Distal fragmented port catheter: case report and review of literature

BACKGROUND: Insertion of long-term central venous catheters (CVC) plays a vital role in providing continuous venous access for therapy in children. CVC line fractures are most commonly seen after long-term periods of therapy during removal. Usual place of rupture is proximal, at the point of entrance of the catheter into the vein, when the subclavian approach is utilized. We discuss a case that shows that CVC can also fracture in places different than the most common location and is possible not to detect that a fracture has occurred if a substantial portion of catheter is removed. METHOD: We report a two-year-old child that was incidentally found to have a distal fragmented piece of CVC left after previous "successful" removal on simple chest films. At time of removal the catheter length was deemed properly. A CT Scan confirmed the suspected diagnosis. Fragment of catheter was successfully removed via femoral percutaneous endovascular technique. RESULTS: CVC fractures can be suspected when there is resistance during removal or the length retrieved is too short. In this case the ease of retrieval and unusual site of rupture was the cause of not noticing that a part of catheter remained fixed to the vessel wall. Different potential mechanisms of CVC rupture include mechanical trauma, manufacturing defect or material degradation. Ruptures should be detected early to prevent complications such as sepsis, endocarditis, thrombosis, embolization, vessel stenosis and dysrhythmia. Best method to remove the fragmented catheter is via percutaneous endovascular retrieval method. After catheter removal a hyperdensity silhouette on a CXR can mimic the fragmented portion of a catheter known as a calcified cast or "ghost". To differentiate a "ghost" from an actual fragmented portion of catheter a CT Scan or echocardiogram is needed. CONCLUSION: Most important single step in preventing such complication is to keep record of the patient length of catheter that was inserted...

Malrotation of the intestine and preduodenal portal vein associated with abdominal situs inversus: a case report

Abdominal situs inversus is a rare condition usually associated with malformations of asymmetric organs such as the heart, liver, spleen and malrotation of the intestines. A case of abdominal situs inversus with intestinal malrotation and preduodenal portal vein is reported. Patient underwent prophylactic Ladd's procedure and preduodenal portal vein was left undisturbed during surgery. This case highlights the importance of rigorous investigation of anatomic features prior to surgery in a patient with heterotaxia. The authors advocate radiological investigation of patients with heterotaxia and prophylactic Ladd's procedure in those with intestinal malrotation.

Duodenal duplication with accessory papilla causing recurrent pancreatitis in a child: a case report

We discuss a 16-year-old male patient who presented with three episodes of recurrent pancreatitis within the last 6 months. Preoperative imaging studies suggested a choledochal cyst within the second portion of the duodenum. Patient was taken to surgery and the lesion was removed. Pathology examination of the cyst revealed a duodenal duplication. The accessory pancreatic papilla entering the closed duplication cyst was the main cause of the pancreatitis in this child.

Renohepaticopancreatic dysplasia: diagnostic dilemma

We present the case of an eighteen day old baby boy hospitalized with an abdominal mass, renal insufficiency and jaundice. Multiple radiographic, radionuclear and surgical interventions were required to diagnose renohepaticopancreatic dysplasia, also known as Ivemark II syndrome. In spite of aggressive intensive care support, the patient developed multisystemic organ failure and died. Clinical presentation and autopsy findings are presented.

Cavernous hemangioma presenting as a right adnexal mass in a child

This is the case of an 11-year-old girl who presented with a right adnexal mass and vague abdominal symptoms since seven months prior to her hospital admission for surgery. CT-scan and sonographic images were those of a benign lesion, probably ovarian torsion or infarction. Serum tumoral markers were normal. A right salpingo-oophorectomy and appendectomy were performed. Pathology examination revealed a cavernous hemangioma of the ovary. The clinicopathologic presentation of this unusual benign ovarian tumor is discussed.

Presacral neuroblastoma in a child: a case report

Presacral location of neuroblastoma is rare. Resection entails an abdomino-sacral approach. This case report discusses clinical, imaging and successful surgical management of a presacral neuroblastoma in a one-year-old male child

Molecular biology and genetics affecting pediatric solid tumors

Since the discovery of oncogenes more than 20 years ago, it has been proven that cancer is a genetically determined disease. Multiple genetic alteration occurs during the course of an illness for neoplasia to develop. Transformation of positive cell growth regulators (oncogenes) and inactivations of negative cell growth regulators (tumor suppressor genes) merge to express a malignant phenotype. These genetic alterations occur as chromosomal translocations, deletions, inversion, amplification or point mutation. The objective of this review is to introduce basic concepts of molecular biology and describe the molecular genetics and biologic clinical findings of the most important solid malignant tumors in children, namely Neuroblastoma, Wilms and Rhabdomyosarcoma. It is the oncology surgeons responsibility to learn basic molecular genetics and tumor biology to provide rational and appropriate care in the setting of multidisciplinary management. Identifications of new oncogenes will continue to be important milestones in diagnosis, early detection of tumor recurrence, and as potential targets for gene therapy. Fusion proteins generated by mutated translocations are true tumor specific antigens and potential targets for therapy. The predicament is that they are proteins needing therapeutic manipulation within the tumor cell nuclei. Technological advances in molecular and genetics will develop tools necessary to manipulate the cell nuclear DNA and target cancer cell

Profile of Internet users: survey of the Surgical Section of the AAP

BACKGROUND: Communication through electronic networks is becoming a most useful resource of health care providers. PURPOSE: Establish the demographic and professional profile and identify the internet service provider of members of the Surgery Section of the American Academy of Pediatrics (AAP). MATERIALS: A short survey questionnaire including variables of age, gender, years of experience, type of practice and internet service provider was mailed to all members of the Surgical Section of the AAP. Two-hundred and six responses of 588 (35%) were received and analyzed. RESULTS: Mean age of the group was 52 years of which 88% were male and 12% female (7.5:1). The group had an average of eighteen years of practice; 185 members (90%) have access to Internet and 188 (92%) use it mainly for e-mailing from either home (25%), hospital/office setting (30%) or both (42%). Twenty-three percent of member were willing to receive section news and correspondence by electronic means, by print-mail 34% and both 44%. Overall type of practice was private 21%, University 54% or combined 23%. No access to internet means an older member (57 yrs, p = 0.02) sharing solo (private) practice (p = 0.006). Two-third of internet service providers were university-based (-edu) or hospital organizations (-org) with a younger age group (48 yrs, p = 0.000001). CONCLUSIONS: E-mailing is becoming the preferred method of communication among many members of the Section of Surgery of the AAP. Net accessibility through University or Children Hospital servers account for the high number of young members in this practice setting

Pediatric thyroid nodules: insights in management

BACKGROUND: Multiple diagnostic studies are utilized to unveil malignancy in pediatric thyroid nodules and determine whether surgical therapy is needed. PURPOSE: The aim of this report was to determine whether management of pediatric thyroid nodules has changed with the current use of diagnostic modalities such as ultrasonography (US), radionuclear scans (RNS) and fine needle aspiration biopsy (FNAB). MATERIAL/METHODS: Twenty-four children with thyroid nodules managed during a ten-year period comprised the study group. Demographic characteristics, clinical manifestations, US and RNS imaging findings, FNAB results, surgical therapy, complications and pathological reports were retrospectively reviewed. US, RNS and FNAB results were categorized as either benign, malignant, suspicious or insufficient. RESULTS: Females outnumbered males by a five to one ratio. Mean age was 14.9 years. Nineteen nodules were benign (79%) and five malignant (21%). All children were euthyroid. Benign nodules were soft, movable, solitary and nontender. Malignant nodules were characterized by localized tenderness, a multiglandular appearance, and fixation to adjacent tissues. US and RNS gave no clue toward management since cystic and hot nodules figured among malignant cases respectively. US achieved 86% accuracy, 80% sensitivity and 88% specificity; RNS showed 26% accuracy, 80% sensitivity and 11% specificity; FNAB achieved 80% accuracy, 60% sensitivity and 90% specificity. Suppressive thyroid hormone therapy was useless in the few cases tried. Physical examination findings, persistence of the nodule, progressive growth and cosmetic appearance where the most common indications for surgery. CONCLUSIONS: Present diagnostic modalities played a minor role in the decision to withhold surgery. US was useful for aiming aspiration of cystic nodules. RNS decided the functionality of the nodule, but its accuracy was far from ideal. FNAB is a safe procedure whose greatest help was to resolve in case of suspicious or malignant cytology that a more radical procedure is needed. Clinical judgement as determined by serial physical findings and suspicion continues to be the most determinant factors in the management of thyroid nodules in children

El rol de Internet en la cirugía pediátrica / The role of Internet in pediatric surgery

Internet, la mayor red de computadoras conectadas se ha constituído en la última adquisición para que los agentes de salud accedan a información. Analizaremos como el desarrollo de esta tecnología es una fuente de educación en Cirugía Pediátrica y describimos conceptos básicos en el uso de esta red. Los elementos básicos de la red de Internet son: el Correo Electrónico (e-mail), Grupos de Discusión (List), Transferencia de Archivos o Documentos y exploración en el "World Wide Web" (WWW). El correo electrónico acerca a los profesionales con intereses comunes. Los cirujanos lo emplean como herramienta de comunicación. Las responsabilidades legales están ligadas a su uso. Los grupos de discusión permiten el debate de casos clínicos, operaciones, investigación, publicación de oportunidades laborales y anuncio de reuniones científicas. La Transferencia de Archivos brinda la oportunidad de obtener artículos de bibliotecas públicas. La WWW es la más fructífera herramienta por su accesible herramienta por su accesible y fácil exploración. La mayoría de los médicos no requieren tener conocimientos extensos sobre computación para explorar el pandemonio de información ofrecida. "Click and Play" con las actuales aplicaciones estimula a los neófitos a conectarse. Se requiere de un equipo (hardware) y programas (software) adecuados junto a un proveedor de servicio de Internet. En el futuro se desarrollarán publicaciones electrónicas, se implementarán progresos en Telemedicina, conferencias internacionales y concentración de la información en un "ciber-espacio" centralizado en Cirugía Pediátrica con ágiles instrumentos de búsqueda

Role of Internet in medicine

Internet, the largest network of connected computers, is becoming the ultimate frontier to access information for health providers. This review focus on how developments of this communication technology have become a useful educational resource in medicine, and describes modest ideas in computer network use. Internet basic resources are electronic mailing (E-mail), discussion groups, file transfer, and browsing the World Wide Web (WWW). E-mail brings physicians with common interest together. Surgeons employ it as a communicating tool. Legal and social responsibility is bounded with its use. Discussion groups permits debate including clinical cases, operations, techniques research, career opportunities, and meetings. File transfer provides the opportunity of retrieving archives from public libraries. The WWW is the most resourceful tool due to its friendly interface and ease of navigation. The average physician needs to know almost nothing on how computers work or where they came from to navigate through this pandemonium of information. Click and play with today graphical applications encourage the computer illiterate to connect. Establishing the connections envelops the need of hardware, software and a service provider. Future development consists of online journals with new ideas in peer-review and authentication, telemedicine progression, international chatting, and centralization of cyber space information into database or keyword search engines

Impact of minimally invasive surgery in children

An important medical technological progress of this century corresponds to the application of minimal invasive surgical techniques in adults and children. Laparoscopic surgery is causing an impact in the results of many procedures done during the pediatric age. Within this review we explore the development of laparoscopic abdominal surgery in children along with basic physiology and complications of establishing a potential working space (pneumoperitoneum). Indications, results, and where we are headed in the management of various of the most common surgical conditions of children are issues discussed. Laparoscopic surgery has proven safe, efficient, technically feasible and well tolerated in most children. Produces early return to activities, reduced hospital stay, less hospital bills, and better cosmetic results when compared to open (conventional) procedures

Trichobezoar in a 11-year old girl: a case report

Bezoars are masses of solidified organic or nonbiological material commonly found in the stomach and small bowel. Identification, therapy, and long-term management of patients with bezoars depends on accurate classification and knowledge on the pathophysiology of formation. Four types of bezoars have been described based on their composition: phytobezoars, trichobezoars, lactobezoars, and miscellaneous. Pediatric trichobezoars are associated to emotional disturbed children with aberrant appetite (trichophagia). Hair strands become retained and attached in the folds of the gastric mucosa because the friction surface is insufficient for propulsion by peristalsis. They generally are asymptomatic until enlargement produce pain, compression or intestinal obstruction. Bezoars are diagnosed with conventional radiology and gastroscopy permits identification of its nature. Currently, management of bezoars consists of: dissolution, suction, lavage, mechanical endoscopic fragmentation using pulsating jet of water, fragmentation with extracorporeal shock wave lithotripsy and surgical removal. Treatment should also focus on prevention of recurrence, since elimination of the mass will not alter the conditions contributing to their formation

Biliary atresia: an overview

Biliary Atresia is the most common cause of persistently direct (conjugated) hyperbilirubinemia in the first three months of life. It is a progressive inflammatory obliteration of the extra- and intrahepatic bile ducts whose pathogenesis remains speculative. This review updates the history, etio-pathological considerations, clinical manifestations, methods of diagnosis, surgical management, and results of this terrible disease in young infants. We will emphasize that persistent jaundice in the newborn period must be managed urgently, a diagnosis should be established early in life, and Kasai portoenterostomy offered to those infants with Biliary Atresia before their eighth week of life. This will allow more than one-third of children to survive. Hepatic transplantation is reserved for those children with failed portoenterostomy, progressive liver failure or late-referral to surgery

Neuronal intestinal dysplasia: a role for surgery?

Neuronal intestinal dysplasia (NID) is a poorly understood colonic motility disorder with characteristic histopathological findings and clinical presentation. It is often associated with Hirschsprung's disease (HD) and can constitute a cause of failure of clinical improvement after adequate resectional pull-through surgery. Other conditions associated with NID are: Chronic Intestinal Pseudo-obstruction (CIPO), anorectal malformations and Multiple Endocrine Neoplasia (MEN) II syndrome patients. To increase the diagnostic yield of NID the pathologist should be aware and use histochemistry evaluation of the rectal biopsy specimen in patients with history of constipation or unexplained bouts of diarrhea. Adequate sampling of the temporary proximal colostomy done to HD patients should be examined for NID pathological changes. Treatment has centered around the clinical picture with most cases managed medically with prokinetic agents, colonic irrigations, and bowel cathartics until improvement and normalization of histology occur. There is evidence of progressive maturation of the enteric nervous system with time. Surgery is indicated for patients with severe clinical deterioration after failed medical management

The pediatric inguinal hernia: is contralateral exploration justified?

To determine if contralateral inguinal hernia exploration is justified we decided to study our experience with 161 consecutive cases who underwent bilateral repair during a 30 months period. 61 of the population were infants younger than two years of age, and 19 premature babies. 69 pts presented with an RIH, 47 with an LIH and 45 pts with BIH. 16 suffered an episode of preoperative incarceration which were all reduced satisfactorily and operated promptly. A positive contralateral finding (either a hernial sac or a patent processus vaginalis) was identified in 74 RIH and 72 LIH patients upon exploration. No incidence of testicular edema/atrophy, vas deferens injury, or recurrence was reported in the six-year follow-up of the study. Statistical analysis of the contralateral findings during surgery with sex, gestational age and age at operation showed that females and infants younger than two months of age had a higher probability of having positive findings. We could not show that prematurity or left-sided hernias were associated with a higher positive contralateral rate. The major benefit of contralateral exploration is based on the fact that it allows discovery and elimination of a patent processus vaginalis so a hernia cannot develop subsequently. We conclude by establishing certain criteria that justifies the routine contralateral exploration of the pediatric hernia: the surgeon should be experienced in child care, associated conditions should not increase the surgical risks significantly, time-consuming dissections of the cord structures should be discouraged, and the operating time should be kept to a minimum