Xanthogranulomatous pyelonephritis in childhood

BACKGROUND

Xanthogranulomatous pyelonephritis is a severe, atypical form of chronic renal parenchymal infection accounting for 6/1000 surgically proved cases of chronic pyelonephritis. Its manifestations mimic those of neoplastic and other inflammatory renal parenchymal diseases and, consequently, it is often misdiagnosed preoperatively.

AIM

To examine the relation between clinical history and the results of renal investigations performed in children with xanthogranulomatous pyelonephritis.

METHOD

A retrospective review of 31 cases presenting with the histopathological diagnosis of xanthogranulomatous pyelonephritis between 1963 and 1999.

RESULTS

The mean follow up was 8.2 years. The male:female ratio was 1:1.1. The left kidney was affected in 26 of the 31 patients. The positive findings on examination and investigation at presentation were: fever, 16 children; pyuria, 26 children; positive urine culture, 16 children. A haemoglobin of < 100 g/l was measured in 27 of 31 patients and 15 of 18 patients tested had a raised erythrocyte sedimentation rate of > 20 mm in the first hour. Twenty six children had renal calculi, with a large reduction in the function of the affected kidney on isotope scintigraphy in 27 of the 29 patients tested. Hypertrophy of the contralateral kidney, shown on imaging, was present in 17 of 31 patients.

CONCLUSIONS

Increasing awareness of this condition should lead to the diagnosis being suspected preoperatively.

Aortopexy for tracheomalacia in oesophageal anomalies

Forty-eight patients with repaired congenital oesophageal anomaly underwent aortopexy for significant tracheomalacia between 1980 and 1990. Indications for aortopexy included recurrent apnoea/cyanosis in 31, near fatal episodes in 16, recurrent respiratory distress and infection in 20 and worsening stridor in 15. Gastro-oesophageal reflux was noted in 30 patients, recurrent fistula in 6 and oesophageal stricture in 14. Aortopexy cured near fatal episodes in all patients and resulted in improvement of airway obstruction in 95%. The procedure failed in 2 patients due to unrecognised bronchomalacia and phrenic nerve palsy respectively. Aortopexy is the primary procedure of choice for significant tracheomalacia when associated with near fatal episodes and significant airway obstruction.

The SIS extracellular matrix scaffold-preliminary results of use in congenital diaphragmatic hernia (CDH) repair

There is no ideal bio-tensile material for tissue replacement in paediatric surgical conditions. A variety of materials have been described to replace or reinforce tissue deficits in congenital diaphragmatic hernia (CDH). The problems with these materials range from extensive surgery to body wall deformity and hernia recurrence. The ideal graft would be safe, strong, have the potential to grow and not require replacement, not affect chest wall development or produce deformity, and have minimal risk of recurrence. Surgisis is a biomaterial composed of porcine intestinal submucosa that provides inherent tensile strength as a collagen lattice and is ultimately replaced by native collagen tissue. Our objective was to prospectively assess the utility of Surgisis as a replacement graft in a cohort of 10 children undergoing primary or recurrent CDH repair. The graft was well tolerated, and there was no recurrence of herniation. We conclude that Surgisis collagen mesh may be a useful alternative for tissue replacement or reinforcement in difficult cases of CDH and diaphragmatic agenesis. The biological framework of Surgisis may also prove useful in other situations of complex tissue loss in children.

Gastroschisis and exomphalos in Ireland 1998-2004. Does antenatal diagnosis impact on outcome?

Antenatal detection of anterior abdominal wall defects (gastroschisis and exomphalos) enables detailed prenatal planning and counselling with appropriate intrauterine transfer, delivery in a tertiary referral centre with prompt access to paediatric surgery and early surgical intervention. The authors believed that there was a relatively low rate of antenatal detection in Ireland and that an improved antenatal screening program would allow increased detection thus avoiding emergency retrievals from peripheral obstetric centres. Our hypothesis was that there was a significant difference in management and outcome in children with anterior abdominal wall defects detected antenatally and those detected at birth. All anterior abdominal wall defects in The Republic of Ireland are assessed and closed in two surgical centres, Our Lady's Hospital for Sick Children, and the Children's University Hospital, Dublin. A retrospective review of all admissions in both centres revealed 96 neonates with anterior wall defects (excluding bladder exstrophy and cloaca) over a 7 year period from 1998 to 2004 inclusive. Medical records, operative reports, neonatal databases and admission details were reviewed. The antenatal data search included anomaly detection, prenatal management plan and intrauterine transfer. Perinatal data included place of birth, weight, gestational age, mode of delivery, time to surgery and type of surgery, the time to establish full enteral feeding and the length of hospital stay were used as overall markers of outcome. Fifty-three patients had gastroschisis and 43 exomphalos with an antenatal detection rate of 53% (n = 28) and 34% (n = 15), respectively, with an overall detection rate of 44%. There was no significant difference in the median birth weight (2.83 vs. 2.85 kg), gestational age at birth (37 vs. 37 weeks), time to full feeding (12 vs.14 days) and length of stay (20 vs. 17 days) between those detected antenatally or postnatally, respectively. About 77 had a primary closure performed of which 63 infants had surgery within the first 24 h of life. There was no difference in the time to surgery, frequency of complications or the surgical outcome in either group. Intrauterine transfer did not affect any outcome measure assessed. The demographics and the presence of associated anomalies did not differ between the groups. The hypothesis that antenatal diagnosis in anterior abdominal wall defects improves outcome has been demonstrated to be false. Despite this result, the importance of antenatal screening and prenatal management of complex foetal conditions with consultation with experienced paediatric and neonatal staff is without doubt.

Glutathione S-transferase: a potential new marker of intestinal ischemia

BACKGROUND/PURPOSE

The accurate and early diagnosis of intestinal ischemia remains difficult chiefly because of a lack of a suitable marker that is noninvasive and easy to use. The glutathione S-transferases (GST) are a family of cytosolic enzymes involved in detoxification and released from a variety of cells when the cell membrane is damaged. The enzymes are distributed widely in the intestine and show isoform specificity in their distribution throughout the intestinal tract. Several previous reports have shown the utility of these enzymes in the diagnosis of liver and renal graft damage during and after organ transplantation. The object of this study was to determine if GST levels correlated with histologic changes of intestinal ischemia in a controlled animal model of mesenteric intestinal ischemia.

METHODS

Control and experimental male Sprague-Dawley rats underwent laparotomy and ligation of the Superior Mesenteric Artery (SMA) and both control and experimental animals were studied at 30, 60, 90, 120, and 240 minutes. Blood taken from the Inferior Vena Cava (IVC) and Portal Vein (PV) and jejunal and ileal perfusates were assayed for alpha and mu isoforms of GST using a commercially available enzyme immunoassay. In addition, jejunal and ileal segments were sampled and reviewed by a histopathologist blinded to the group being studied.

RESULTS

A reproducible pattern of intestinal ischemia was noted with worsening grades of injury observed with greater ligation times. Luminal alpha and mu GST release (as measured by the appearance in luminal perfusate) increased with increasing ischemia times. Increased ischemia times resulted in increased levels of alpha and mu GST in both portal and systemic venous samples but lagged behind the appearance of raised luminal GST values.

CONCLUSIONS

The results suggest that GST may be an interesting and useful marker in the early detection of intestinal ischemia. Its detection in peripheral blood has implications for a more detailed study design to determine the sensitivity and specificity of this marker in more diverse clinical conditions such as necrotizing enterocolitis and superior mesenteric artery occlusion.

Noninvasive measurement of regional blood flow in man

Regional blood flow in man is ideally measured by techniques that are noninvasive, accurate, and can measure flow repetitively with comparative ease. Although numerous noninvasive techniques are available, no single method records blood flow accurately in every location. The neophyte investigator is often faced with a confusing array of methods and can spend considerable time searching for the ideal one. This paper presents current methods available to the clinical or metabolic researcher and comments on the strengths and limitations of each method. It is hoped that this will allow more rapid selection of a flow measurement method that is tailored to each individual's need.

Renal function following extracorporeal lithotripsy in children

Although extracorporeal shockwave lithotripsy (ESWL) has revolutionised the management of urinary calculous disease, the long-term effects of ESWL on renal function are not known. This study of 18 children demonstrated a mild, statistically insignificant decrease of 15% in DTPA measured glomerular filtration rate following ESWL. In view of this, we recommend that pretherapy and posttherapy estimates of renal function be obtained in all patients undergoing ESWL. Long-term follow-up is necessary to further quantify the effects of ESWL on the developing kidney.

Extracutaneous Sweet syndrome involving the gastrointestinal tract in a patient with Fanconi anemia

Acute febrile neutrophilic dermatosis, or Sweet syndrome, is a cutaneous eruption characterized clinically by the appearance of painful red plaques and nodules and histologically by an intense dermal neutrophilic infiltrate. Extracutaneous manifestations are rare. We report a patient in whom otherwise typical cutaneous Sweet syndrome was accompanied by an extracutaneous manifestation in the ileum.

Multifocal infantile myofibromatosis and generalized fibromuscular dysplasia in a child: evidence for a common pathologic process?

Infantile myofibromatosis (IM) is a condition characterized by the formation of spindle cell tumors of skin, soft tissue, and viscera. Although small vessel involvement by the process is a frequently identified and indeed diagnostically useful histological finding, involvement of large vessels is not widely reported. Fibromuscular dysplasia (FMD) is a noninflammatory arteriopathy characterized by intimal, medial, and/or adventitial fibroplasias leading to luminal compromise and aneurysm formation. Although venous disease has been reported, involvement of arterioles and viscera has not been identified. We report a patient in whom IM was diagnosed, on the basis of multiple soft tissue tumors present from birth, who subsequently developed generalized and ultimately fatal FMD. These two conditions exhibit overlapping pathologic features, including pronounced intimal fibroplasia. Their occurrence in a single individual may provide insights into the pathogenesis of both conditions, suggesting that they represent part of the same spectrum of vascular myofibroblastic proliferations.

Gastric stromal tumors in children

Gastrointestinal stromal tumors (GIST) in children are rare and their behavior has been regarded as difficult to predict on pathological criteria. We report our experience with two gastric GISTs in children aged 10 and 11 years. Both remain alive and free of disease at 5 years and 2 years respectively. Comparison of the pathological features in the resected specimens with a recently proposed guidelines for predicting outcome in this group of tumors is reported.

Alpha glutathione S-transferase: a potential marker of ischemia-reperfusion injury of the intestine after cardiac surgery?

BACKGROUND

The aim of the study was to assess the utility of alpha glutathione S-transferase (alphaGST) as a potential marker of intestinal ischemia-reperfusion injury in children after cardiac surgery.

METHODS

Twenty-six patients undergoing cardiac surgery were enrolled in this longitudinal experimental study. Blood samples were drawn for analysis at specified time points during surgery and analyzed for alphaGST levels. Clinical indices of splanchnic morbidity were assessed up to discharge from hospital. Results were analyzed using Mann-Whitney tests and linear mixed effects models.

RESULTS

Two groups were identified. Group 1 (n = 16) showed no intestinal morbidity and group 2 (n = 10) had signs of intestinal morbidity. Statistical differences were shown between the 2 groups with respect to time with aortic cross-clamp (ACC) in situ, time on cardiac bypass, duration of operation, time to enteral feeding and full feeding, time on mechanical ventilation, and time in the intensive care unit postoperatively. The serum concentration of alphaGST was significantly higher for group 2 and this rise was greatest after removal of the ACC.

CONCLUSIONS

AlphaGST showed significant elevation in patients with prolonged bypass times and ACC times. These patients also displayed signs of intestinal morbidity, suggesting that this marker may be useful in screening patients at risk for intestinal pathology. This rise in alphaGST was associated with a prolonged ischemia time, and was greatest after the cross-clamp was released, suggesting that it is a postischemic reperfusion phenomenon leading to its elevation. A low alphaGST level appears to exclude significant intestinal ischemia.

The novel use of small intestinal submucosal matrix for chest wall reconstruction following Ewing's tumour resection

Chest wall reconstruction following major tumour resection remains a challenging problem in the paediatric population due to the need for growth and development following the repair. Synthetic non-biodegradable grafts and materials have led to asymmetrical growth and significant functional and cosmetic compromise. The ideal graft material should be biological non-immunogenic which enables natural healing and facilitates further growth. Ewing's sarcoma is an uncommon primitive neuroectodermal tumour which rarely occurs in the ribs. However, recent improvements in management have produced a significantly improved survival; increasing the importance of chest wall reconstruction. We prospectively assessed the utilisation of Surgisis (an acellular collagen matrix) as a replacement graft in two children undergoing primary chest wall reconstruction following tumour resection. Surgisis is derived from porcine small intestinal submucosa (SIS) that serves as a template for tissue reconstruction and remodeling. The graft was well tolerated; there was no herniation and it allowed normal symmetrical chest movement and growth to occur. The properties of SIS allows natural collagen growth and compares favourably with marlex mesh and other forms of chest wall reconstruction. We believe its unique properties allow it to act as a suitable framework for chest wall reconstruction allowing chest wall growth and development.

Nissen fundoplication for gastro-esophageal reflux in repaired tracheo-esophageal fistula

One hundred and fifty three patients had repair of tracheo-oesophageal fistula in a 15 year period of observation. Of these 55 had associated gastro-oesophageal reflux and of these 12 (8%) underwent a Nissen fundoplication. All patients manifested significant failure to thrive but weight-gain was documented in all patients following their fundoplication. Twenty five percent of patients demonstrated recurrent reflux in this study and emphasises the difficulty of treating gastro-oesophageal reflux in repaired tracheo-oesophageal fistula patients. Careful selection is important.

Pancreatic cystadenoma. A clinicopathologic study

A retrospective study of 19 patients with pancreatic cystadenoma included 15 patients with microcystic and 4 with mucinous cystadenomas. The typical clinical presentation was that of an elderly woman with an upper abdominal mass. An association with diabetes mellitus and extrapancreatic malignant disease was noted. Total tumor resection provided the best chance of cure and removed the risk of compression of adjacent organs and, in mucinous cystadenomas, the risk of malignant transformation.

In-situ emergency paediatric surgery in the intensive care unit

The role of surgery in the intensive care unit (ICU) remains unclear. Although previously shown not to increase morbidity for patent ductus arteriosus ligation, Broviac catheter insertion, and recently, general neonatal and paediatric surgery, there remains a reluctance to operate on sick patients in the ICU (in-situ surgery, ISS). A retrospective study of 25 critically ill children and neonates who underwent ISS was performed. Surgery was aided by operating loupes and a high-intensity headlight. ISS was not associated with any morbidity, and although a 36% mortality occurred in this small series, in no case was this due to ISS. ISS avoids the risks of transfer to the operating theatre and the potential delays in theatre access. Our results suggest that ISS in a tertiary-level paediatric surgical hospital is safe and does not impact adversely on clinical outcome.

Infrared laser Doppler flowmeter in the determination of small bowel perfusion after ischemic injury: comparison with the clearance of locally generated hydrogen and fluorescein angiography

The determination of small bowel perfusion after an ischemic insult is difficult. Regional perfusion was determined in an animal model of neonatal intestinal ischemia using the techniques of laser Doppler flowmetry and the clearance of locally generated hydrogen. Both methods reliably measured tissue perfusion in the areas of maximal ischemic injury. However, considerable variability, perhaps owing to motion artifact, was seen in areas of patchy necrosis. The results suggest that the laser Doppler flowmeter is a suitable technique to measure tissue perfusion in areas of maximal ischemia. However, efforts to reduce motion artifact will be necessary if the laser Doppler is to be used in tissue sites where blood flow is critical for safe anastomosis. This will be a subject of future study.

External carotid artery ligation for life-threatening hemorrhage in exsanguinating orbital facial congenital hemangiopericytoma

A 7-week-old infant with a locally invasive, orbital, congenital hemangiopericytoma underwent emergency external carotid artery (ECA) ligation for exsanguinating hemorrhage from an intraoral biopsy site. ECA ligation was successful in controlling the life-threatening hemorrhage and in reducing tumor size and vascularity. The location and extensive nature of the tumor prevented primary excision. Preoperative adjuvant chemotherapy was unsuccessful in controlling tumor growth. After ECA ligation, with reduction in tumor bulk and blood supply, the tumor was radically excised. This technique has important implications in the management of patients with extensive hemangiopericytomas or sino-facial tumors previously regarded as unresectable and which present with life-threatening hemorrhage.

The effect of two-stage orchiopexy on testicular growth

Testicular growth was measured in 33 males who had undergone 2 orchiopexies on the developing testis. Multiple surgery on the abdominal or canalicular testis was associated with a high rate of testicular atrophy (40%) and a 46% decrease in testicular volume. A similar decrease (43%) in testicular volume was noted in those patients with an infracanalicular testis but no testis atrophied in this group. The results suggest that primary orchiectomy be considered in the high testis provided the contralateral testis is normal, or alternatively a Fowler-Stephens or microvascular transplant if it is not. Patients with an infracanalicular testis may undergo a careful second-stage orchiopexy. All patients with retarded testicular growth should perform routine self-examination.

Experience with aortic grafting during excision of large abdominal neuroblastomas in children

BACKGROUND

Total or near total resection of high-risk, stage 4 abdominal neuroblastoma has been correlated with improved local control and overall survival but may be complicated by vascular injury. We describe our experience in the management of significant aortic injuries during this procedure.

METHODS

With the institutional review board waiver, medical records of children who had major abdominal aortic reconstruction during neuroblastoma resection from 1996 to 2006 were retrospectively reviewed.

RESULTS

There were 5 children with aortic grafting: 3 girls and 2 boys. Mean age at surgery was 7.2 years (range, 16 months to 17 years). Two children were operated on for recurrent retroperitoneal disease. Tumor encasement of the aorta was seen in all children. In 3 children, the injury occurred during dissection of paraaortic and interaortocaval lymph nodes below the level of the renal arteries. In the remaining 2 children, injury occurred early during mobilization of the tumor. Three polytetrafluoroethylene tube grafts and 1 on-lay patch graft were used to repair the 4 distal aortic injuries. One 4-year-old female with aortic and renal arterial injuries was managed with an aortic Dacron tube graft and a polytetrafluoroethylene tube graft for the renal artery. The mean period of follow-up is 28 months after aortic graft (range, 3 months to 10 years). Total colonic ischaemia, transient acute tubular necrosis, and duodenal perforation were seen in one child, who needed subtotal colectomy and ileostomy. Another child with an omental patch over the graft had a transient duodenal obstruction, which was managed conservatively. There were no other complications, and 4 of the 5 children are disease-free to date. One child at 10 years after his distal aortic tube graft remained asymptomatic with normal distal blood flow on magnetic resonance angiogram and with normal growth.

CONCLUSION

The neuroblastoma surgeon should be prepared to perform aortic and vascular reconstruction. Aortic encasement, preoperative radiation therapy, and reoperative surgery were observed in these patients and may be risk factors.

Validation of transport measurements in skeletal muscle with N-13 amino acids using a rabbit isolated hindlimb model

We are studying the transport of C-11 and N-13 labeled amino acids in tumor-bearing rabbits to determine the role of amino acid transport in the pathogenesis of muscle wasting in cancer. To validate a new, in vivo, method for measuring transport in skeletal muscle with these compounds, an isolated hindlimb model was developed in rabbits. The limb was perfused with a non-recirculating, normothermic, constant pressure system and a cell-free perfusate. Hemodynamic and metabolic parameters were measured during the first 75 min. of perfusion and found to remain normal and stable. Flow varied directly with perfusion pressure over the normal range of resting flows in the intact rabbit hindlimb. Time-activity curves (TAC's) were recorded from the medial thigh following bolus co-injection of L-[amide N-13] glutamine or N-13 L-glutamate with Tc-99m human serum albumin (HSA) into the femoral artery. Regional plasma flow was determined from the Tc-99m data. The N-13 TAC's consistently manifested a three-phased washout with half times of approximately 30 sec., 5 min. and 2 hr. Capillary and cellular transport parameters were computed from the N-13 data using a double barrier, single capillary model of capillary and cellular transport and assuming that the three washout components result, respectively, from tracer throughput, extraction into the interstitial space and extraction into the intracellular space. This interpretation was validated and the sensitivity of the technique to transport processes demonstrated by examining the effects on the N-13 TAC's and computed transport parameters of several factors known to influence cellular transport of amino acids, viz., the insulin concentration, amino acid concentration and pH of the perfusate. Time-activity curves and transport parameters for N-13 L-glutamine in the isolated limb were very similar to those observed in the intact rabbit hindlimb, suggesting that studies in the perfused model are indicative of amino acid transport in vivo. The methodology described here is especially well suited for studying the specific effects on transport of factors which influence amino acid metabolism in skeletal muscle (e.g., hormones and monokines).

The use of the trapdoor incision for access to thoracic inlet pathology in children

Lesions at the thoracic inlet are difficult to access via a thoracic or cervical approach. The use of the anterior cervico-thoracic trapdoor incision has been reported to give good exposure to the anterior superior mediastinum in adults. We report our experience of four cases where a trapdoor incision was used to gain excellent access and exposure to thoracic inlet pathology in children.

Emergency liver transplantation after Kasai portoenterostomy

Three patients with stable liver function after Kasai portoenterostomy developed acute liver failure secondary to liver necrosis. Doppler ultrasound at presentation revealed reversed diastolic hepatic arterial blood flow. Two patients survived after urgent liver transplantation. Liver necrosis should be suspected in children with chronic liver disease presenting with fever and rapidly deteriorating liver function.

Orthotopic liver transplantation for acute hepatic failure in children

Thirty children received 35 liver transplants for fulminant or late-onset liver failure between March 1988 and May 1993. Aetiology included non-A non-B hepatitis in 12, Wilson's disease in 8, drug-induced hepatic failure in 6, hepatitis B in 1, hepatitis A in 1, tyrosinaemia in 1 and congenital haemochromatosis in 1. Three patients were retransplanted, one each for hepatic artery thrombosis, non-A non-B graft reinfection, and chronic rejection. Two of these three patients received a third transplant for chronic rejection and hepatic artery thrombosis. One patient in the retransplant group survived. Overall, graft and patient survival at a mean follow-up of 17 months were 49% and 57%, respectively. Mortality was related to vascular complications in three patients (hepatic venous obstruction, portal vein thrombosis and hepatic artery thrombosis). Two patients died of primary sepsis (cerebral aspergillosis and cytomegalovirus (CMV) pneumonitis in association with graft-versus-host disease). Systemic sepsis and multiorgan failure was documented as a cause of death in four children and sepsis in association with chronic rejection in a further three patients. One child died of respiratory failure 4 weeks after transplantation. Mortality in eight children less than 2 years was 75% and this was significantly greater than for older children (P < 0.003, Mantel Cox). Earlier referral, even in the absence of a definitive diagnosis and particularly in children under 2 years is advisable and may improve survival.

Diffuse cavernous hemangioma of the rectosigmoid and low anterior resection using the autostapler

Over 200 cases of colonic hemangioma have been reported, with more than 50% occurring in the rectosigmoid. These benign vascular neoplasms usually present in childhood, often with life-threatening hemorrhage. Lack of awareness of the condition continues to lead to errors in diagnosis and management, and may contribute to previously reported mortality rates of 50%. We report a case of diffuse cavernous hemangioma of the rectosigmoid in a 10-year-old boy and its treatment by low anterior resection using the end-to-end autostapler.

Abdominopelvic mesh compartmentalization reduces the complications of radiotherapy in children: a preliminary report

AIM

The aim of this report was to assess the effects of radiotherapy (RT) in children with abdominopelvic tumours in whom a biodegradable (Polyglactin 910) mesh had been inserted prior to commencement of radiotherapy.

METHODS

Retrospective analysis was carried out of four patients with abdominopelvic tumours who underwent radiotherapy between 2000 and 2002 as part of their management.

RESULTS

All children tolerated radiotherapy well with no evidence of acute or chronic radiation enteritis. One child developed prolonged postoperative ileus and a second child developed infective diarrhoea and fever, not related to radiation.

CONCLUSION

We have highlighted a good tolerance of radiotherapy in children following the insertion of a Polyglactin 910 mesh prior to starting radiation and would recommend further larger studies with longer follow-up to support this.