Abnormal heart rate characteristics before clinical diagnosis of necrotizing enterocolitis.

OBJECTIVE: Earlier diagnosis and treatment of necrotizing enterocolitis (NEC) in preterm infants, before clinical deterioration, might improve outcomes. A monitor that measures abnormal heart rate characteristics (HRC) of decreased variability and transient decelerations was developed as an early warning system for sepsis. As NEC shares pathophysiologic features with sepsis, we tested the hypothesis that abnormal HRC occur before clinical diagnosis of NEC. STUDY DESIGN: Retrospective review of Bells stage II to III NEC cases among infants <34 weeks gestation enrolled in a prospective randomized clinical trial of HRC monitoring at three neonatal intensive care units. RESULT: Of 97 infants with NEC and HRC data, 33 underwent surgical intervention within 1 week of diagnosis. The baseline HRC index from 1 to 3 days before diagnosis was higher in patients who developed surgical vs medical NEC (2.06±1.98 vs 1.22±1.10, P=0.009). The HRC index increased significantly 16 h before the clinical diagnosis of surgical NEC and 6 h before medical NEC. At the time of clinical diagnosis, the HRC index was higher in patients with surgical vs medical NEC (3.3±2.2 vs 1.9±1.7, P<0.001). CONCLUSION: Abnormal HRC occur before clinical diagnosis of NEC, suggesting that continuous HRC monitoring may facilitate earlier detection and treatment.

Follow-up abdominal computed tomography after splenic trauma in children may not be necessary.

Nonoperative management of splenic injuries in children is well accepted. However, the need for follow-up abdominal CT to document splenic healing has not been well studied. We retrospectively reviewed initial and follow-up abdominal CT examinations of pediatric patients admitted to our institution with documented splenic trauma who were managed nonoperatively. Eighty-four patients were admitted to our pediatric surgical service with splenic injury documented by CT from 1994 through 1998. The standard approach for splenic injury was bedrest for 5 to 21 days and limited activity for up to 90 days at the discretion of the attending surgeon. Thirty-five of the 84 had follow-up CTs during outpatient follow-up to evaluate and document splenic healing by CT criteria. The initial and follow-up studies were randomized and read blindly by pediatric radiologists using a modified American Association for the Surgery of Trauma grading system (I-V). The age range of the patients was 6 months to 17 years (mean +/- SE; 11 +/- 1 years). Nineteen (54%) were male and 16 (46%) were female. Causes of splenic trauma included motor vehicle accident (22), fall (seven), assault (four), pedestrian versus vehicle (one), and sports injury (one). Eight children (23%) had grade II injuries, 14 (40%) had grade III injuries, and 13 children (37%) had grade IV injuries on initial CT scan. Seven (88%) of the grade II splenic injuries were healed by 64 +/- 11 days. The remaining grade II injury had healed by 210 days. Thirteen (93%) of the grade III splenic injuries were healed by 76 +/- 7 days. The remaining grade III injury was healed by 140 days. Spleens in 10 (77%) of the 13 patients with grade IV injuries were healed by 81 +/- 8 days. Of the three remaining grade IV injuries two were healed by 173 +/- 14 days. The remaining patient's spleen was radiologically considered to have a grade III defect 91 days from the time of injury, and no further CTs were obtained. Of the 34 patients who underwent follow-up CT imaging until splenic healing was demonstrated the mean time to complete healing was 87 +/- 8 days postinjury (range 11-217 days). These data suggest that routine follow-up abdominal CTs may not be necessary to allow children to resume their normal activities after an appropriate time of restricted activity.

Left upper lobe bronchus reimplantation for nonpenetrating thoracic trauma.

Trauma to the tracheobronchial tree has been diagnosed and treated with increasing frequency over the last several decades. However, most reports have dealt with management of injuries to the trachea and main stem bronchi, as approximately 80% of blunt tracheobronchial injuries occur within this area. With few exceptions, injury to the lobar bronchi has resulted in thoracotomy and lobectomy. We describe a patient with an injury to the left upper lobe bronchus who presented with delayed obstruction of the airway by fibrogranulation tissue. A successful segmental resection of the bronchial occlusion with reimplantation was performed, thereby preserving the patient's otherwise normal left upper lobe. This case demonstrates that resection and reimplantation of an injured lobar bronchus are feasible, even in a delayed setting.

Effects of carotid artery repair following neonatal extracorporeal membrane oxygenation.

Between 1 June 1991 and 30 June 1996, 62 neonates were placed on extracorporeal membrane oxygenation (ECMO). In 61 the right carotid artery was cannulated. At the time of decannulation, a decision was made regarding carotid artery repair (CAR) based on the condition of the vessel. Thirty-two patients underwent end-to-end CAR and 29 had artery ligation. There was no difference between groups in gestational age or birth weight, but the ligation group contained 11 patients with congenital diaphragmatic hernia, compared to 2 in the repair group. The time on ECMO was 148 h for the repair group and 297 h in the ligation group. Follow-up contrast-enhanced magnetic resonance imaging (MRI) studies and ultrasound (US) demonstrated 2 occluded vessels in the repair group (7%); 3 vessels appeared stenotic on MRI. Follow-up neurologic examination was normal or near-normal in 17 of 19 repair infants and 9 of 16 ligation patients. Two repair infants had slight delays in development, while 3 ligation patients had significant delays. Follow-up US showed 3 grade I changes in the repair group with 1 hydrocephalus. There was 1 grade I and 1 grade III change in the ligation group. Follow-up MRI showed 6 minimal changes in the repair group and 9 in the ligation group. CAR does not adversely affect neurologic outcome after neonatal ECMO. The early patency rate was 93%, although 12% of the vessels appeared stenotic. Long-term follow-up confirmed persistent patency. CAR, if technically feasible, should be encouraged following neonatal ECMO therapy.

Treatment of refractory chylothorax with externalized pleuroperitoneal shunts in children.

BACKGROUND: Traditional therapy for refractory chylothorax in the pediatric population has included pleurodesis and thoracic duct ligation. These procedures are associated with high morbidity and questionable success rates. METHODS: We retrospectively reviewed our experience with 15 patients who underwent treatment for chylous effusions using pleuroperitoneal shunts with exteriorized pump chambers. Mean patient age at time of shunt placement was 2.1 (0.1 to 11.5) years and the most common indication (7 of 15) was refractory chylothorax following surgical correction of congenital heart disease. Mean chylothorax duration before shunt placement was 76 (5 to 810) days and shunts were in place for an average of 104 (12 to 365) days. A total of 19 chylous effusions (pleural or pericardial) were treated with shunts. RESULTS: Nine of 11 right-sided chylothoraces, 5 of 6 left-sided chylothoraces, and 2 of 2 chylopericardia resolved with shunt therapy (84% total). Pleuroperitoneal shunting failed to clear the effusion in 3 children. There were six episodes of shunt malfunction that were repaired and two episodes of infection. Inguinal or umbilical hernia developed in 4 patients. CONCLUSIONS: Externalized pleuroperitoneal shunting is a safe, effective, and minimally invasive treatment for children with refractory chylous effusions.

The role of peritoneal drainage for intestinal perforation in infants with and without necrotizing enterocolitis.

BACKGROUND/PURPOSE: This report reviews our experience using peritoneal drainage (PD) as initial therapy for intestinal perforation in premature infants with and without necrotizing enterocolitis (NEC). METHODS: A chart review was conducted of 18 consecutive premature infants who underwent PD for intestinal perforation from 1995 to 1998. Infants were divided into two groups. Group 1 consisted of eight infants who had intestinal perforation without evidence of NEC. Group 2 consisted of 10 infants who had perforation associated with evidence of NEC. A cohort of 10 infants with intestinal perforation treated with primary laparotomy between 1990 and 1995 was identified by chart review for historical control. RESULTS: All infants improved immediately after PD. In group 1, all survived. Seven (88%) recovered systemically after PD. Of these, five (63%) never required laparotomy. Two (25%) required delayed laparotomy. One infant (12%) failed to continue to improve 48 hours after PD and underwent urgent laparotomy and recovered. In group 2, eight (80%) infants survived. Six (60%) recovered from NEC after PD, but five required delayed laparotomy for obstruction or persistent drainage. Four infants (40%) failed to progress from their initial improvement after PD. Three underwent laparotomy; two recovered and one had total intestinal necrosis and died. The fourth infant died without exploration and total intestinal necrosis was discovered during autopsy. Thus, seven of eight survivors (88%) in group 2 required laparotomy at some point in their course. CONCLUSIONS: In premature infants with intestinal perforation, PD allows acute improvement and usually systemic recovery. In infants without evidence of NEC, PD may afford definitive treatment. In contrast, infants with evidence of NEC will likely require laparotomy, but initial PD may allow systemic stabilization and recovery of much of the involved intestine before laparotomy.

Successful treatment of a patient with stage IV rhabdoid tumor of the kidney: case report and review.

The clinical course of a 31-month-old patient with advanced (stage IV) rhabdoid tumor of the kidney (RTK) and an analysis of treatment variables that may impact survival are presented. Treatment included complete resection of abdominal disease, radiation therapy to the abdomen and chest, and chemotherapy on a schedule of dose intensification by reduction of the interval between cycles. Inclusion of doxorubicin in treatment was associated with survival among patients in published series (P = 0.002). The patient was in continuous complete remission 60 months from diagnosis. Stage IV rhabdoid tumor of the kidney can be effectively treated with intensive multimodal therapy. Doxorubicin may be an important component of a successful therapeutic regimen.

Successful management of stage 4S neuroblastoma and severe hepatomegaly using absorbable mesh in an infant.

This report describes the use of an absorbable mesh in an infant with stage 4S neuroblastoma who required decompressive laparotomy. At the time of laparotomy, a SILASTIC silo was placed. After 12 days, the liver had not reduced in size despite chemotherapy and radiation therapy. Because of concern for infection, the silo was removed, and an absorbable polygalactin (Vicryl) mesh was placed. Wet-to-dry dressings were used to manage the mesh. A granulation base developed that provided a physiological closure of the abdominal cavity. Forty-two days after placement of the absorbable mesh, the liver had reduced to a size that permitted mobilization of skin flaps for a surgical abdominal closure. The liver continued to reduce in size, allowing the fascial edges to draw together. The patient is now 2 years old with no signs of residual tumor or ventral hernia.

Ureteropelvic junction injuries secondary to blunt abdominal trauma.

PURPOSE: To describe the clinical and imaging findings of ureteropelvic junction (UPJ) injuries caused by blunt trauma. MATERIALS AND METHODS: In two children (aged 10 and 16 years) and eight adults (aged 23-82 years) with UPJ injuries, findings at computed tomography (CT) (n = 10), excretory urography (n = 6), and retrograde pyelography (n = 8) were retrospectively reviewed to identify the location and extent of contrast material extravasation. Clinical and follow-up data were correlated with radiologic findings. RESULTS: CT and urography played complementary roles in diagnosis. UPJ avulsion, defined as complete transection of the ureter with no filling of the ipsilateral ureter below the level of the UPJ, was diagnosed in four patients. UPJ laceration, defined as contrast material extravasation from the UPJ with contrast material in the ipsilateral ureter distal to the point of injury, was diagnosed in six patients. Medial perirenal contrast extravasation was seen in all 10 patients but failed to help differentiate UPJ avulsion from laceration. A distinctive pattern of contrast material extravasation at CT termed "circumrenal urinoma" was present in five patients and was found to be specific for UPJ injury. CONCLUSION: Medial perinephric contrast material extravasation was highly suggestive of UPJ injury. Demonstration of ureteral filling differentiated UPJ laceration from avulsion.

Neurological outcome is diminished in survivors of congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation.

In a series of 61 infants who had congenital diaphragmatic hernia (CDH) treated at our center from 1978 through 1996, 37 of 59 (61%) survived the perioperative period with two infants lost to follow-up. Nine (47%) of 19 infants survived before the introduction of extracorporeal membrane oxygenation (ECMO) into our region in 1986. Since 1986, 28 (70%) of 40 infants survived. Eighteen infants required ECMO, and 12 (75%) survived. A chart review was performed to determine whether infants surviving CDH are suffering from delays in neurological development, and, if so, whether this is attributable to ECMO. Of 12 ECMO survivors, 8 (67%) exhibited functional or anatomic evidence for neurological delay. Of 21 non-ECMO survivors, where adequate follow-up was available to make an assessment of neurological development, five (24%) exhibited evidence for delay. This difference was significant (P < .05, Fisher's Exact test). Of these five infants, three were premature, and one had DiGeorge syndrome. More ECMO survivors required diaphragmatic (67%) and abdominal (67%) patches at the time of diaphragmatic repair than non-ECMO survivors (4% and 12%, respectively; P < .05, Fisher's Exact test). In addition, more ECMO survivors required gastrostomy tube placement for feeding (50%) than non-ECMO survivors (16%; P < .05, Fisher's Exact test). A greater need for Nissen fundoplication in ECMO survivors (42%) than in non-ECMO survivors (12%) approached significance (P = .05, Fisher's Exact test). There were trends toward higher 1 and 5 minute APGAR scores and initial and best preoperative P(O2) in the non-ECMO survivors. A comparison between ECMO survivors who exhibited evidence of neurological delay with those who did not showed no differences in duration of ECMO, incidence of intracranial complications during ECMO, need for gastrostomy tube feeding or Nissen fundoplication, or incidence of carotid artery repair between the two groups. Infants surviving CDH who require ECMO have a greater incidence of neurological delay than those who do not. This is likely because of severity of the presenting illness as reflected by a greater need for diaphragmatic and abdominal patches during diaphragmatic repair, the need for Nissen fundoplication and gastrostomy tube feeding, and a trend toward poor APGAR scores and best preoperative P(O2) levels in these patients. However, there may be characteristics of ECMO, as yet unidentified, that may contribute to this outcome.

Hernia survey of the Section on Surgery of the American Academy of Pediatrics.

The members of the Section on Surgery of the American Academy of Pediatrics were surveyed to determine the practice of North American pediatric surgeons in infants with inguinal hernia (IH). Case-scenario multiple-choice-design questionnaires regarding hernias and hydroceles were sent to all members of the Surgical Section, and responses were received from 292 (50%). In healthy full-term infant boys with asymptomatic reducible IH, 82% of responders perform repair electively, no matter what the age or weight. In full-term girls with a reducible ovary, 59% perform surgery at the next available time; if the ovary is nonreducible but asymptomatic, 44% operate emergently or urgently and 42% at the next elective slot. In former preemies, the pattern of repair is as follows. (1) For those recently discharged after 2 months in the neonatal intensive care unit (NICU) with reducible IH, 65% perform the repair when convenient. (2) A general anesthetic is used in 70%; 15% use spinal anesthesia, and 11% use caudal block with sedation. (3) If the repair is done in the hospital outpatient (same-day) unit, 36% wait until 50 weeks postconception (PC) and 33% wait until 60 weeks PC. (4) if the baby's weight is at least 1,000 g. 71% perform the repair before discharge. The pain control choice after childhood IH repair is Tylenol for 30%, local infiltration biquivacaine for 30%, caudal block for 22%, regional block for 11%, and Tylenol/codeine combined for 7%. In 6-week-old full-term infants with communicating hydroceles without definite "hernia," two thirds treat as an IH with elective repair as soon as possible. With respect to contralateral exploration in infants with unilateral IH, 65% perform it in males if they are < or = 2 years of age and 84% use it in females of up to 4 years of age. This approach is not influenced by presenting side, presence of hydrocele, or history of prematurity. Laparoscopic evaluation of the contralateral IH is performed by only 6% of responders, 40% of whom use the open ipsilateral sac for laparoscope introduction.

Congenital diaphragmatic hernia: experience in a single institution from 1978 through 1994.

BACKGROUND: Congenital diaphragmatic hernia continues to be a difficult management problem. Essentially all information on the condition has been compiled in a retrospective manner due to the individualized care that each infant must undergo. We contribute a review of our patients to add to the current fund of knowledge and to assess our experience before and since the introduction of extracorporeal membrane oxygenation in our institution. METHODS: This is a review of records of infants with congenital diaphragmatic hernia treated from 1978 through 1994. Repair has generally been accomplished early with only one repair being accomplished with an infant placed on extracorporeal membrane oxygenation preoperatively. RESULTS: Overall survival was 63%. Survival was 42% before extracorporeal membrane oxygenation becoming available in our region in 1986, and 75% afterward. Since 1986, 16 of 33 (48%) infants have required extracorporeal membrane oxygenation and 73% have survived. CONCLUSIONS: Overall survival in our series is comparable with that of other reported series. There appears to be an improvement in survival since the introduction of extracorporeal membrane oxygenation. Our present practice of early repair, and postrepair extracorporeal membrane oxygenation if needed, results in a survival rate comparable with that of currently available series reports regardless of the method of treatment reported.

Anesthetic techniques for pediatric thoracoscopy.

BACKGROUND: Since 1981, we have performed 68 thoracoscopic procedures in 62 patients aged 7 months to 21 years. METHODS: We reviewed the anesthetic and ventilation strategy used for each procedure to determine which anesthetic strategies are safe and effective for particular children and conditions. RESULTS: Regional anesthesia with sedation was used for six procedures in 5 patients with a mean age of 16 years (range, 9 to 21 years). One patient required conversion to general anesthesia. General anesthesia with one-lung ventilation was attempted for 18 procedures in 17 patients with a mean age of 12 years (range, 7 months to 18 years). Two patients required conversion to two-lung anesthesia secondary to pulmonary intolerance. One of these patients and 2 others required thoracotomy. General anesthesia with two-lung ventilation was used for 44 procedures in 41 patients with a mean age of 9 years (range, 1 to 17 years). There were no anesthesia-related difficulties. CONCLUSIONS: Regional anesthesia should be limited to the older, more cooperative patient. General anesthesia with one-lung ventilation is useful in adolescents, as they tolerate collapse of one lung well, and it is particularly desirable for procedures requiring exposure of the mediastinum and for talc pleurodesis. General anesthesia with two-lung ventilation can be used in any age group but is generally necessary for infants and small children, as they often will not tolerate the collapse of one lung, and in the larger child or adolescent with severe pulmonary compromise.

Pediatric equestrian injuries: assessing the impact of helmet use.

OBJECTIVE: To assess the impact of helmet use on the pattern, and severity of pediatric equestrian injuries. DESIGN: A prospective observational study of all children less than 15 years of age who were brought to the University of Virginia children's Emergency Department with horse-related injuries. RESULTS: During the two-year period of the study, 32 children were evaluated. Two children were injured when a horse stepped on them. Thirty children fell from or were thrown from a horse. Of these, 20 were wearing a helmet. Head injuries were more frequent in those patients not wearing helmets. The mean Modified Injury Severity Scale (MISS) score for riders without a helmet (12.9) was significantly higher (more severe) than that for helmeted riders (2.8). All three patients with a Glascow Coma Score < 15 on arrival were not wearing a helmet at the time of injury. The frequency of hospitalization was significantly higher for those not wearing a helmet. Compared with other common mechanisms of childhood injury the mean Modified Injury Severity Scale score of injured riders was exceeded only by that of pedestrians struck by a car. CONCLUSION: Equestrian injuries are more severe than those suffered from other common pediatric mechanisms. Helmet use is associated with decreased frequency and severity of central nervous system injury.

Use of video-assisted thoracic surgery in the treatment of chylothorax.

Chylothorax, a potentially lethal disorder that may cause profound respiratory, nutritional, and immunologic complications, has become increasingly common in recent years. Medical therapy has been found to have a significant failure rate. Therefore, surgical treatment of complicated chylothorax has become a mainstay of care. Between 1987 and 1993, ten patients at the University of Virginia Hospital were treated with video-assisted thoracic surgery for complicated chylothorax. Twelve thoracoscopic procedures were performed. Patients ranged in age from 7 months to 82 years. Causes included iatrogenic (2), congenital (2), caval thrombosis (2), amyloid (2), blunt trauma (1), and metastatic carcinoid tumor (1). In 10 cases, video-assisted thoracic surgery was employed as the principal mode of therapy: 8 using talc pleurodesis alone, 1 using talc pleurodesis and clipping of the thoracic duct with application of fibrin glue, and 1 requiring clipping of a pleural defect with application of fibrin glue. In 2 cases, a video-assisted thoracic operation was used in conjunction with pleuroperitoneal shunting: a previously placed pleuroperitoneal shunt that was malfunctioning was repositioned thoracoscopically after a pleural adhesiolysis, and a pleural adhesiolysis was performed thoracoscopically before placement of a pleuroperitoneal shunt. In all cases the effusion resolved after the video-assisted thoracic operation without further intervention. Video-assisted thoracic surgery offers an effective means of treating chylothorax, regardless of cause, allowing the advantage of access to thoracic structures without the morbidity of more extensive procedures.

Laparoscopic ultrasound-guided drainage of lymphoceles following renal transplantation.

The development of a lymphocele is an uncommon but well-documented complication of renal transplantation. In most patients, lymphoceles remain asymptomatic, and no intervention is required. In some cases, however, lymphoceles become symptomatic and cause systemic and local manifestations. Ultrasonic scanning can easily diagnose and locate the size and position of perirenal fluid collections. Many of these patients can be managed conservatively by aspiration and drainage of the lymphocele under radiologic guidance. However, if the lymphocele remains symptomatic or reaccumulates after aspiration and drainage, surgical intervention may be required. We describe two different ultrasound-guided laparoscopic techniques for drainage of a perirenal lymphocele into the peritoneal cavity. Successful drainage was accomplished in 5 patients, with 1 patient suffering an injury to the ureter of the transplant kidney. Recommendations regarding patient selection and operative technique are presented.