF) in patients with various complications of neutropenia, we treated this patient with recombinant human (rh) G-CSF. We found that once rhG-CSF restored neutrophil counts to normal, progressive wound healing followed. Thus, rhG-CSF therapy may be useful in treating neutropenic patients with wound complications.

Immune consequences of nonoperative treatment of splenic trauma in the rat model

To investigate the immunologic consequences of non-operative management of splenic injury, three parameters were studied: survival following pneumococcal sepsis, clearance of blood-borne bacteria, following Hemophilus influenzae challenge, and antibody response to type III pneumococcal capsular polysaccharide. Two hundred twenty-five Sprague-Dawley rats were divided into three groups and subjected either to a splenectomy, a sham operation, or standard blunt trauma. A significant increase in mortality was noted in the splenectomized group as compared with both the traumatized and control groups when challenged with Streptococcus pneumoniae. In both the control and trauma groups, H influenzae cleared significantly within 18 hours. Blood-borne bacteria persisted at the same level for 72 hours in the splenectomized animals. Four and 11 days later, the antibody level in both traumatized and control groups was higher than in the splenectomized subjects (P less than .001). There was no difference in the serum antibody level between the control and trauma groups at four days. However, at 11 days the trauma group showed a significant decrease in the antibody level (P less than .05). It can be concluded that following spontaneously-healing splenic trauma in the rat model, survival, bacterial clearance, and antibody response were all superior to that observed in the splenectomized subjects. In addition, the healed splenic disruption did not impair clearance of blood-borne encapsulated bacteria.

The role of pediatric surgery in the medical school curriculum

In most medical schools, exposure to pediatric surgery is presented as a subspecialty elective. We have offered it as an integral part of the surgical clerkship for 10 years in the belief that it provides an excellent educational environment. To confirm this concept, the quizzes (Q), final examinations (FE), and grades of students assigned to the pediatric surgical service were prospectively studied. All students (N = 139) in the surgical clerkship entered the study. Thirty-two students were randomly selected and assigned to the surgical service of a major pediatric hospital (P-Surg) for 50% of their clerkship. The other students (N = 107) were assigned to a variety of adult surgical services (G-Surg) and served as the control group. All students attended the same seminars, used the same educational materials, were examined with the same test items, and were evaluated by the same oral examiners. Test items were electronically scored and the database was analyzed on an IBM computer. The statistical analysis was performed using a Student's t test and chi 2 analysis. There was no significant difference in the demonstrated cognitive performance and grades awarded to the two groups of students. We conclude that a pediatric surgical service provides an atmosphere that is educationally comparable to the adult general surgical service.

Omphalocele with pyloroduodenal obstruction by extrinsic hepatic compression: a case report

The diagnosis of gastroduodenal obstruction by hepatic compression following omphalocele closure must be suspected in the presence of persistent nonbilious vomiting. We feel that computed tomography (CT) is the appropriate imaging method to define the liver abnormality. Nonsurgical management is the best approach with nutritional support maintained by total parenteral nutrition until physiological resolution of the obstruction occurs.

Acute scrotal swelling as the first evidence of intraabdominal trauma in a battered child

Acute scrotal pathology often reflects intraabdominal disease. A bluish discoloration of the scrotum may represent blood migrating from a ruptured intraabdominal organ. A case of a battered child presenting with a swollen bluish scrotum is reviewed to draw attention to an early sign of intraperitoneal hemorrhage.

Intramural hematoma of the duodenum

Intramural duodenal hematoma in children is one of the least common injuries encountered. Because of the rarity of this problem, there has been little conformity of opinion as to the relative merits of operative vs nonoperative management. We reviewed 182 cases of this condition, of which 168 were taken from the English literature and 14 from our hospital. Pancreatitis was the most common associated intra-abdominal lesion (21%), while central nervous system, skeletal, and thoracic injuries (5%) accounted for the major extra-abdominal injuries. Hemophilia, von Willebrand's disease, and idiopathic thrombocytopenic purpura occurred in 7 cases and played a major role in the prognosis. Of these cases, 121 patients were treated surgically and 61 conservatively. The average hospitalization was 14 days for the surgical group and 11 days for the conservative group. There were 18 complications in the surgical group. It appears that most patients with intramural duodenal hematoma would respond well to conservative management. Surgery should be reserved for those cases that remain obstructed over seven to ten days or have evidence of perforation.

Intussusception: evolution of current management

The records of 583 children who were treated for intussusception at the Children's Hospital of Buffalo in the period 1930-1985 were reviewed. Following a change in management in 1970 from operative treatment to hydrostatic reduction of the intussusception by barium enema, two main groups are defined. In earlier years 95% of patients underwent operative reduction whereas in the latter period 92% had barium reduction attempted. The remaining 8% in this group had clinical contraindications for hydrostatic enema attempt. Ten percent had pathological lead points. Recurrent intussusception occurred in 50 cases (8.5%), 66% following barium enema reduction and 33% after surgery. The mortality in the earlier group was 3.9% and 1.3% in the latter group. No deaths occurred in patients treated successfully with barium enema reduction, and there were no deaths in the children with simple uncomplicated intussusception requiring surgery.

Advances in the management of infected urachal cysts

Persistent urachal remnants are uncommon congenital anomalies. Unless an umbilical fistula exists, infection may be the first indication of this abnormality. Five children received initial treatment for this problem at the Children's Hospital of Buffalo during a 20-year period, 1964 to 1984, and a sixth was seen secondarily. There were four boys and two girls; their ages ranged from 8 months to 9 years. Lower abdominal mass with fever and local tenderness were the most common presenting signs. Ultrasound was the most accurate study, correctly diagnosing the cyst in both patients so examined. Incision and drainage alone was performed in one patient. The other five were managed with antibiotic therapy and complete excision as the primary procedure. Cultures were obtained in five patients and were positive in four, growing Staphylococcus aureus in three and Escherichia coli in one. Significant genitourinary abnormalities were discovered in four of the five patients evaluated. It is concluded that the previously recommended therapy of incision and drainage followed by delayed resection was developed in the preantibiotic era to minimize the mortality from sepsis and the morbidity from recurrence. Our experience indicates that the use of appropriate antibiotics followed promptly by complete cyst excision as a primary procedure is both possible and safe in most cases. Furthermore, the large number of associated genitourinary abnormalities suggests that a complete work-up for these conditions should be performed.

Percutaneous central venous catheterization in children: first line choice for venous access

Percutaneous central venous (CV) catheters using the jugular and subclavian veins have been widely used for hemodynamic monitoring and for venous access in difficult clinical situations. However, peripheral venous cutdowns (PVC) still remain the primary mode of short-term venous access in children. To evaluate percutaneous CV line insertion as a routine procedure, a prospective study of 115 patients (75 CV and 40 PVC) was performed. Ages ranged from 1 day to 17 years; age and weight were similar in both groups. Eighty-three CV lines were attempted, with a success rate of 93%, while 82% of 49 PVC insertions were successful. Complications occurred in 11 (14%) patients with CV access and 31 (78%) with PVC lines. In the latter group, poor flow was a problem in 65%, infiltration in 37.5%, and phlebitis in 27.5%. In the CV group, arterial puncture occurred during insertion in 2 (3%) patients with no adverse sequelae, catheter slippage occurred in 4 (5%), and poor flow in 2 (3%). A large majority (79.2%) of CV lines functioned successfully until no longer needed, as compared with 15% of PVC catheters. The latter were removed before completion of treatment because of poor flow (40%), phlebitis (20%), or catheter problems (10%). Catheter sepsis was documented in only one CV line. Two cutdowns had major local infections. The average catheter longevity was 10.2 days for CV lines, 4.1 days for PVC.(ABSTRACT TRUNCATED AT 250 WORDS)

Presentation of congenital diaphragmatic hernia past the neonatal period

Congenital diaphragmatic hernias (CDHs) presenting beyond the neonatal period are a rare and unusual problem; they occurred in 11 of 83 children at our institution. Two discrete clinical groups were apparent: (1) younger children, with mainly respiratory symptoms; and (2) older children with gastrointestinal (GI) complaints. Chest roentgenograms suggested CDHs, but GI contrast studies were necessary for confirmation in eight patients. The diagnosis was made preoperatively in ten of 11 children. At operation, no peritoneal sacs were found, the hernial contents were viable in all patients, and malrotation was present in six of 11 patients. None had evidence of pulmonary hypoplasia. Congenital diaphragmatic hernias do present beyond the neonatal age group in a significant number of cases (13% in our series), and a diagnosis of CDH should be considered in any child with persistent GI or respiratory problems and abnormal chest x-ray film findings. The mortality rate in these patients is small, but morbidity may be significant.

The impact of computed tomography scanning on the child with renal trauma

A six-year experience using computed tomography (CT) in the diagnosis of blunt abdominal trauma was reviewed to assess the impact of CT scanning on a patient with renal injury. Three questions were evaluated: Does the increased sensitivity of the CT scan alter the indications for surgery? Does the CT scan help predict the course and eventual outcome of nonoperative therapy? Are there circumstances when the CT scan is not the most efficient and cost effective method of diagnosis? One hundred seventy six consecutive patients with suspected renal trauma were reviewed. One hundred thirty eight were evaluated by CT scan and IVP, the other 38 by excretory urogram alone. Forty four renal injuries were identified. Four of these patients required urgent surgery and four others required later operation for unsuspected congenital anomalies. The injuries sustained by the other 36 cases resolved without surgery. Each patient has been followed for 1 to 5 years following their trauma, and their status assessed by questionnaire and physical examination. The CT technique provides better definition of the injury upon which to base the decision to operate or to enter the patient into nonoperative management. The extravasation seen on CT scan is frequently exaggerated and should not be an absolute indication for exploration. The scan provides improved follow-up data as to completeness of healing and allows directions to be given to the parents concerning resumption of full physical activities. The patients with asymptomatic posttraumatic hematuria, have in our experience, a very low incidence of intraperitoneal or retroperitoneal injuries. Therefore, these patients do not require the advantages of CT scan and may be screened by the less expensive intravenous pyelogram.

The avoidable excesses in the management of perforated appendicitis in children

During a five-year period from 1979 to 1985, 100 consecutive children with perforated appendicitis were managed at our institution. These patients were divided into two groups, which were determined by length of illness and physical findings. Group A consisted of 88 children with signs and symptoms of peritonitis from appendiceal perforation. They were treated with fluid resuscitation, antipyretics, and triple antibiotics (ampicillin, gentamicin, clindamycin), and appendectomy within a few hours of hospitalization. Saline lavage was used. Group B was composed of 12 patients with a periappendiceal mass without generalized peritonitis who had symptoms of 6 to 12 days duration. They were treated nonoperatively with triple antibiotics and underwent interval appendectomy 4 to 6 weeks later. The complication rate for Group A was 6.8%. This included three wound infections (3.4%), one intra-abdominal abscess (1.1%), one patient with pneumonia and ileus (1.1%), and a small bowel obstruction (1.1%). These results are equivalent to the lowest complication rate reported in the literature, in which the treatment included transperitoneal drainage, antibiotic lavage, and parenteral antibiotics. Group B patients had a 16.7% complication rate, which included one small bowel obstruction and one recurrent intra-abdominal abscess. Our method of management resulted in the lowest complication rate reported to date in children with perforated appendicitis. Transperitoneal drainage, delayed wound closure, and antibiotic lavage were not used. Subcuticular incisional closure resulted in minimal wound care and excellent cosmetic results. The experience demonstrates that with proper timing of surgery and appropriate use of contemporary antibiotics, the morbidity of perforated appendicitis can be limited and excesses of treatment can be avoided.

Present concepts in the treatment of Wilms' tumor

Before 1969, 58 patients with Wilms' tumors treated at Children's Hospital of Buffalo had an all-stage survival of 57%. From 1970 to 1983, following the National Wilms' Tumor Study protocols, this survival rate has improved to 79% in the last 47 patients. With continued attention toward early diagnosis, accurate and complete staging, refinement of radiation and chemotherapy protocols, and absolute follow-up of all patients, the relapse-free survival rate will continue to improve.

Present concepts in the treatment of neuroblastoma

The outlook for the child with neuroblastoma remains dismal. The tumor has been known to undergo spontaneous resolution, and this phenomenon has led to increased interest and research in possible immune mechanisms that may be involved. Treatment often involves the use of surgery, radiation, and chemotherapy, frequently producing a short-term response, but a cure of the disease in an advanced stage can rarely be attributed to any of these treatment modalities. The present staging and treatment method used by the authors is that of the Pediatric Oncology Group (POG) #8104. As far as the immunological therapeutic approach is concerned, promising results have been obtained in animal studies with monoclonal antibodies and immunocellular components. Cumulative data from various pediatric centers have showed that the patient's age strongly influences the prognosis in all stages of the disease.

Advances in the treatment of rhabdomyosarcoma

Rhabdomyosarcoma is the most common soft tissue sarcoma in children under 15 years of age. Several decades ago it was associated with an 80% mortality rate. Recent advances with combined modality therapy have improved the 5-year survival rate to almost 70%. The focus for the improvement in treatment regimens is now shifting to concerns regarding the preservation of body function and the treatment of far advanced disease. Regardless of age, histology, stage, or site of primary tumor, there has been no group where chemotherapy has not been proven beneficial. The current recommendations used by the Intergroup Rhabdomyosarcoma Study, with regard to chemotherapy, are summarized. Radiation therapy adjunctive to surgery has a useful place in the treatment of rhabdomyosarcoma, but prophylactic nodal irradiation is not recommended. Involved nodes should, however, be treated. Since the potentially adverse side effects of chemotherapy and radiation are accentuated when combined, radiation therapy is no longer recommended in patients with group I rhabdomyosarcoma. Prognostic factors and future considerations from the operative standpoint are presented.

Wilms' tumor--treatment and results: a five-decade experience

During the past 53 years, 105 patients with Wilms' Tumor have been treated at the Children's Hospital of Buffalo. Prospective and retrospective staging of these cases has allowed comparison with other reported series. All-stage survival improved from 37% with operation alone to 46% with operation and planned radiotherapy. During the past 22 years, with the addition of adjunctive chemotherapy, all-stage survival is now 80% with lesser stage survival approaching 100%. Participation in the cooperative National Wilms' Tumor Study has brought the most effective proven treatment to the patient in the shortest period of time.

The effect of the immunomodulator corynebacterium parvum on hemisplenectomized mice

The immunomodulator Corynebacterium parvum stimulates the reticuloendothelial system and causes splenic hypertrophy. The ability of C parvum to stimulate splenic regeneration in hemisplenectomized mice and decrease susceptibility to intranasal pneumococcal challenge was studied. Mice were divided into two groups, control sham-operated (n = 48) and hemisplenectomized (n = 47) animals. Ten days later, each group was divided into two subgroups, those injected with C parvum (700 mcg IVP) and those injected with an equivalent volume of saline. The animals were challenged with Streptococcus pneumoniae, which was injected into one nostril three weeks postoperatively, and mortality was assessed. Four and one-half weeks postoperatively, splenic tissue was removed, measured, weighed, and submitted for histologic examination. The number of spleen cells per gram of tissue was assessed. Treatment with C parvum resulted in a significant increase in the splenic weight in both hemisplenectomized and control animals compared to similar saline-injected mice (P less than 0.001). The percentage increase in spleen weight of hemisplenectomized mice (106%) was significantly greater than that for control animals (56%; P less than 0.01). There was no significant difference among experimental groups in the number of spleen cells per gram of splenic tissue or in the histologic characteristics, indicating that C parvum stimulated relatively normal splenic growth. Survival following pneumococcal challenge was significantly increased for hemisplenectomized mice by C parvum treatment to a level that did not significantly differ from control mice. This study demonstrates that in mice the deficits related to resistance to infection and spleen size following hemisplenectomy are significantly improved by treatment with C parvum.

The intercostal vein: an alternate route for central venous alimentation

During the course of parenteral nutrition in infants, access to the central venous system may become limited due to thrombotic occlusion of the superior and inferior caval venous systems. When this problem arises, central venous access via the intercostal vein into the azygos system can provide a safe, relatively easy solution. A new technique utilizing this approach has been developed at our institution using silicone elastomer tubing joined with a Broviac catheter for long-term use. Thus far, six catheters have successfully been inserted with a mean duration of 52 days; one catheter was in place for as long as 110 days.

The nonoperative management of pediatric hepatic trauma

Although nonoperative therapy is well-accepted for renal and splenic injuries in children, this mode of treatment has not been widely advocated for children with blunt hepatic injury. Surgical repair or excision of the traumatized tissue has been the generally accepted standard of care. In the present series, 17 consecutive children between 2 and 13 years of age with liver trauma were managed by nonoperative means. Patients were carefully selected for treatment based on clinical criteria and initial computed tomography (CT) scan findings. The 17 patients with hepatic trauma identified by CT scan all responded to initial resuscitative measures. The children clinically remained stable and required only a limited number of transfusions. No immediate surgical intervention was necessary for isolated hepatic injuries. However, one patient required exploration due to an associated renal pedicle avulsion. One child required exploration on the fourth post-injury day because of a suspected infected hematoma. The remaining 15 injuries resolved without operation. Healing was documented on follow-up CT scans. The mean time required for resolution of the injury was 4 months. One child developed a late subhepatic hematoma which resolved without drainage. The progression of healing of hepatic parenchymal injuries was observed by serial CT scans. The liver injury progressed through stages of coalescence, resorption, and remodeling prior to final healing. Utilizing proper patient selection, many blunt liver injuries can be managed nonoperatively.

Chronic relapsing pancreatitis in childhood caused by pancreaticobiliary ductal anomaly

Chronic relapsing pancreatitis is a rare childhood disease. Although various obstructive phenomena have been implicated in its etiology, few reports have described the role played by anomalies of the pancreaticobiliary ductal system. Recently, a patient with a complex anomalous ductal communication was treated by us for chronic relapsing pancreatitis. This particular anomaly, and its clinical presentation, has not previously appeared in the literature. The problems associated with the diagnosis and surgical management of this patient have prompted this report.

Vasoactive intestinal peptide producing neuroblastoma

The Verner-Morrison syndrome has been described in 19 previous patients with ganglioneuroma and ganglioneuroblastoma but never neuroblastoma. Its occurrence following treatment of a neuroblastoma with chemotherapy with maturation of the tumor has only been reported on one previous occasion. Our case suggests that vasoactive intestinal polypeptide may be used not only as a diagnostic indicator for the presence of a neural crest tumor but also as a marker to monitor maturation of the tumor and indicate an improving prognosis.

Dental disease masquerading as suppurative lesions of the neck

Three female patients ages 16, 16, and 12, and an 8-yr-old male presented with neck pathology/2 with abscesses, 1 with a submandibular mass and 1 with a spontaneously draining abscess. In 2 instances, routine oral cavity examinations including percussion of the teeth, failed to reveal significant pathology. A detailed examination by a dentist, intraoral roentgenograms, and in the first child a sinogram, identified the etiology of the lesions as periapical infections. Review of the literature reveals that these patients characteristically receive multiple surgical procedures and courses of antibiotics prior to the recognition of intra-oral disease. Extraction, or root canal, is the definitive therapy that leads to involution of the sinus tract. These four typical cases are reported to illustrate the presentation and pathogenesis of this disease entity, and the importance of an adequate dental examination prior to surgery for a draining sinus of the neck.

The abdominal technetium scan (a decade of experience)

Out of 270 children with gastrointestinal symptoms, the indications for technitium scanning were: gastrointestinal tract bleeding (165 patients), abdominal pain (99 patients) and a history of intussusception (6 patients). Thirty children had abnormal findings, while the remaining 240 patients had "normal" scans. Four of the 30 children with positive scans were not explored, while the others underwent laparotomy. Of the 26 operated patients, 12 (46%) had a Meckel's diverticulum. Nine patients (34%) had other pathologic lesions that were detected by the scan. Five had true "false positives" as no pathologic lesions were found. Of the 240 children with negative scans, 19 were eventually explored because of persistent symptoms or clinical findings. Two of these had a Meckel's diverticulum. Eleven had a negative exploration while six had other surgical lesions. Technitium scan should reliably detect around 80%-90% of Meckel's diverticula. It will also accurately exclude the diagnosis of Meckel's diverticulum in over 90% of patients.

Fungal infection of a vascular prosthesis

Chronic debilitating hematological disorders and cytotoxic drugs may create conditions causing a predisposition to fungal infections of vascular grafts. Under such circumstances routine bacteriological investigations should be supplemented by specific fungal media cultures and microscopic examination of removed infected graft.