A single-incision laparoscopic technique for retrieval and replacement of disconnected ventriculoperitoneal shunt tubing found in the peritoneum.

A 7-year-old girl presented with signs and symptoms of increased intracranial pressure 2 years after insertion of a ventriculoperitoneal (VP) shunt. Evaluation revealed disconnection of the distal shunt catheter and migration into the peritoneal cavity. A single-incision laparoscopic procedure was performed to locate and remove the disconnected shunt tubing, and the new shunt catheter was inserted through the laparoscopic port site. Laparoscopy is being used more frequently for evaluation and repair of distal VP shunt malfunctions, but generally still requires multiple incisions for port placement and insertion of the new shunt catheter. The single-incision technique used here is technically feasible, allows excellent visualization of the peritoneal cavity and does not require any incisions beyond the previous one used for initial shunt insertion.

Surgery-associated complications in necrotizing enterocolitis: A multiinstitutional study.

PURPOSE: This study was designed to evaluate the wound and stomal complication rate associated with surgical intervention in infants with necrotizing enterocolitis (NEC). METHODS: Comprehensive demographic and perioperative data were collected prospectively from 4 separate university hospitals on 51 infants with surgically treated NEC. The postoperative complication rate included wound (infection, dehiscence) and stomal (prolapse, retraction, necrosis, stricture) problems. For analysis, patients were grouped based on gestational age less than 28 weeks (group I, n = 30) and >/=28 weeks (group II, n = 21). Z-score analysis was used for intergroup evaluation. RESULTS: Significantly more infants in group I (21 of 30 [70%] versus group II, 6 of 21 [29%]; P <.001) were treated initially with Penrose drainage alone, but most eventually underwent laparotomy (group I, 28 of 30 [93%] versus group II, 19 of 21 [91%]; P value, not significant). The combined stomal/wound complication rate was significantly higher in group I (14 of 30 [47%]) versus group II (6 of 21 [29%]; P <.025). Of 51 patients, one operation was required in 23 (45%), 2 in 18 (35%), 3 in 8 (16%), and 4 in 2 (4%). CONCLUSIONS: Although the stomal/wound complication rate was significantly higher in group I, both groups had very substantial complication rates, emphasizing the vulnerability of this infant population. Parents, especially of very premature babies, should be advised that multiple operations are likely and that complications should be expected.

Intraventricular pressure dynamics in ventriculocholecystic shunting: a telemetric study.

Extracranial cerebrospinal fluid shunting is the current mainstay of therapy for hydrocephalus. The generally preferred extracranial site for cerebrospinal fluid absorption is the peritoneal space; however, the cardiac atrium and the pleura are also commonly used. On occasion other CSF recipient sites, such as the gallbladder, are used secondarily when the more common absorptive spaces are unavailable or unsuitable. The gallbladder, though, exhibits its own pressure dynamics in response to physiological stimuli. The effects of gallbladder contraction on intraventricular pressure (IVP) in the presence of a ventriculocholecystic (VGB) shunt are unknown. We had the opportunity to place a VGB shunt in a 4-year-old child who was coupled to a noninvasive telemonitor. After a period of acclimation, we examined the IVP dynamics of that shunting system both pre- and postprandially. We found that before ingestion of food, the gallbladder provides a CSF recipient site similar to that of the peritoneal space. However, after ingestion of a meal containing fat, we found that IVP rose more than 10 cm water in a stereotypic fashion consistent with postprandial gallbladder contraction. The increase in IVP lasted for several hours reaching a peak at approximately 75 min postprandially. We conclude that the VGB shunt is a viable alternative for extracranial cerebrospinal fluid shunting; however, one must be aware of the peculiar dynamics of this shunt in relation to food ingestion and the potential for unusually high IVPs.

Institutional Review Board approval for prospective experimental studies on infants and children.

BACKGROUND/PURPOSE: The Declaration of Helsinki requires Institutional Review Board (IRB) approval for experimental studies on human subjects. The authors questioned whether published prospective surgical experimental studies document IRB approval for infants and children. METHODS: Prospective studies were identified in 5 surgical and 2 major pediatric journals from 1997 through 1999. Documentation of IRB approval was recorded. Results were analyzed using Pearson chi(2) tests and a multivariate regression model. Statistical significance was defined as P less than .05. RESULTS: A total of 149 prospective experimental studies on pediatric subjects were evaluated; the majority being interventional or therapeutic studies (105 of 149). More than 75% were from academic medical centers (125 of 149), grant-supported (110 of 149), and appeared in surgical journals (110 of 149). Slightly less than 25% of studies (40 of 149) documented IRB approval. Observational studies, grant support, and publication in nonsurgical journals all correlated positively with IRB approval and were statistically significant variables (P<.001, P<.001, P<.001, respectively). Interventional or therapeutic, institutionally or privately-funded studies found in surgical journals were most likely to avoid IRB documentation (P<.001). CONCLUSIONS: The majority of prospective pediatric studies in the surgical journals omit IRB documentation. Strict requirements for specific IRB approval and documentation in compliance with the Declaration of Helsinki would allow higher ethical standards for the clinical investigation of infants and children.

Salivary gland choristoma of the anterior chest wall.

Salivary gland choristoma (heterotopic salivary gland tissue) is a rare condition that occurs at various locations within the head and neck. Diagnostic criteria and embryogenesis of this entity remain unclear. Presented herein is the first reported case of salivary gland choristoma on the anterior chest wall. Surgical treatment is recommended.

Anabolic recovery relative to degree of prematurity after acute injury in neonates.

PURPOSE: In contrast to full-term infants, premature neonates generate accelerated growth rates after birth in an attempt to "catch up" to normal weight-for-age levels. Because this catch-up ability is related to gestational age, the authors postulated that there would be significant differences in anabolic recovery based on the degree of prematurity. To evaluate this hypothesis in surgical and septic neonates, we used serial postoperative prealbumin (PA) serum concentrations as an index of the return to anabolic metabolism after surgical stress. METHODS: Serum PA concentrations were measured on the day of surgery (DOS) and daily for a 10-postoperative day (POD) period in 73 acutely ill neonates after surgery. These infants were divided into two groups: mature infants with gestational ages > or =35 weeks (average, 38.2+/-1.84; n = 55), and premature infants with gestational ages < or =34 weeks (average, 29.7+/-2.93; n = 18). Infants were subgrouped based on insult type into either surgery (n = 56), or sepsis (n = 17). Statistical significance between groups at the given postoperative times was established using independent unpaired t tests assuming unequal variances. RESULTS: There was no significant difference in the daily nitrogen and caloric intake between the groups. Although recovery of hepatic prealbumin synthesis after the resolution of injury insult increased progressively in both gestational age groups, premature infants increased prealbumin production significantly earlier and to a greater degree than their nearer-term counterparts. CONCLUSIONS: These results suggest an earlier return of anabolic protein metabolism after acute injury in premature neonates versus infants that are born nearer term in both the surgery and the sepsis subgroups. These findings may be useful in modifying strategies for protein and nutritional repletion in acutely stressed preterm infants.

Pediatric wound infections: a prospective multicenter study.

OBJECTIVE: Surgical wound infections remain a significant source of postoperative morbidity. This study was undertaken to determine prospectively the incidence of postoperative wound infections in children in a multi-institutional fashion and to identify the risk factors associated with the development of a wound infection in this population. SUMMARY BACKGROUND DATA: Despite a large body of literature in adults, there have been only two reports from North America concerning postoperative wound infections in children. METHODS: All infants and children undergoing operation on the pediatric surgical services of three institutions during a 17-month period were prospectively followed for 30 days after surgery for the development of a wound infection. RESULTS: A total of 846 of 1021 patients were followed for 30 days. The overall incidence of wound infection was 4.4%. Factors found to be significantly associated with a postoperative wound infection were the amount of contamination at operation (p = 0.006) and the duration of the operation (p = 0.03). Comparing children who developed a wound infection with those who did not, there were no significant differences in age, sex, American Society of Anesthesiologists (ASA) preoperative assessment score, length of preoperative hospitalization, location of operation (intensive care unit vs. operating room), presence of a coexisting disease or remote infection, or the use of perioperative antibiotics. CONCLUSIONS: Our results suggest that wound infections in children are related more to the factors at operation than to the overall physiologic status. Procedures can be performed in the intensive care unit without any increase in the incidence of wound infection.

Nutritional support of the pediatric oncology patient.

The child with a malignancy frequently will have associated cachexia with significant weight loss and malnutrition. The reasons for this are multifactorial and may be related directly to the tumor, such as increased metabolic rate, circulating peptides leading to anorexia, and decreased intake due to poor appetite or gut involvement. There appears to be other reasons involved, including increased whole body protein breakdown, increased lipolysis, and increased gluconeogenesis. Release of certain cytokines, such as tumor necrosis factor, interleukin-1, interleukin-6, and others may increase the cancer cachexia. Malnutrition in these children leads to intolerance of chemotherapy and radiotherapy as well as increased local and systemic infections. For many years, oncologists were hesitant to provide nutrition support to cancer patients for fear that tumor growth would be enhanced. Pediatric oncologists learned early that starvation plays no positive role in cancer therapy. Adjunctive nutritional support, either enterally or parenterally, supports the patient during therapy with surgery, chemotherapy, or radiation. Many studies have now shown that the nutritionally replete patient tolerates therapy better and in some pediatric malignancies may enhance survival.

Neonatal lipid utilization increases with injury severity: recombinant human growth hormone versus placebo.

Increased lipid oxidation has been observed in injured adult and pediatric patients who receive growth hormone (GH). In infants, whose bodies make fat more readily (de novo lipogenesis), this effect has not been tested. After surgery for necrotizing enterocolitis or gastroschisis, 22 neonates (average gestational age, 35 weeks; average postnatal age, 7 days) were provided basal protein-calorie parenteral repletion, and were prospectively randomized to receive either recombinant human GH (rhGH, 0.2 mg/kg/d) or placebo for 6 days. Injury severity was established by serial serum C-reactive protein (CRP) levels (high v low stress: CRP > or = 6.0 mg/dL v < 6.0 mg/dL). Indirect calorimetry was used to measure energy expenditure (MEE), respiratory quotient (RQ), net lipid oxidation (Fe), and lipid oxidative O2 consumption (VO2f). Among the GH+ group, MEE, Fe, and VO2f were significantly higher for the high-stress patients (MEE: 52.87 +/- 13.35 v 42.57 +/- 9.47 kcal/kg/d; P < .03: Fe; 18.32 +/- 27.74 v 0.81 +/- 13.47 kcal/kg/d; P < .02; VO2f: 7.21 +/- 9.86 v 0.01 +/- 7.42 L/d, P < .02), and RQnp was significantly lower in the high-stress patients (RQnp: 0.93 +/- 0.14 v 1.05 +/- 0.11; P < .02). In addition, Fe and RQnp were directly proportional to carbohydrate intake (CHO) in the high-stress patients (CHO to Fe: Pearson r = -.701; CHO to RQnp: Pearson r = .714; P < .05). Lipid oxidation was directly proportional to stress severity, was higher in the GH group (18.32 v 11.91 kcal/kg/d for the placebo group), and was depressed in response to increased CHO intake in all groups. Lipid is an important energy source in acutely injured, especially severely stressed neonates. Lipid substrate utilization is improved with GH supplementation during acute metabolic stress. In addition, excess carbohydrate delivery reduces the amount of lipid utilized for energy metabolism. An appropriately balanced, mixed-fuel formula should be used for caloric repletion in this infant population.

Stratification of injury severity using energy expenditure response in surgical infants.

AIM OF STUDY: Injury severity stratification has important clinical outcome significance and can influence nutritional management. Although surgery alone has been shown not to increase measured energy expenditure (MEE) substantially, large increases in MEE can result from severe underlying acute illness, which frequently necessitates surgery (like sepsis or intense inflammation). The authors hypothesized that the magnitude and duration of the MEE response to surgery associated with a severe preoperative acute injury would exceed that of surgery in which no substantial preoperative stress was present, thus representing an index of overall injury severity in surgical infants. METHODS: MEE (kcal/kg/d) was determined on postoperative days (POD) 2, 5, and 8 in 12 infants (average age, 47 days) after two separate injury insults (at least 8 days apart). In each patient, one operation resulted in a peak serum C-reactive protein (CRP) concentration of less than 6.5 mg/dL (low stress), and the second operation, preoperatively associated with sepsis or a major inflammatory insult, resulted in a peak CRP of more than 6.5 mg/dL (high stress). Data were paired so that each child served as his or her own control. The initial basal protein-calorie delivery was similar in both groups. MAIN RESULTS: The mean peak CRP values were 14.1 +/- 10.7 mg/dL (high stress) and 4.1 +/- 2.3 mg/dL (low stress) and returned to normal levels earlier (before POD 8) after injury insult in the low-stress group. Analysis of energy expenditure on POD 2 demonstrated significantly elevated mean MEE values in the high-stress group (58.0 +/- 12.2 kcal/kg/d v 39.4 +/- 9.5 kcal/kg/d in the low-stress group; P = .0001). In contrast, analysis of POD 8 energy expenditure showed significantly lower mean MEE values in the high-stress group (50.7 +/- 12.0 kcal/kg/d) v (66.4 +/- 15.1 kcal/kg/d in the low-stress group; P = .0118) group. CONCLUSION: The early (POD 2) hypermetabolic response to injury as determined by MEE effectively differentiated the two stress groups. This finding suggests that acute underlying illness is an important determinant of postoperative MEE. Furthermore, in the low-stress group, serial CRP levels returned to normal earlier, associated with significantly greater late (POD 8) MEE values. Because MEE is directly proportional to growth rate in healthy infants, and growth is retarded during acute metabolic stress, these findings suggest that increased energy is utilized for growth recovery following the earlier resolution of the acute injury response in the low-stress group. These data indicate that serial postoperative MEE can be used to stratify injury severity and may be an effective parameter to monitor the return of normal growth metabolism in surgical infants.

Early postoperative alterations in infant energy use increase the risk of overfeeding.

AIM OF STUDY: Energy needs in infants are decreased after surgery because of growth inhibition (resulting from catabolic stress metabolism), decreased insensible losses, and inactivity. Using standardized formulas that account for growth, activity, and insensible losses during this stress period can lead to overfeeding in excess of 200% of the actual measured requirement. Overfeeding during this acute injury period can result in increased CO2 production from lipogenesis. This study determined the effects of a reduced rate of mixed caloric repletion on infant energy use during the early postoperative period. METHODS: C-reactive protein (CRP), oxygen consumption (VO2), carbon dioxide production (VCO2), measured energy expenditure (MEE), and total urinary nitrogen (TUN) were measured serially in seven infants (average age, 78 days) during the first 72 hours after abdominal or thoracic surgery. Nonprotein respiratory quotient (RQnp), and values for oxidation of carbohydrate (Ce) and fat (Fe) were calculated. Injury severity was stratified based on serum CRP concentrations of > or = 6.0 mg/dL (high stress) or < 6.0 mg/dL (low stress). Recovery from acute stress was analyzed by comparing studies in which CRP had decreased to < or = 2.0 mg/dL (resolving stress group) with those in which CRP values were greater than 2.0 mg/dL (acute stress group). RESULTS: Average total caloric intake (64.56 +/- 18.51 kcal/kg/d; approximately 50% of predicted energy requirement) exceeded average MEE (42.90 +/- 9.98 kcal/kg/d) by approximately 50%. Average TUN was 0.18 +/- 0.07 g/kg/d (high stress 0.2 +/- 0.05 versus low stress 0.16 +/- 0.09 g/kg/d). Average RQnp was 1.05 +/- 0.13 and average Ce was 37.28 +/- 16.86 kcal/kg/d. The average calculated Fe was 0.0 +/- 12.27 kcal/kg/d, reflecting approximately equal amounts of fat oxidized compared with fat generated from excess glucose (lipogenesis). When individual studies were analyzed at a CRP cutpoint of 2.0 mg/dL, overfeeding (RQ > 1.0) was significantly less likely in the resolving (2/6 studies, 33.4%) versus acute stress (9/13 studies, 69.2%, Z test P < .001) group. Five of seven (5/7) patients (9/19 individual studies) had negative Fe values (average -9.89 +/- 10.02) reflecting net lipogenesis. The RQnp for these nine studies was 1.14 +/- 0.11 versus 0.97 +/- 0.09 for the remaining 10, and this difference was significant (P < .01). A significant correlation existed between carbohydrate intake and VCO2 (Pearson r = .6951, P < .01). In addition, there was a good correlation between carbohydrate intake and VCO2 (Pearson r = .6591, P < .01). The coefficient of variation for MEE was 8.0% (low stress) versus 30.2% (high stress). CONCLUSION: Lipogenesis with increased CO2 production is substantial, even at reduced caloric delivery rates that exceeded MEE by only 50%, during the early postoperative acute metabolic stress period in infants. These data suggest that caloric requirements during stress are likely equal to or only minimally in excess of actual MEE. Intersubject variability, especially in more severely stressed infants, underscores the importance of serial measurements of energy expenditure to enable precise caloric delivery and avoid overfeeding. In the absence of calorimetric measurement, the data suggest that PBMR (predicted basal metabolic rate) should be used to estimate caloric delivery until CRP values are < or = 2.0 mg/dL.

Patterns of power mower injuries in children compared with adults and the elderly.

Power mower trauma remains an alarmingly frequent cause of serious injury in young children. The patterns of mower-related injuries in children < 15 years old (n = 13) were compared with those of adults aged 15-64 (n = 16) and elderly victims > or = 65 years old (n = 6), who were similarly injured over the past 5 years. Children were more likely to be injured in accidents involving high-energy riding mowers. Of those children injured, 69% (9 of 13) were playing in the yard while 31% (4 of 13) were riding on the mower with a guardian when the injury occurred. Amputations in children were more frequent and more extensive than in the adults and included one forearm, two Symes, and three below-knee amputations. The need for transfusion was also significantly increased in children (62% vs. 6% adults, p < 0.005), who were also more likely to require prolonged hospitalization (11.8 days vs. 5 days in adults, p < 0.005). Aggressive efforts to increase public awareness regarding the cause and nature of power mower injuries are warranted to decrease the incidence of this debilitating but preventable trauma in young children.

The metabolic response to surgery in neonates.

Over the past 35 years, surgery-associated mortality in the neonate has declined from greater than 60% to less than 10%. This progress is attributable, almost entirely, to a better understanding of the pathophysiologic changes that can occur during the perioperative period. It is increasingly apparent that the acute metabolic response to injury plays a central role in determining the clinical outcome of the critically ill infant. This article highlights recent developments as they relate to the infant response to acute injury and to show how this knowledge might be used to improve the care of these patients.

Overfeeding the critically ill child: fact or fantasy?

Overfeeding occurs when the administration of calories and/or specific substrate exceeds the requirements to maintain metabolic homeostasis. These requirements are substantially altered during periods of injury-induced acute metabolic stress. Excess nutritional delivery during this period can further increase the metabolic demands of acute injury and place an added burden on the lungs and liver. The result is to increase pulmonary and hepatic pathophysiology, as well as to increase the risk of mortality. It is important, therefore, to ensure that caloric intake not exceed demand. Precise caloric delivery is best determined during acute injury states by measuring energy expenditure. Due to substantial interpatient variability, estimates of energy needs on the basis of disease categories, subject age, or body composition can be misleading and usually result in overfeeding. The delivery of caloric amounts normally required for healthy infants is inappropriate for acutely-stressed, critically ill infants in whom total energy requirements are much lower due to inhibited growth, reduced insensible losses, and decreased activity. Such nutritional administration can result in overfeeding by 200% of measured energy expenditure. Overfeeding cannot reverse tissue catabolism until the acute metabolic stress response has resolved. In these acutely-stressed infants, measured energy expenditure constitutes the total energy requirement, and caloric delivery in excess of this amount should be avoided until metabolic stress parameters indicate resolution of the acute injury state. Enteral delivery should be used in preference to parenteral feeding. Even if total caloric delivery cannot be achieved enterally, the provision of a small amount of the total energy budget via the enteral route is generally possible and is likely advantageous.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of postoperative sepsis in infants with the use of metabolic stress monitoring.

OBJECTIVES: To evaluate the ability of serial protein metabolic monitoring to detect postoperative injury due to serious bacterial infection in infants by comparing changes observed in these protein parameters with more conventionally accepted indexes of infection. DESIGN: Retrospective review of infants whose postoperative course was complicated by bacterial infection compared with a matched cohort of infants in whom bacterial infection did not develop postoperatively. SETTING: Neonatal and pediatric intensive care units at the Wake Forest University Medical Center, Winston-Salem, NC. PATIENTS: Critically ill infants (N = 40) recovering from major surgical intervention. MAIN OUTCOME MEASURES: Serum C-reactive protein, prealbumin, and tumor necrosis factor concentrations were compared with the white blood cell count, immature-total neutrophil ratio, and body temperature obtained within 24 hours before and following the new onset of culture-established postoperative bacterial infection in 13 infants. These infants were compared with a matched cohort of 27 infants in whom postoperative bacterial infection did not develop. RESULTS: Only C-reactive protein (P = .0001) and prealbumin (P = .0003) levels were significantly altered in association with the onset of serious bacterial infection (paired t test). The C-reactive protein levels were clearly superior to all other variables in predicting postoperative infection (at cutoff point > 6.0 mg/dL; sensitivity, 92%; specificity, 96%). The predictive power of prealbumin level was lower, but acceptable (at cutoff point < or = 9.0 mg/dL; sensitivity, 85%; specificity, 74%). CONCLUSIONS: Monitoring of serial protein metabolic stress with C-reactive protein and prealbumin levels in infants following operations is more effective than the white blood cell count, immature-total neutrophil ratio, or temperature in detecting serious postoperative infections.

Hamartomas of the chest wall in infants.

Chest wall hamartomas in infancy are rare lesions with distinct clinical, radiologic, and pathologic characteristics. Four cases treated at Children's Hospital of Los Angeles are presented and previously reported cases are reviewed. Chest wall hamartomas arise antenatally and present as hard, immobile masses, which may cause respiratory insufficiency. An extrapleural mass arising from the ribs can be seen radiographically. Histologically, these lesions are hypercellular and consist of a disorganized array of mesenchymal tissues endogenous to the chest wall. Rapid growth may occur, but usually is self-limited. Chest wall hamartomas are usually benign. This series includes the malignant transformation of one of these lesions. En bloc resection is curative, but the large residual chest wall defect frequently results in scoliosis.

Treatment of complicated congenital splenic cysts.

Although rare in occurrence, the potential for congenital splenic cysts to enlarge, rupture, or become infected has been well documented. Presented is the case of a 13-year-old boy with an infected epidermoid cyst of the spleen, which presented as a solitary splenic abscess. The entity has traditionally been treated by splenectomy or, more recently, percutaneous drainage. However, given the inability of percutaneous drainage or sclerotherapy to permanently obliterate congenital splenic cysts, the authors managed this condition with percutaneous drainage and interval partial splenectomy. This achieves complete removal of the lesion while preserving splenic function.

Relationship of metabolic indexes to postoperative mortality in surgical infants.

Acute injury is known to evoke a metabolic stress response, characterized by cytokine release and reprioritization of hepatic protein synthesis to increase acute phase proteins at the expense of visceral proteins. The impact of these evolving, stress-induced, perioperative metabolic changes on clinical outcome in surgical infants has not yet been determined. The cytokine (tumor necrosis factor [TNF]), acute phase protein (C-reactive protein [CRP]), and visceral protein (prealbumin [PA]) responses to acute metabolic stress were evaluated in 41 infants (average age, 47 days) preoperatively and on postoperative days 1 through 7 (POD 1 to 7) following major surgery. Infants were retrospectively grouped according to whether they survived (group 1) or died within 30 days of surgery (group 2). Peak CRP values in the postoperative period were also included for both groups. Peak CRP levels (14.9 +/- 5.5 v 8.1 +/- 5.7 mg/dL) were significantly increased (P = .0056) and preoperative prealbumin levels (6.0 +/- 2.7 v 11.0 +/- 5.2 mg/dL) were significantly decreased (P = .0005) in group 2 (nonsurvivors) compared with group 1 (survivors). Though serum TNF levels were substantially increased in nonsurvivors compared with survivors, both preoperatively (16.5 +/- 35.2 v 0.6 +/- 2.6 pg/mL) and on POD 1 (3.6 +/- 6.8 v 0.6 +/- 2.7 pg/mL), these values did not reach statistical significance (P > .05). The most significant difference (P = .0001) was observed in persistently depressed late (POD 4 to 7) prealbumin levels in nonsurvivors relative to survivors (5.3 +/- 3.1 v 10.5 +/- 4.3 mg/dL), suggesting an increased risk of poor outcome if acute metabolic stress had not abated by this time.(ABSTRACT TRUNCATED AT 250 WORDS)