Congenital hypothyroidism following maternal I-131 therapy in unsuspected pregnancy.

The authors report a term infant with congenital hypothyroidism following maternal radioiodine (I-131) treatment for papillary thyroid cancer in unsuspected pregnancy. The woman received 150 millicuries (mCi) of I-131 during the second trimester of pregnancy. Antenatal care was done in the other hospital without the awareness of previous I-131 treatment during pregnancy. The child presented with congenital hypothyroidism and recurring attacks of postprandial bilious vomiting due to midgut malrotation and Ladd bands. This case reminds physicians of the importance of obtaining an accurate menstrual history and providing information on conception in fertile woman before receiving I-131 treatment.

Endoscopic management of foreign body in the upper gastrointestinal tract: a tertiary care center experience.

BACKGROUND: Foreign body (FB) in the upper gastrointestinal tract (UGIT) is a common clinical problem in endoscopic practice. At present, many physicians recommend endoscopy for both diagnosis and treatment. To date, few have report endoscopic findings and management of FB in UGIT. OBJECTIVE: To report the authors' experience and outcome of the endoscopic management of foreign body ingestion at Siriraj Hospital. MATERIAL AND METHOD: Medical records of patients with FB ingestion in the UGIT, who underwent endoscopic management between January 2004 and January 2008 at Siriraj Hospital, were reviewed. RESULTS: The analysis included 34 patients of which 58.82% were men. The mean age of the group was 18.26 years (range 10 months - 86 years). 58.82% of patients were younger than 5 years. Esophagogastroduodenoscopy (EGD) was performed in 100% of cases, under general anesthesia (GA) in 85.29%, and under transintravenous anesthesia (TIVA) in 14.71%. Endoscopic management was successful in all cases. The extractions were done with rat-tooth forceps, polypectomy snare, dormia basket, or tripods. There were no procedure related complications. CONCLUSION: The ingested FB varied widely according to the underlying medical condition and age. In a tertiary care center endoscopic removal of FB in UGIT could be safely performed with a very good result.

Validation of clinical scoring system in the primary care of children with suspected acute appendicitis.

Objective: To establish a scoring system for the diagnosis of acute appendicitis in children in order to decrease the rate of negative and delayed appendectomies and delayed. Methods: Record charts of pediatric patients admitted with suspected appendicitis at the Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital during July 2000 - September 2001 were retrospectively reviewed. Clinical predictors were listed out and weighed as coefficients, which were later formed into a score equation. The score was then prospectively studied in the following year from October 2001-September 2002. The score was used to aid decision making in the management of cases suspected of appendicitis. The out come was compared to the conventional management based on histologically confirmed diagnosis. Results: The retrospectively collected data listed out 14 significant variables. Using logistic regression, the parameters were weighed as coefficients, which became scores to each parameter. The score was applied to a consecutive series in the following year. By using the score, the patients were categorized into three groups: discharged, observed and operated. The accuracy of the score is 85.83% with a positive predictive value of 96.55% and negative predictive value of 75.81%. From this study group, the negative appendectomy rate is 4.17% and the perforation rate is 6.67%. Compared to the previous year during which 133 children were treated under the conventional management, the negative appendectomy rate was 4.51% and the perforation rate was 21.8% Conclusion: The scoring system is an accurate diagnostic tool, which proves the importance of history taking, physical examination in coordination with laboratory investigations and close observation. Altogether these parameters can reduce the rate of misdiagnosis and delayed diagnosis of pediatric appendicitis.

Slide tracheoplasty with pericardial patch augmentation for reconstruction of severe congenital tracheal stenosis involving carina : A case report.

Objective: Slide tracheoplasty seems to be the most efficient surgical procedure for correcting long-segment funnel-shaped congenital tracheal stenosis. However, in cases of extremely long-segment or those involve carina, slide tracheoplasty when operated alone has certain degree of limitations which often need additional operative procedure. The authors report a technique of slide tracheoplasty in combination with pericardial patch augmentation in a child with congenital tracheal stenosis involving the carina. Methods: A 3-month-old girl, previously diagnosed with Tetralogy of Fallot and congenital tracheal stenosis, presented with severe cyanosis and serious major airway obstruction after a few days of upper respiratory tract infection (URI). Because of the failure to maintain her ventilation with a high positive pressure ventilator, an emergency slide tracheoplasty with a modified right Blalock’s Taussig shunt was performed under a cardiopulmonary bypass. The intraoperative finding revealed a complete tracheal ring stenosis involving the lower half of the trachea and carina. It was transected at the middle and a vertical incision was made at the posterior wall of the upper trachea and anterior wall of the lower and extended into orifices of the main bronchus. The upper and lower tracheal flaps were slid together and sutured with interrupted Proline 5-0. Consequently, she still had significant obstruction of the main bronchi postoperatively and needed a re-operation two days later. Under cardiopulmonary bypass support, the lower anastomotic sutures were removed and an additional bronchial incision was made into the main bronchus. The anterior upper tracheal flap was separated into two, and each equal flap was pulled down and sutured to the main bronchus. Then an autologous pericardial patch was used to cover all the airway defects. Intraoperative fiberoptic bronchoscopy demonstrated adequate tracheo-bronchial lumen. Results: The child had postoperative hyperactive airway reaction and needed prolonged ventilator support and tracheostomy for tracheal toileting. Repeated postoperative bronchoscopy found moderated granulation tissue which was easily removed by catheter suction. Unfortunately, the patient expired six months after the surgery due to uncontrolled sepsis. However, a bronchoscopic finding before the patient’s death revealed adequate major airway patency. Conclusion: Combined slide tracheoplasty with pericardial patch augmentation made reconstruction of the complex congenital tracheal stenosis involving carina or tracheal bronchus possible and minimized the result of unflavoric excessive granulation tissue forming caused by pericardial tracheoplasty alone.

Comparison of morphine given by an intravenous sliding scale or by intramuscular route for postoperative pain relief in pediatric patients: An interim analysis.

Objective: To assess the efficacy in pain relief, complication, practicality and patient’s compliance of morphine given by IV sliding scale (IV) compared to that given intramuscularly (IM) in children after surgery. Methods: One hundred and third-two children were randomly allocated to receive postoperative morphine via IM route (0.1 mg/kg) on a 6-h PRN basis or IV route on a sliding scale basis. Blood pressure, heart rate, respiratory rate, SaO2, nausea/vomiting, pain score using CHEOPS and patient’s compliance were recorded. A questionnaire was used to evaluate the satisfaction with and practicality of these techniques among nurses. Results: This study was terminated early and interim analysis was performed because 47% of the patients in the IM group refused treatment and only 32 patients remained for study (age 1.9-12y, ASA 1). The proportions of patients with moderate to severe pain (IM 73.3%, IV 76.5%), median of maximum CHEOPS score (IM 9, IV 10), average CHEOPS score (IM 6.01, IV 6.03), and morphine consumption (IM 0.157,IV 0.144 mg/kg/24h) of both groups were not statistically different. Neither respiratory depression nor desaturation was detected. Nurses preferred using the sliding scale technique due to better patient’s compliance. Conclusion: The IV sliding scale was superior to IM technique regarding patient’s compliance and nurses’ preference. The degree of pain relief obtained and complications of treatment were not different.

Laparoscopic cholecystectomy versus open cholecystectomy in children.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is well accepted as the standard cholecystectomy only in adult patients. However, the advantages of LC over open cholecystectomy have never been proved in pediatric patients because the number of pediatric cholecystectomies is limited as well as the faster ability of pediatric patients to resume their normal activity. MATERIAL AND METHOD: Retrospective study of 42 pediatric cholecystectomies (laparoscopic cholecystectomy (n = 8) (LCs), open cholecystectomy alone (n = 8) (OCs) and open cholecystectomy concomitant with splenectomy (n = 26)(OCs + S)) done in Siriraj University Hospital, Bangkok, Thailand between 1992 and 2000 was conducted. RESULTS: Statistical comparison revealed that LC was superior to OC in regard to diet resumption. LCs resumed soft diet on 1.38 days, whereas OCs and OCs + S could resume soft diet on 3.38 and 3.35 days respectively. The average length of hospitalization following LCs was significantly shorter than OCs' and OCs + S' ones (3.00 vs 8.38 and 4.85 days respectively). There was no morbidity and mortality in LCs, whereas two OCs and three OCs + S had complications. CONCLUSION: In this preliminary study, laparoscopic cholecystectomy is a preferred method of cholecystectomy in children because it has a shorter post-operative interval of diet resumption and shortens hospitalization with minimal morbidity. However, this study has a limited number of patients and further study is still required to conclude the benefits of LC.

Gastric perforation in very low birth weight infants following indomethacin administration: 2 case reports.

Two very low birth weight infant who had received intravenous Indomethacin for closure of ductus arteriousus developed massive pneumoperitoneum on the first and fifteenth day after administration. Isolated gastric perforation, sparing the entire intestine was found on laparotomy. Pathological findings in the first case shows transmural hemorrhage without inflammation. This report aims to discuss the contribution that Indomethacin makes in the pathogenesis of intestinal perforation in newborn patients.

Necrotizing enterocolitis after operation for ileal atresia.

NEC usually affects newborns especially low birth weight often with history of perinatal stress. It usually manifests itself within five to ten days after birth with abdominal distension, bilious vomiting and bloody diarrhea. Development of NEC after operation seldom occur. It was first reported in patients underwent open-heart surgery employing hypothermia and cardiopulmonary by-pass. Later it was found to be common among gastroschisis patients post repair of abdominal wall defect. Clinical pictures of usual case of NEC and that develop after operation are partly resemble and partly differ. NEC is rarely seen after other operative procedures especially intestinal atresia. Review of the literatures revealed only eight such cases. Our report of two cases following operation for intestinal atresia with explanation both on similar and different clinical pictures from usual of NEC.