Fetus in fetu: a rare cause of a neonatal mass.

Fetus in fetu is an unusual digression from the normal twinning process which often presents as a mass in neonates. Approximately 80 reports have been documented in the literature to date. The increasing use of routine obstetric ultrasound has identified more cases during the antenatal period. This allows more time for both the neonatology team and the parents to develop a coordinated treatment plan for the anticipated child. We report a case of a fetus in fetu which was first seen as a complex cystic mass during antenatal ultrasound at 21 weeks and was confirmed by subsequent imaging and surgical treatment shortly after birth.

Uterine cervical extrarenal Wilms tumor managed without hysterectomy.

This report describes an unusual case of uterine cervical Wilms tumor treated successfully without hysterectomy or radiation therapy. The 12-year-old white girl developed a persistent vaginal discharge. Her pelvic examination revealed a large mass involving the entire upper vagina, obscuring the cervix. Biopsy of the mass was consistent with Wilms tumor with favorable histology. The tumor was not initially resected because the resection would involve hysterectomy and partial resection of the bladder wall. The patient was treated with preexcisional chemotherapy consisted of alternating vincristine, doxorubicin, cyclophosphamide and carboplatin/etoposide. Repeat magnetic resonance imaging after 5 weeks of chemotherapy demonstrated marked reduction of the tumor size. The tumor was easily removed by transsection of the stalk followed by cold-knife conization of the cervix. The patient received four more cycles of chemotherapy and remained in complete remission 12 months after completion of chemotherapy. This report suggests that in selected cases, chemotherapy can reduce tumor size sufficiently in patients with bulky cervical Wilms tumor to allow local resection and avoid hysterectomy.

Laparoscopic pyloromyotomy.

Extramucosal pyloromyotomy is a method with predictable morbidity and outcome for the cure of infantile hypertrophic pyloric stenosis. The method created by Ramstedt is successfully performed using a laparoscopic approach. Preliminary reports, including 266 cases treated by laparoscopic pyloromyotomy (LP), suggest that morbidity is comparable to that of open approaches. Advantages of LP include superior cosmetic result and no reported wound infections to date. For the experienced laparoscopic surgeon, LP is an precise and efficient technique, and the preferred method for the management of infantile hypertrophic pyloric stenosis.

Laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis: report of 11 cases.

Pyloromyotomy remains the standard of care for the treatment of infantile hypertrophic pyloric stenosis. Open pyloromyotomy is effective and is the gold-standard technique. The authors report on the techniques of laparoscopic pyloromyotomy. The clinical courses of the first 11 infants treated with laparoscopic pyloromyotomy we with the courses of 14 infants treated recently with open pyloromyotomy. The average surgical time for the laparoscopic group was 25.4 minutes. The average time (postoperatively) until full feedings was 19.0 hours. In the open pyloromyotomy group the average surgical time was 26.1 minutes, and the time until full feedings was 23.2 hours. These results are not significantly different. When compared with open pyloromyotomy, the laparoscopic approach appears to be equally safe and effective, with superior cosmetic results. The authors believe that laparoscopic pyloromyotomy is an excellent alternative procedure for the management of hypertrophic pyloric stenosis.

Diagnostic pneumoperitoneum accurately predicts the presence of patent processus vaginalis.

Ninety-four infants with unilateral indirect inguinal hernia underwent repair and diagnostic pneumoperitoneum (DPP). Contralateral groin exploration was performed in all patients including those with a negative DPP result. Thirty-seven (39%) of the 94 patients had a positive DPP result, and 36 of 37 (97%) had a patent processus vaginalis (PPV) on the side contralateral to the clinical hernia. Fifty-seven (61%) of the 94 patients had a negative DPP result, and 54 (95%) of these had no PPV. Female patients had a 1:1 correlation between DPP and PPV. DPP can predict the presence of PPV in the contralateral groin of patients with unilateral hernia with precision and minimizes the need for diagnostic groin exploration.

Gastric carcinoma in children.

Primary gastric carcinoma accounts for only 0.05% of pediatric gastrointestinal malignancies. The pattern, presentation, and location of childhood gastric carcinoma are similar to those of adult gastric carcinoma. Diagnosis is based on a high index of suspicion in children who present with symptoms mimicking acid peptic disease. Delay in diagnosis is common and avoided by early upper gastrointestinal radiography and endoscopy with biopsy. Surgical therapy alone may prolong survival but thus far it has proven only palliative. The role of chemotherapy and radiation in gastric carcinoma is still not well defined, although some new studies in adults may support the use of etoposide, doxorubicin, and cisplatin as primary therapy or combined with surgery and radiation. Long-term survival in children is rare. We present the case of a 3-year survivor, free of disease, treated with resection and chemotherapy.

Blunt bile duct injuries in children.

Three of 87 children with blunt liver injuries initially managed without operation required late intervention for bile leakage. Abdominal computed tomography scans in these patients showed liver injuries extending into the porta hepatis. Clinical courses were characterized by persistent abdominal pain, low-grade fever, and prolonged ileus. Radionucleide scan confirmed the suspicion of bile leakage. One patient had complete transection of the common bile duct, which was repaired surgically. Another had partial transection of the left hepatic duct, managed successfully with transampullary biliary decompression. The third patient with an intrahepatic injury was managed with a drain placed at celiotomy. Nonoperative management of blunt pediatric liver injuries carries a risk of persistent bile leakage. Radionucleide scan and endoscopic retrograde cholangiopancreatography are reliable modes of diagnosis and localization. Transampullary biliary decompression is a newer, effective modality for management of the proximal and/or partial bile duct injuries. Treatment must be individualized according to the site and extent of injury.

Congenital absence of the vas deferens: recurrence in a family.

We report on 2 brothers with congenital absence of the vas deferens discovered in childhood during inguinal hernia repairs. The vas is absent unilaterally in one sib and bilaterally in the other. The unusual presentation of inguinal hernias in these children is discussed as well as mechanisms of inheritance and associated risk of renal anomalies.

Required surgical therapy in the pediatric patient with dermatomyositis.

A review of 96 patients with the established diagnosis of childhood dermatomyositis revealed that 15 patients required surgical therapy in addition to diagnostic biopsy. Four of the patients had perforation of the esophagointestinal tract, and 11 required surgical therapy for abscesses, calcific deposits, or treatment of pneumothorax. The life-threatening lesions were perforations of the esophagus and intestine. The best surgical therapy is closure, resection, and adequate drainage. Prognosis depends on treatment of the underlying medical disease.

Long-term depressed immune function in patients splenectomized for trauma.

Peripheral blood from asplenic trauma patients (ASP) was analyzed for immunoglobulin concentrations, complement levels, T- and B-lymphocyte populations, and mitogen response of T cells, and compared to a similar analysis performed on the blood of normal controls (C). The interval from splenectomy to testing averaged 1,471 +/- 193 days (mean +/- SEM) in the ASP. Total lymphocyte count averaged 2,941 +/- 234 in the ASP with a T-cell count of 2,030 +/- 182 and a B cell count of 351 +/- 58. The average control lymphocyte count of 1,769 +/- 147 was significantly less than ASP (p less than 0.001) as were the T-cell count of 1,328 +/- 107 (p less than 0.005) and the B-cell count of 124 +/- 18 (p less than 0.001). Responses to PHA were diminished in ASP lymphocytes by 38% at 3 days (p less than 0.01) and by 49% at 5 days (p less than 0.001) when compared to C. Levels of IgM were significantly decreased (p = 0.05) in ASP. Levels of C3, C4, and C5 were similar in ASP and C. These data demonstrate persistent abnormalities in immune function in adult ASP without underlying lymphoreticular disorders and suggest a possible explanation for the increased septic risk in this patient group.