Thoracic empyema and pectoral abscess resulting from attempting suicide by injection of benzene in the pleural cavity.

BACKGROUND: Exposure to hydrocarbon compounds, such as benzene may cause injury to several organ systems. It occurs accidentally or intentionally by ingestion, inhalation, cutaneous exposure and either subcutaneous injection or intravenous injection. We report a patient who injected benzene into the left hemithorax and secondly attempted to commit suicide with paracetamol. CASE PRESENTATION: A 52-year old man was admitted in the hospital because of an attempted suicide with an injection of benzene in the left hemithorax and ingestion of 50 tablets of 500 mg paracetamol. He developed a hydro-tensionpneumothorax due to inflammatory pleural effusion as a reaction to intrathoracic benzene. Therefore a chest-tube was inserted. A few days later he developed an empyema in the left lung and secondly a pectoral abscess, which required surgical debridement. After surgery, recovered fully and after 23 days of hospitalisation he was discharged to a psychiatric care facility. CONCLUSION: Hydrocarbon poisoning is either accidentally or intentionally and leads to thoracic pathology in rare cases. The most affected organ system is the respiratory system, and the cytotoxic effects of hydrocarbons can manifest as respiratory failure, pneumonitis and even acute respiratory distress syndrome (ARDS).

Endoplasmic reticulum stress, unfolded protein response and altered T cell differentiation in necrotizing enterocolitis.

BACKGROUND: Endoplasmic reticulum (ER) stress and activation of the unfolded protein response (UPR) play important roles in chronic intestinal inflammation. Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in preterm infants and is characterized by acute intestinal inflammation and necrosis. The objective of the study is to investigate the role of ER stress and the UPR in NEC patients. METHODS: Ileal tissues from NEC and control patients were obtained during surgical resection and/or at stoma closure. Splicing of XBP1 was detected using PCR, and gene expression was quantified using qPCR and Western blot. RESULTS: Splicing of XBP1 was only detected in a subset of acute NEC (A-NEC) patients, and not in NEC patients who had undergone reanastomosis (R-NEC). The other ER stress and the UPR pathways, PERK and ATF6, were not activated in NEC patients. A-NEC patients showing XBP1 splicing (A-NEC-XBP1s) had increased mucosal expression of GRP78, CHOP, IL6 and IL8. Similar results were obtained by inducing ER stress and the UPR in vitro. A-NEC-XBP1s patients showed altered T cell differentiation indicated by decreased mucosal expression of RORC, IL17A and FOXP3. A-NEC-XBP1s patients additionally showed more severe morphological damage and a worse surgical outcome. Compared with A-NEC patients, R-NEC patients showed lower mucosal IL6 and IL8 expression and higher mucosal FOXP3 expression. CONCLUSIONS: XBP1 splicing, ER stress and the UPR in NEC are associated with increased IL6 and IL8 expression levels, altered T cell differentiation and severe epithelial injury.

Efficacy and safety of a parenteral amino acid solution containing alanyl-glutamine versus standard solution in infants: a first-in-man randomized double-blind trial.

BACKGROUND & AIMS: Efforts are directed at reaching the optimal composition of pediatric amino acids (AA) infusions. The goal was to demonstrate the safety and efficacy of a newly developed parenteral AA solution containing alanyl-glutamine (GLN-AA) compared to Standard-AA. METHODS: This is a randomized (2:1), double-blind, multicentre clinical pilot trial. Infants after surgical interventions were allocated to receive GLN-AA or Standard-AA over a minimum of 5 days to maximum of 10 days. AA profiles in blood samples obtained at baseline, day 7, and end of treatment were compared to normal ranges. Data regarding safety, and efficacy were also collected. RESULTS: Infants were comparable for (safety population) gestational age at birth (36 vs 38 weeks), birth weight (2460 vs 2955 g), and day of life during start intervention (1 vs 2 days). Plasma AA profiles in infants treated with GLN-AA (n = 13) were closer the normal ranges than those in infants treated with Standard-AA (n = 6). There were no clinical or statistical differences in adverse events, safety and efficacy parameters between both groups. CONCLUSION: This first-in-man study shows that GLN-AA is safe in infants after surgical interventions, and is well tolerated. Compared to reference values, GLN-AA better reflects the amino acid requirements of the infant.

The gap in referral criteria for pediatric intestinal transplantation.

BACKGROUND: Advancement in treatment of children with intestinal failure did not lead to change in generally accepted referral criteria for intestinal transplantation. Therefore, a study was conducted to evaluate the current referral criteria and to identify potential new criteria for pediatric intestinal transplantation among transplant centers in Europe, the United States, and Canada. METHODS: The literature was searched to identify discussion points regarding current referral criteria and potential needs for extension. Questionnaires were sent to 50 centers performing pediatric intestinal transplantation. Close-ended questions were analyzed with descriptive statistics. Open-ended questions were analyzed by two reviewers using the thematic analysis method. Data were analyzed with SPSS version 17. RESULTS: A total of 18 questionnaires were completed (response rate, 36%; 14 centers in Europe and 4 centers in the United States and Canada). Of all the respondents, 77% considered referral of children as too late and suggested that education of referring hospitals could improve this. Of all the respondents, 50% considered the current referral criteria as too general. More specifically, respondents suggested that "persistent hyperbilirubinemia" must be defined by a time-and-value limit and that the list of referral criteria should include recurring septic episodes and fluid/electrolyte disturbances. CONCLUSIONS: Referral criteria for pediatric intestinal transplantation can be improved by defining more specified decision moments and by educating referring hospitals.

Late vs early ostomy closure for necrotizing enterocolitis: analysis of adhesion formation, resource consumption, and costs.

BACKGROUND: Surgeons prefer to close ostomies at least 6 weeks after the primary operation because of the anticipated postoperative abdominal adhesions. Limited data support this habit. Our aim was to evaluate adhesion formation-together with an analysis of resource consumption and costs-in patients with necrotizing enterocolitis who underwent early closure (EC), compared with a group of patients who underwent late closure (LC). METHODS: Chart reviews and cost analyses were performed on all patients with necrotizing enterocolitis undergoing ostomy closure from 1997 to 2009. Operative reports were independently scored for adhesions by 2 surgeons. RESULTS: Thirteen patients underwent EC (median, 39 days; range, 32-40), whereas 62 patients underwent LC (median, 94 days; range, 54-150). Adhesion formation in the EC group (10/13 patients, or 77%) was not significantly different (P = 1.000) from the LC group (47/59 patients, or 80%). No differences were found in the costs of hospital stay, surgical interventions, and outpatient clinic visits. CONCLUSIONS: Ostomy closure within 6 weeks of the initial procedure was not associated with more adhesions or with changes in direct medical costs. Therefore, after stabilization of the patient, ostomy closure can be considered within 6 weeks during the same admission as the initial laparotomy.

The timing of ostomy closure in infants with necrotizing enterocolitis: a systematic review.

PURPOSE: The optimal timing of ostomy closure is a matter of debate. We performed a systematic review of outcomes of early ostomy closure (EC, within 8 weeks) and late ostomy closure (LC, after 8 weeks) in infants with necrotizing enterocolitis. METHODS: PubMed, EMbase, Web-of-Science, and Cinahl were searched for studies that detailed time to ostomy closure, and time to full enteral nutrition (FEN) or complications after ostomy closure. Patients with Hirschsprung's disease or anorectal malformations were excluded. Analysis was performed using SPSS 17 and RevMan 5. RESULTS: Of 778 retrieved articles, 5 met the inclusion criteria. The median score for study quality was 9 [range 8-14 on a scale of 0 to 32 points (Downs and Black, J Epidemiol Community Health 52:377-384, 1998)]. One study described mean time to FEN: 19.1 days after EC (n = 13) versus 7.2 days after LC (n = 24; P = 0.027). Four studies reported complication rates after ostomy closure, complications occurred in 27% of the EC group versus 23% of the LC group. The combined odds ratio (LC vs. EC) was 1.1 [95% CI 0.5, 2.5]. CONCLUSION: Evidence that supports early or late closure is scarce and the published articles are of poor quality. There is no significant difference between EC versus LC in the complication rate. This systematic review supports neither early nor late ostomy closure.

Does the colon play a role in intestinal adaptation in infants with short bowel syndrome? A multiple variable analysis.

PURPOSE: We sought to examine in a multiple variable model the impact of residual colonic length on time to intestinal adaptation in a cohort of infants with short bowel syndrome. METHOD: Infants with a surgical diagnosis of short bowel syndrome who underwent operation 90 days or younger were included in this analysis. Univariate Cox proportional hazards models for time to full-enteral feeds were developed. Predictors significant at the .2 level were entered into a stepwise multiple variable Cox proportional hazards model. RESULTS: A total of 106 infants were included in the cohort (70 adapted). Predictors meeting the criteria for the multiple variable model were as follows: multidisciplinary management (P = .045), Serial Transverse Enteroplasty Procedure (P = .057), percent small bowel (P < .001), percent large bowel (P < .001), preserved ileocecal valve (P = .001), number of septic (P < .001), and central line complications (P < .001). The final model included the following: multidisciplinary management (hazard ratio [HR], 1.932; 95% confidence interval [CI], 1.137-3.281), percent small bowel (HR, 1.028; 95% CI, 1.02-1.04), and septic events (HR, 0.695; 95% CI, 0.6-0.805). CONCLUSIONS: The colon does not seem to play a significant role in intestinal adaptation. However, in addition to highlighting the importance of residual small bowel length, our model highlights the benefit of multidisciplinary intestinal rehabilitation and reduction of septic complications in achieving intestinal adaptation.

Gastric emptying scans: unnecessary preoperative testing for fundoplications?

PURPOSE: Delayed gastric emptying (DGE) as indicated by preoperative gastric emptying scan (GES) is one rationale for performing a gastric emptying procedure (GEP) at time of fundoplication for gastroesophageal reflux disease (GERD). However, the role of GES and GEP in the surgical management of GERD remains unclear. We examined the use of preoperative GES in fundoplication patients. METHODS: Retrospective chart review of patients undergoing fundoplication from 2000 to 2005 in a single institution including patient demographics, operative procedure, and postoperative outcomes at 1-year follow-up was analyzed using chi(2) test. RESULTS: Of 76 fundoplication patients, 39 (51%) had preoperative GES with 11 patients (28%) having DGE and 16 GEP performed. Developmentally delayed children were more likely to have GES. There were no significant differences in postoperative complications, length of hospital stay, or use of anti-GERD medications at 1 year between patients who had preoperative GES and those who did not. In the developmentally delayed group, there were no differences in outcomes between those with preoperative GES and those who did not. CONCLUSIONS: There were no differences in outcomes for GERD patients with or without preoperative GES or GEP postfundoplication. The use of GES in the management of GERD requires further evaluation.

Outcomes after muscle flap vs prosthetic patch repair for large congenital diaphragmatic hernias.

BACKGROUND: Repair of large congenital diaphragmatic hernia (CDH) defects still pose a significant challenge, as the defects cannot be repaired primarily. Two techniques have been widely used: autologous anterior abdominal wall muscle flap and prosthetic patch. The latter has been used more often. Our goal was to compare the short-term and long-term outcomes of these 2 approaches. METHODS: This is a retrospective review of all neonates undergoing CDH repair at our institution from 1969 to 2006. RESULTS: Of 188 children undergoing surgery for CDH, primary repair could not be accomplished in 51 infants (27%). Nineteen had muscle flap repair, and 32 had prosthetic patch repair (Gore-Tex [W.L. Gore and Associates, Flagstaff, AZ], n = 15; Marlex [Bard Inc, Cranston, NJ], n = 9; Surgisis [Cook, Bloomington, IN], n = 5; SILASTIC [Dow Corning, Midland, MI], n = 3). There was no significant difference in gestational age or birth weight between groups. Three patients developed an abdominal wall defect at the muscle flap donor site, but none required surgical intervention. Chest wall deformities were found in 9 patients, 3 after a muscle flap and 6 after a prosthetic patch (P = .7). Postoperative bowel obstruction occurred in 3 muscle flap patients and 1 patch patient (P = .2). There were 10 recurrences among survivors: 2 after a muscle flap and 8 after a prosthetic patch (P = .3) There were 2 deaths among the muscle flap patients (10%), and 3 deaths among the prosthetic patch repair patients (9%) (P = .1). Results were confirmed after controlling for age and comorbidities between both groups in a multivariate logistic regression. CONCLUSION: These results suggest that autologous anterior abdominal wall muscle flap and prosthetic patch repairs provide similar short-term and long-term outcomes.

Establishing norms for intestinal length in children.

BACKGROUND: Existing data on pediatric intestinal length (IL) are limited because most studies report postmortem values. Using prospective data, appropriate norms for IL were developed. METHOD: The IL measurements, using a silk suture on the antimesenteric border, were prospectively made on patients between 24 weeks of gestational age and 5 years of age undergoing laparotomy. Patients with gastrointestinal malformations or those above or below 2 SDs for growth parameters were excluded. A curve fitting process was applied to determine the best model for IL (small bowel and colon separately) from among postconception age, weight, and height at surgery. RESULTS: One hundred eight patients participated in this study. Highly predictive (R(2) > 0.8) models for IL were determined for all predictor variables (postconception age, weight, and height) examined suggesting that all of these variables are excellent predictors determinants of IL. Although all models had statistically similar properties, the model using height had the best performance across the full range of the variable. CONCLUSION: Although age, weight, nor height was definitely superior for the prediction of IL, we propose that until external validations of our models occur, height at surgery be used for the prediction of expected small intestinal and colon length in infants.

Absence of the interstitial cells of Cajal in a child with chronic pseudoobstruction.

Absence or altered distribution of the interstitial cells of Cajal (ICCs) has been described in association with intestinal pseudoobstruction in adults. We report the first pediatric case with regional absence of ICCs in the distal small bowel and colon associated with intestinal pseudoobstruction. This report highlights that abnormalities of the ICCs in intestinal pseudoobstruction should be considered early in the diagnostic workup of children with intestinal pseudoobstruction.