Mechanical elongation of the small intestine: evaluation of techniques for optimal screw placement in a rodent model.

INTRODUCTION: The aim of this study was to evaluate techniques and establish an optimal method for mechanical elongation of small intestine (MESI) using screws in a rodent model in order to develop a potential therapy for short bowel syndrome (SBS). MATERIAL AND METHODS: Adult female Sprague Dawley rats (n = 24) with body weight from 250 to 300 g (Σ = 283) were evaluated using 5 different groups in which the basic denominator for the technique involved the fixation of a blind loop of the intestine on the abdominal wall with the placement of a screw in the lumen secured to the abdominal wall. RESULTS: In all groups with accessible screws, the rodents removed the implants despite the use of washers or suits to prevent removal. Subcutaneous placement of the screw combined with antibiotic treatment and dietary modifications was finally successful. In two animals autologous transplantation of the lengthened intestinal segment was successful. DISCUSSION: While the rodent model may provide useful basic information on mechanical intestinal lengthening, further investigations should be performed in larger animals to make use of the translational nature of MESI in human SBS treatment.

The epidemiology of knee injuries in children and adolescents.

BACKGROUND: Injuries in childhood and adolescence are frequent and the knee is one of the most common sites of injuries. This study aimed to analyze the epidemiology, gender distribution, age, and circumstances of knee injuries in childhood at a Level I Trauma Center in Austria. METHODS: All pediatric and adolescent trauma patients who presented in a 2-year period were recorded. Children managed with knee injuries were selected prospectively. Patients were divided into five age groups: infants (younger than 1 year); pre-school aged children (1-6 years); pre-pubertal school-aged children (7-10 years); early adolescent patients (11-14 years); and late adolescent patients (15-18 years). Five diagnosis-related groups were formed: extraarticular soft tissue injuries, intraarticular soft tissue injuries, patella disorders, fractures, and overload injuries. RESULTS: The study included 23,832 patients up to the age of 18 years, who presented with 1,199 knee injuries. There was a male predominance (m:f = 58,6%:41.4%). Boys had a lower mean age at presentation (11.9 years) as girls (12.3 years). The most common accident sites were outdoors (34.8%) and sports facilities (32.8%). Leading injury mechanisms were falls on level surfaces (58.1%) and traffic accidents (13.4%). The number of knee injuries and its severity increased with age. Knee injuries did not occur in infants. In general, extraarticular soft-tissue injuries were most common and fractures were rare. CONCLUSION: Knee injuries in children and adolescents are rare and extraarticular soft-tissue injury is the most frequent type of knee trauma. The number of knee injuries and its severity increases with age with a male predominance. Sports facilities and traffic injuries are important scenes of knee trauma. Mechanisms and patterns evaluated in this study can serve as the basis for knee-injury prevention efforts in children and adolescents and may be used for necessary precautions. LEVEL OF EVIDENCE: IV.

Single-port appendectomy in obese children: an optimal alternative?

INTRODUCTION: The aim of this study was to evaluate our experience with single-port appendectomy (SPA) in obese children. METHODS: From January 2003 to June 2009, 94 SPA (65 women and 29 men, mean age of 12.4 years) were performed in children with appendicitis. Sixty-five of these patients were found to have normal weight, whereas 29 were obese. Patients' records were evaluated regarding operative time, intra- and post-operative complications, initiation of oral intake and histopathological findings. RESULTS: There was no significant difference in operative time between obese and normal weight patients. In the obese group, one wound healing disturbance was documented. In the normal weight group, there were one post-operative bleeding and one wound infection. There was no difference with regards to the introduction of feeds following appendectomy between the groups. Histological examinations revealed 15 normal, 32 acute, 21 phlegmonous, 20 chronic and two perforated cases of appendicitis, three neurogenic appendicopathies and one case of enterobius vermicularis related appendicitis. CONCLUSIONS: Our results indicate that the advantages of single-port appendectomy in the evaluation of the peritoneal cavity, the minimal rate of intra-operative incidents with this technique and superior cosmetics validate this alternative approach of minimal access appendectomy in obese children.

The management of traumatic fractures in children.

Fractures in children require a specific treatment depending on age. While obstetric fractures usually heal well even in case of significant dislocations and conservative therapy, the proportion of operative interventions among all pediatric fractures is increasing with age. Though the vast majority of fractures in childhood are still treated non-operatively, a trend towards early operative interventions and cast-free mobilization has been noticeable in the recent years. The methods of operative stabilization differ between the respective age groups: While K-wire osteosynthesis and a minimal invasive approach using elastic stable intramedullary nailing (ESIN) are common in the group of school aged children, the use of external fixation and plate osteosynthesis has been accepted for the treatment of fractures in adolescents. Bioresorbable implants do not yet play a decisive role in the management of pediatric fractures. This review is focusing on the current indications and concepts for stabilization of frequent pediatric fractures.

Single-center 10-year experience in the management of anterior abdominal wall defects.

BACKGROUND: Anterior abdominal wall defects can be managed with various techniques, since no one technique can be applied to all types of defects. The aim of this study is to present a single-center experience using biomaterials and evaluate the outcomes. METHODS: The clinical data obtained from 33 neonates (24 gastroschisis and 9 omphaloceles) managed for anterior abdominal wall defects at a single center from 1995 until 2005 were evaluated. RESULTS: Primary skin closure of the defect was possible in 22 (67%) cases; however, 4 of 22 (12%) required an inner patch. In seven (21%), two patches were employed. The grafts used were: seven (22%) Goretex, four (12%) dura and one (3%) bovine pericard. CONCLUSION: In our single-center experience, both synthetic (Goretex patches) and natural biomaterials (dura and bovine patches) were found to be alternatives to manage these defects. The advantages and disadvantages of the alternatives are presented.

Mortality and economics in short bowel syndrome.

The incidence of patients with short-bowel syndrome (SBS) has increased over the years due to progress of intensive care medicine and parenteral nutrition techniques. These techniques have significantly improved the prognosis of neonates, children and adults who have lost major parts of their intestinal tract. Long-term survival is possible and does not depend primarily on the length of the remaining bowel but on complications such as parenteral nutrition-associated cholestasis, recurrent septicaemia, central venous catheter infections, and the motility of the remaining intestine. Thus, the overall related mortality in infants with SBS ranges from 15 to 25%, and in adults from 15 to 47%, depending on the age of the patients, the underlying disease, and the duration on total parenteral nutrition. Home parenteral nutrition (HPN) significantly decreases the complication rate and improves the psychological situation of the patient. Additionally, HPN reduces in-hospital cost significantly. Nevertheless, the annual costs/patient are between $100000 and $150000. The mortality rate of SBS patients on HPN is about 30% after 5 years, which is still lower than the 5-year survival rate of intestinal grafts, and it is about equal to patients' survival after intestinal transplantation. However, the overall costs of a successful intestinal transplantation are already lower after 2 years when compared with the cost of a prolonged HPN programme.

Experience with gastro-intestinal duplications in childhood.

BACKGROUND: Intestinal duplications are rare congenital malformations. The different locations and sizes of these duplications require a specific diagnostic and surgical approach. This study reviews our paediatric patients with intestinal duplications in order to analyse the influence of prenatal sonography and laparoscopy on the clinical course. PATIENTS AND METHODS: Thirteen duplications of the alimentary tract in 12 patients have been treated over a 10-year period from 1989 to 1999. Six of our patients were diagnosed prenatally by ultrasound and were free of symptoms until surgery, except for one patient who had meconium-ileus owing to cystic fibrosis. In another five patients, the diagnosis was made on the basis of symptoms with signs of obstruction. In one child, the duplication was found incidentally during an operation for an anorectal malformation. The location of the 13 duplications was the stomach in three cases, the duodenum in one case, the jejunum in two cases, the ileum in six cases and the rectum in one case. Laparotomy was performed in ten patients. Two cases were treated by laparoscopic-assisted resection. CONCLUSION: Early diagnosis and treatment of uncomplicated intestinal duplications by means of prenatal sonographic screening and laparoscopic-assisted resection, respectively, are desirable in this congenital malformation. Resection of the duplication with or without minimal resection of the adjacent normal intestine should be mandatory.

The role of laparoscopy in the diagnosis and treatment of intestinal duplication in childhood. A report of two cases.

In children, the diagnostic approach for cystic abdominal tumors (e.g., intestinal duplication) usually includes CT scan, ultrasound (US), and MRI. In small children and babies, the diagnosis is often made by laparotomy. We present our preliminary experience with laparoscopic-assisted surgery (LAS) in two girls. Both children underwent US as the diagnostic approach using imaging techniques. If an intraabdominal mass was identified as cystic or solid, the second step was diagnostic laparoscopy with LAS. One of the girls, a 9-year-old, had a history of appendectomy and abdominal cramps. US revealed a cystic structure in the right lower quadrant. Laparoscopy showed an intestinal duplication, which was mobilized; a segmental small bowel resection was then performed. The second girl, a (6-month-old,) had an antenatal diagnosed cystic mass. A small bowel duplication was found laparoscopically, completely mobilized and excised, and harvested through a small umbilical incision. The postop course was uneventful. In former times, transverse laparotomy and Pfannenstil incision were the most common surgical approaches. LAS combines an excellent means of exploration with the simultaneous performance of definitive surgery. Perfect cosmetic results can be achieved even in children with rare pathology.

Congenital short-bowel; a case study and review of the literature.

A congenital short bowel (CSB) is a rare entity in pediatric surgery. We present the case of a newborn boy with a total small intestinal length of 47 cm, malrotation and gastroesophageal reflux, who is 19 months old at the time of this report. Main treatment steps were Ladd's procedure, a fundoplication and long-term parenteral nutrition. We suggest that missing physiological herniation of the gut into the coelomic cavity may impair normal intestinal growth and rotation and lead to congenital short bowel. Review of all cases reported in the literature shows a considerable mortality of 88%. The limiting factor seems to be reduced motility of the short small bowel causing functional obstruction and liver failure.

Method for the determination of vitamin K1(20) in human plasma by stable isotope dilution/gas chromatography/mass spectrometry.

A method for the quantitative determination of vitamin K1(20) (VK), an essential cofactor in the carboxylation of clotting factors, is presented. The assay is based on gas chromatography/electron impact mass/spectrometry. The preparation of deuterium-labelled vitamin K1(20) for use as an internal standard is described. The method involves extraction of VK from human plasma and its derivatization to the heptafluorobutyryl ester after reduction of one carbonyl group with zinc. The detection limit was found to be 1.0 pg and the limit of quantitation 2.0 pg ml-1 plasma. This permits the measurement of vitamin K1(20) even in small quantities of plasma, which is highly desirable in investigations dealing with clotting abnormalities in neonates and infants.

[Thoracic neuroblastoma]. / Thorakale Neuroblastome.

Between 1984 and 1994 operations for thoracic neuroblastomas were performed in ten patients (six boys, four girls). The median age was 17 months, the follow-up ranges between 6 months and 11 years; one patient died 3 years postoperatively. Complete excision of the tumour was the only therapy in four patients presenting with stage I (n = 2) and II a (n = 2) disease. Following resection, chemotherapy was carried out in four patients with stage II b (n = 2) and III (n = 2). Chemotherapy was the primary procedure in two patients with stage IV; resection of the tumour and postoperative chemotherapy followed. Thoracic neuroblastomas have a favorable outcome. The basic biology seems to differ from that of other sites and may not warrant such aggressive surgical therapy. Complete excision is recommended, if possible, but is not imperative.