An unusual late complication of necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) now is managed frequently successfully without surgical intervention. NEC may result in strictures, which present after the acute inflammatory process has resolved. Strictures usually present as obstruction in the first year or two of life. A case report is presented of an 11-year-old child who had symptoms from a previously undiagnosed NEC stricture as a result of pica when coins obstructed the stricture. As treatment of NEC continues to improve, more and later complications of this disease can be expected. J Pediatr Surg 36:1853-1854.

Effect of cross-sectional imaging on negative appendectomy and perforation rates in children.

PURPOSE: To compare negative appendectomy and perforation rates in children who underwent ultrasonography (US), computed tomography (CT), or no imaging before urgent appendectomy. MATERIALS AND METHODS: All children who underwent urgent appendectomy during a 4(1/2)-year period were identified in a surgical billing database. Pathology reports were coded as negative or as showing acute inflammation or perforation. Imaging up to 14 days before appendectomy or abscess drainage was noted, and imaging-based diagnoses were compared with pathologic findings. Patient age and sex were recorded. RESULTS: Two hundred ninety-nine children, 176 (59%) male and 123 (41%) female (mean age, 10.4 years; age range, 1--21 years), underwent urgent appendectomy. One hundred twenty-six (42%) underwent no imaging, 121 (41%) underwent US with or without CT, and 52 (17%) underwent CT only; 44 (15%) underwent both US and CT. There were significantly higher rates of appendectomy with normal pathologic findings ("negative appendectomy") in patients who underwent no imaging (14% [18 of 126]) or US (17% [20 of 121]) versus the rates in those who underwent CT only (2% [one of 52]) (P =.02 and P =.007, respectively). The negative appendectomy rate was 7% in 96 patients who underwent CT with or without prior US. The perforation rates were not significantly different. CONCLUSION: As compared with children who underwent no preoperative imaging and those who underwent US, children who underwent CT had a significantly lower negative appendectomy rate, without a significantly higher perforation rate.

Imaging evaluation of suspected appendicitis in a pediatric population: effectiveness of sonography versus CT.

OBJECTIVE: The purpose of this study was to compare the diagnostic accuracy of graded compression sonography with that of helical CT for the diagnosis of appendicitis in a pediatric and young adult population. SUBJECTS AND METHODS: Between June 1996 and April 1999, 386 pediatric and young adult patients with suspected appendicitis were examined using sonography, CT, or both: 233 underwent sonography only, 71 underwent CT only, and 82 underwent sonography and CT. All sonograms and CT scans were prospectively interpreted as showing positive or negative findings for appendicitis by one of six pediatric radiologists. CT and sonographic findings were correlated with surgical and histopathologic findings or findings at clinical follow-up. RESULTS: Helical CT had a significantly higher sensitivity (95% versus 78%, p = 0.009) and accuracy (94% versus 89%, p = 0.05) than graded compression sonography for the diagnosis of appendicitis in children, adolescents, and young adults. The specificity of both techniques was 93%. Twenty of 82 patients who underwent both sonography and CT had discordance between the findings of the two examinations. The CT results were correct in a significantly greater number of patients with discordant examinations (17/20 patients [85%]). CONCLUSION: Helical CT has a significantly higher sensitivity and accuracy than graded compression sonography for the diagnosis of appendicitis in a pediatric and young adult population, particularly in children more than 10 years old.

Evaluation of suspected appendicitis in children and young adults: helical CT.

PURPOSE: To evaluate the accuracy of helical computed tomography (CT) for the diagnosis of appendicitis in children and to assess the utility of CT in establishing alternative diagnoses. MATERIALS AND METHODS: The medical records of 154 children (median age, 12 years; age range, 1-20 years) who were suspected to have appendicitis and who underwent CT were reviewed. The gastrointestinal tract was opacified in 151 of 154 patients: Only orally administered contrast material was used in 126 patients; only rectally administered contrast material, in 21 patients; and both oral and rectal contrast material, in four patients. CT findings were correlated with surgical and histopathologic findings or with clinical follow-up findings. RESULTS: Sixty-four CT scans were interpreted as positive for appendicitis and included 58 true-positive and six false-positive scans. Ninety scans were interpreted as negative and included 87 true-negative and three false-negative scans. CT had a sensitivity of 95% and a specificity of 94% for the diagnosis of appendicitis. In addition, in 32 (34%) of 93 patients without appendicitis, an alternative diagnosis was established on the basis of CT findings. CONCLUSION: Helical CT is useful in a pediatric population to diagnose or exclude appendicitis and to establish an alternative diagnosis.

Selective management of pediatric pancreatic injuries.

BACKGROUND: Despite trauma being the most common cause of pediatric pancreatitis, the diagnosis and management is often difficult. METHODS: The hospital course, diagnostic and surgical procedures, and complications for all children with traumatic pancreatitis evaluated at a Regional Level I Trauma Center were reviewed retrospectively. RESULTS: Twelve of 3,500 children (0.35%, mean age, 8.7 +/- 1.2 years) were reviewed. Intraoperative diagnosis was made in three after penetrating trauma. Nine children sustained blunt pancreatic trauma (BPT) with serial radiographic imaging confirming the diagnosis in seven. Serial serum amylase levels, when performed, were normal in two and elevated in six, but did not predict injury severity or need for further intervention. Endoscopic retrograde cholangiopancreatography was performed in three children and indicated the need for surgical intervention in two and prevented planned laparotomy in one. Two children underwent computed tomography-guided fluid drainage. Pseudocysts developed in five children. Mortality rate from penetrating injuries was 66% with no deaths from BPT. CONCLUSIONS: A combination of serial radiographic, laboratory, and ERCP findings will improve the diagnosis and management of BPT. Penetrating or main ductal injuries require surgical intervention, and fluid collections may require drainage, but, otherwise, most BPT can be managed nonoperatively with minimal morbidity and mortality.

Pediatric hepatic trauma: does clinical course support intensive care unit stay?

PURPOSE: The objective of this study is to determine if grade of liver injury predicts outcome after blunt hepatic trauma in children and to initiate analysis of current management practices to optimize resource utilization without compromising patient care. METHODS: A retrospective review of 36 children who had blunt hepatic trauma treated at a pediatric trauma center from 1989 to present was performed. Hepatic injuries graded (AAST Organ Injury Scaling) ranged from grade I to IV. Injury Severity Score (ISS), Glasgow Coma Score (GCS), transfusion requirements, liver transaminase levels, associated injuries, intensive care unit (ICU) length of stay, and survival were analyzed. RESULTS: Mean (+/-SEM) age was 6.6+/-0.8 years, mean grade of hepatic injury was 2.4+/-0.2, mean ISS was 17+/-2.6, mean GCS was 13+/-1, and mean transfusion was 15.4 mL/kg of packed red blood cells (PRBC). There were three deaths with a mean ISS of 59+/-9 and a mean GCS of 3+/-0. Death was not associated with a high-grade liver injury, survivors versus nonsurvivors, 2.3+/-0.2 versus 2.7+/-0.3, but was associated with ISS, 13+/-1.4 versus 59+/-9 (P = .005) and GCS, 14+/-1 versus 3+/-0 (P = .005). Only one patient (grade III, ISS = 43) underwent surgery. There were no differences in mean ISS or GCS between grades I to IV patients. The hepatic injury grades of patients requiring transfusion versus no transfusion were significantly different, 3.4+/-0.2 versus 2.2+/-0.2 (P = 0.04). Abused patients had high-grade hepatic injuries and significant laboratory and clinical findings. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were significantly higher in grade III and IV injuries than in grades I and II, 1,157+/-320 versus 333+/-61 (P= .02) and 1,176+/-299 versus 516+/-86 (P= .04), respectively. No children with grade I or II injury had a transfusion requirement or surgical intervention. There were no liver-related complications. CONCLUSIONS: Mortality and morbidity rates in pediatric liver injuries, grades I to IV, correlate with associated injuries not the degree of hepatic damage. ALT, AST, and transfusion requirements are significantly related to degree of liver injury. Low-grade and isolated high-grade liver injuries seldom require transfusion. Blunt liver trauma rarely requires surgical intervention. In retrospect, the need for expensive ICU observation for low-grade and isolated high-grade hepatic injuries is questionably warranted.

Antenatal diagnosis of choledochal cyst.

We report five infants in whom antenatal diagnosis of choledochal cyst was established by ultrasonography, and we review the seven previously reported cases. All but one infant had cystic dilatation of the common bile duct (type 1 cysts), and all infants were diagnosed during the second or third trimester. Eight of 12 infants (67%) developed jaundice in the first few days of life, but only 25% had a palpable abdominal mass. Seven of nine infants (78%) demonstrated complete obstruction of the distal common bile duct on intraoperative cholangiography. Liver histology was available for six patients. Five of six had cirrhosis or fibrosis with bile duct proliferation. All of the infants with fibrosis or cirrhosis had distal common bile duct obstruction. Despite liver biopsy findings of extensive fibrosis plus ascites with failure to thrive in one of our patients, all five patients demonstrated clinical and biochemical improvement following surgical excision and porto- or choledochoenterostomy. All were free of symptoms by 6 months of age. Congenital choledochal cyst should be considered in the differential diagnosis of any sonolucent abdominal mass of the fetus. Neonates with distal common bile duct obstruction and fibrosis in association with presumed choledochal cyst should have prompt surgical exploration, intraoperative cholangiography, and close postoperative follow-up. The long-term outcome with prompt surgical correction is excellent.

Indications for open surgical removal of airway foreign bodies.

Airway foreign bodies can usually be extracted by skillful application of endoscopic techniques. We report our experience in the management of 2 infants in whom sharp, pointed objects dictated consideration for an open surgical approach. Clinical presentation and treatment options will be discussed in the successful management of these 2 patients, one with a crab claw in the subglottis and the other with an electronic diode in the lung. Extensive training and a full complement of modern instruments are required, but in highly selected cases, an open surgical procedure entails less risk than endoscopic extraction.

Diagnosis and management of congenital vascular rings: a 22-year experience.

Between 1968 and 1990, we operatively treated 39 patients (19 boys, 20 girls) with congenital aortic arch anomalies. Median age was 7 months (range, 1.5 months to 23 years). Thirty-seven patients (95%) had respiratory symptoms. Barium swallow was diagnostic in 95%. Right arch with aberrant left subclavian artery and double aortic arch were the most common types (11 each). Treatment of an aortic diverticulum was documented in 19 patients; the aortic diverticulum was excised (9), managed by aortopexy (7), or left in situ (3). Postoperative recovery was rapid, with a median intensive care unit stay of 2 days, time to oral feeding of 1 day, and postoperative time to discharge of 7 days. Two deaths occurred: 1 infant had undergone emergent operation for control of hemorrhage from an aortotracheal fistula due to tracheostomy tube erosion, and the other had multiple associated congenital heart defects. Postoperative complications included bleeding (1), pneumonia (5), and chylothorax (4). One boy had persistent severe symptoms due to an untreated aortic diverticulum and underwent subsequent excision of the aortic diverticulum with complete relief of symptoms. Median length of follow-up was 12.5 months, with at least 97% of survivors completely or nearly completely free of symptoms from the vascular ring. These results suggest that early repair of congenital aortic vascular rings, including fixating or excising an associated serious aortic diverticulum, is safe and effective and allows for normal tracheal growth.

Neurofibromatosis 1: recognition and management of associated neuroblastoma.

Neurofibroma and neuroblastoma both arise from the neural crest, and there has long been speculation regarding a pathogenetic relationship between them. Clinical characteristics do not necessarily distinguish these tumors, therefore the diagnosis of neuroblastoma should be considered in all children with neurofibromatosis 1 (NF-1) who have a rapidly growing or inaccessible mass. A careful physical examination, imaging studies, and urinary catecholamine measurement are indicated. In a child with NF-1 and malignancy, direct tissue examination may be necessary to differentiate malignant from nonmalignant tumor and guide therapy. Furthermore, with the significantly increased risk of certain types of childhood cancer in these patients, we recommend evaluation for this common heritable condition in all patients with malignancy.

Prediction of successful primary closure of congenital abdominal wall defects using intraoperative measurements.

To determine whether intragastric pressure (IGP) and central venous pressure (CVP) would reliably predict successful primary closure of congenital abdominal wall defects (omphalocele/gastroschisis) in newborn infants, we developed the following prospective intraoperative management protocol. Following a temporary trial of fascial closure, infants who had an IGP less than 20 mm Hg or an increase in CVP of less than 4 mm Hg were primarily closed. If IGP was greater than 20 mm Hg or if CVP increased by more than 4 mm Hg, the temporary closure of the abdomen was reopened and a prosthetic silo was placed. Ten infants who were less than 24 hours old and averaged 2.7 kg (range, 1.4 to 4.2 kg) and 37-weeks gestation (range, 32 to 41 weeks) were studied. Eight infants met criteria for primary closure. Their IGP averaged 14 +/- 4 mm Hg (+/- SD) (range, 8 to 19 mm Hg), and their increase in CVP averaged 1 +/- 2 mm Hg (range, -2 to 3 mm Hg). In the two infants who required staged repair, IGP averaged 25 +/- 1 mm Hg (+/- SD) (range, 24 to 25 mm Hg), and the increase in CVP averaged 7 +/- 1 mm Hg (range, 6 to 8 mm Hg). All patients were anesthetized with fentanyl (12.5 micrograms/kg) and paralyzed with metocurine (0.3 mg/kg) intraoperatively. There were no postoperative complications in either group of patients related to increased intraabdominal pressure, and all patients were extubated within 48 hours of the initial surgery. We conclude that the intraoperative measurement of changes in IGP and CVP can serve as a guide to the operative management of congenital abdominal wall defects and can reliably predict successful outcome following repair.

The effect of adenosine triphosphate on the functional status of the ductus arteriosus.

We investigated whether a low-dose infusion of ATP-MgCl2 could affect the functional status of the ductus arteriosus during hypoxia-induced pulmonary vasoconstriction. Three-day-old piglets were made hypoxic by ventilation with a mixture containing 10% oxygen, 4% CO2, and balance nitrogen. Serial infusions of ATP-MgCl2 at 0.1, 0.5, and 1.0 mg/kg/min were compared with preinfusion hypoxia baselines. The functional status of the ductus arteriosus was determined by change in transit time of a bolus of iced saline between thermistor probes in the pulmonary artery and aorta. The method was validated using a Blalock-Taussing shunt (subclavian to pulmonary artery) in 3-week-old piglets instrumented in a similar manner. In these three-day-old piglets, hypoxia alone produced a significant elevation in pulmonary artery pressure and reduction in PO2. All dose rates of ATP-MgCl2 produced a significant decrease in mean pulmonary artery pressure. Systemic pressure was significantly decreased only during the 1.0-mg/kg/min infusion. Transit times of a bolus of iced saline during the validation were definitive for characterizing a situation of "shunt open" or "shunt closed." Infusion of ATP-MgCl2 produced no change in the status of the ductus arteriosus in 45 (94%) of the determinations. In only three cases was the effect of ATP-MgCl2 sufficient to result in a functional change in the status of the ductus arteriosus. Pre- and postductal pulmonary artery PO2 were not altered during ATP-MgCl2 infusion, thus corroborating the transit time determinations. From these results, we conclude that an infusion of ATP-MgCl2 does not alter the functional status of the ductus arteriosus.

Adenosine triphosphate (ATP) treatment of hypoxic pulmonary hypertension (HPH): comparison of dose dependence in pulmonary and renal circulations.

In this study we investigated the relationship between pulmonary and renal responses to a low dose infusion of adenosine triphosphate-magnesium chloride (ATP-MgCl2) in a newborn piglet model of hypoxic pulmonary hypertension (HPH). Three- to five-day-old piglets were cannulated for the measurement of pulmonary and systemic arterial pressure, pulmonary and renal artery flow, and urine output. The animals were then made hypoxic by ventilation with a mixture containing 10% oxygen, 4% CO2, and balance nitrogen. Serial infusions of ATP-MgCl2 at 0.01, 0.025, 0.05, 0.1, 0.5, and 1.0 mg/kg/min were compared to preinfusion hypoxia baselines. Hypoxia alone produced a significant elevation in pulmonary artery pressure (73%) and a reduction in pO2. All dose rates of ATP-MgCl2 greater than or equal to 0.05 mg/kg/min produced a significant decrease in mean pulmonary artery pressure. However, as baseline mean pulmonary artery pressure increased there was an increased sensitivity to ATP-induced vasodilation. Pulmonary artery flow did not change during ATP infusion, thus, the change in pulmonary vascular resistance accounted for the decrease in pulmonary artery pressure. In contrast to the response of the pulmonary vasculature, systemic pressure was significantly decreased only during the 1.0 mg/kg/min infusion. Renal blood flow decreased by 46% during hypoxia and decreased further only during the highest dose rate of ATP infused (i.e., 1.0 mg/kg/min). Creatinine clearance (Ccr) and fractional reabsorption of Na (FreNa) also fell during hypoxia, but were not further altered during all but the highest dose of ATP infused.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenosine triphosphate: a potential therapy for hypoxic pulmonary hypertension.

In this study we investigated whether a low-dose infusion of ATP-MgCl2 could ameliorate the pulmonary hypertension resulting from hypoxic pulmonary vasoconstriction. Three-week-old piglets were anesthetized, intubated, ventilated with room air, and cannulated for the measurement of pulmonary and systemic arterial pressure and pulmonary artery flow (cardiac output). The ventilator inflow was then changed to a mixture containing 10% oxygen, 4% CO2, and balance nitrogen. Serial infusions of ATP-MgCl2 at 0.1, 0.5 and 1.0 mg/kg/min were compared to preinfusion hypoxia baselines. Hypoxia alone produced a significant elevation in pulmonary artery pressure. Although all dose rates of ATP-MgCl2 produced a significant decrease (30%) in mean pulmonary artery pressure, we observed a maximum decrease in MPAP at the lowest rate of ATP infusion. Pulmonary artery flow rose slightly during ATP infusion; therefore, it was the change in pulmonary vascular resistance that accounted for the decrease in pulmonary artery pressure. In contrast, the systemic pressure was significantly decreased only during the 1.0 mg/kg/min infusion. The predominant pulmonary effects are a result of the virtual clearance of ATP-MgCl2 in a single pass through the circulation. Adenosine in the presence or absence of MgCl2 produced only a 10% reduction in mean pulmonary artery pressure, and MgCl2 had no effect when infused alone. From these results, we conclude that a low-dose infusion of ATP-MgCl2 could ameliorate the vasoconstriction associated with hypoxic pulmonary hypertension without significant deleterious systemic side effects.

Neonatal ovarian cysts: sonographic-pathologic correlation.

The authors reviewed the prenatal (11 infants) and postnatal (17 infants) sonograms and the clinical, surgical, and pathologic findings in 17 infants with an ovarian cyst to determine the sonographic features and natural history of neonatal ovarian cysts. An uncomplicated cyst (nontwisted, nonhemorrhagic) was completely anechoic and the cyst wall was imperceptible with sonography (five cases). A twisted or hemorrhagic cyst was cystic with a fluid-debris level, cystic with a retracting clot, septated with or without internal echoes, or solid (12 cases). These complicated cysts contained liquid and/or organized hematoma. Eleven of the 12 complicated cysts had a thin, highly echogenic wall. Cyst torsion commonly occurred in utero and could be diagnosed on prenatal sonograms by a typical sonographic appearance (eight cases). All of these infants were asymptomatic after birth. Four infants with hemorrhagic or twisted cysts were symptomatic. All cysts except one that resolved spontaneously were treated surgically, including three twisted cysts that showed no change in size over a 1-8-month interval. All of the cysts were of follicular origin.

Hemodynamic effects of primary closure of omphalocele/gastroschisis in human newborns.

To determine whether they could establish reliable, objective criteria that would predict safe, primary closure of abdominal wall defects (omphalocele/gastroschisis) in newborn infants, the authors measured intraoperative changes in intra-gastric pressure (IGP), central venous pressure (CVP), cardiac index (CI), systolic arterial blood pressure (BP), and heart rate (HR). Eleven neonates, who averaged 2.7 kg (range 1.5-4.1 kg) and 36 weeks gestation (range 30-41 weeks) were anesthetized with fentanyl (7.5-12.5 micrograms/kg), metocurine (0.3 mg/kg), and oxygen. Three infants had defects that were too large to close primarily. Of the eight infants who underwent primary closure, four required re-operation within 24 h because of oliguria or poor peripheral perfusion. Infants who required re-operation had intra-gastric pressures of 20 mmHg or more, a decrease in CI of 0.78 1.min.m2 or more, and an increase in CVP of 4 mmHg or more. Heart rate, BP, and systemic vascular resistance did not differ in infants requiring and not requiring re-operation. The authors conclude that intraoperative measurement of changes in IGP, CVP, and/or CI can reliably predict success or failure of primary operative repair of abdominal wall defects in human neonates.

The efficacy of computed tomography in evaluating abdominal injuries in children with major head trauma.

Physical examination may be unreliable in the evaluation of children with blunt abdominal trauma particularly in those with associated major head injuries. In the absence of obvious clinical signs or physical findings of intraabdominal injury, the usefulness of abdominal computed tomography in children is controversial. To test the efficacy of CT scans, a 12-month prospective study of computed tomography for the initial assessment of children with blunt abdominal trauma and major head injuries was carried out. Of 320 pediatric trauma admissions to our regional trauma center, 65 consecutive patients with Glasgow Coma Scores less than ten were managed with sequential head and abdominal computed tomography in the emergency room for (1) closed head injury and (2) suspected abdominal trauma. Fifteen patients (23%) were found to have significant intraabdominal injury. Only two required operative intervention. No patients died as a result of the abdominal injuries. In children with significant head trauma and suspected abdominal trauma, combined head and abdominal CT proved to be reliable.

Intestinal ischemic injury following mild hypothermic stress in the neonatal piglet.

The core body temperature of unanesthetized neonatal piglets was lowered 4 +/- 1 degrees C for 4.5 h. Although systolic blood pressure, arterial blood gases, and pH were similar in hypothermic and control animals, grossly evident small intestinal injury occurred in 94% of hypothermic piglets but in none of the controls (p less than 0.01). The histopathology of the intestinal lesions in the experimental animals was characteristic of ischemic injury and ranged from superficial mucosal necrosis to transmural infarct. The lesions were more frequent in the mid- and distal small bowel and involved the muscularis propria only in the distal small bowel. The location and histopathologic characteristics of the bowel lesions in these animals support the concept that mild hypothermia could be a pathogenetic factor in the ischemic bowel lesions of human neonatal necrotizing enterocolitis.