Life-threatening air rifle injuries to the heart in three boys.

Air rifles, or BB guns, are generally thought of as childhood toys. Although most injuries are not serious, life-threatening events have been reported. Within a 1-year period, 3 boys presented after BB gun shots to the chest, all requiring surgical intervention for penetrating injuries to the heart. A 15-year-old underwent window pericardiotomy for hemopericardium with thrombus 24 hours after admission. Another, 5 years of age, underwent emergent exclusion of the cardiac apex for a traumatic ventricular septal defect. The third, 8 years old, had a right ventricular injury requiring an urgent subxiphoid pericardial window for tamponade. All recovered uneventfully. Increased public awareness, adult supervision, safety training, and appropriate legislation are needed to decrease the risks of these potentially lethal weapons.

Diaphragmatic plication in the extremely low birth weight infant.

A case of acquired diaphragmatic paralysis in an extremely low birth weight infant complicated by respiratory failure, recurrent atelectasis, and pneumonia is described. Diaphragmatic plication led to a rapid improvement in pulmonary function and allowed for discontinuation of mechanical ventilation in less than 1 week. Therapeutic options for acquired diaphragmatic paralysis, including the rationale for early operative intervention, in this patient population are discussed.

Successful ex utero intrapartum treatment (EXIT) procedure for congenital high airway obstruction syndrome (CHAOS) owing to laryngeal atresia.

Congenital high airway obstruction syndrome (CHAOS) caused by laryngeal atresia was diagnosed by prenatal ultrasound in a male fetus at 18-weeks-gestation. Findings included enlarged lungs, inverted diaphragms, dilated trachea distal to the obstruction, and ascites. At 35 weeks' gestation, a planned ex utero intrapartum treatment (EXIT) procedure was performed, allowing bronchoscopic evaluation of the airway and placement of a tracheostomy. The postnatal course was marked by gradual recovery of diaphragmatic function with corresponding weaning from conventional ventilation to positive airway pressure. The sustained improvement in diaphragmatic and pulmonary function after the EXIT procedure for laryngeal atresia is one of the first reported for this entity and provides encouragement for future attempts.

Percutaneous needle aspiration of small interloop abscesses in children.

Treatment of small postoperative interloop abscesses (ILA) can be challenging. In children, these collections have usually been drained surgically at a second operation. This article describes three children with small postoperative ILAs who were treated by percutaneous needle aspiration and parenteral antibiotics, with good outcomes. The advantages of this technique and its utilization in the management of children with ILAs are discussed.

Minimal head trauma in children revisited: is routine hospitalization required?

OBJECTIVE: Children with a question of occult head injury are routinely hospitalized despite having both normal central nervous system (CNS) and computed tomographic (CT) scan examinations. We determined the incidence of significant CNS morbidity after occult head injury to determine whether or not hospital admission was necessary in children after minimal head trauma. METHODS: We reviewed the records of children admitted to a level I trauma center with a question of closed head injury, an initial Glasgow Coma Scale equal to 15, a normal neurologic exam, and a normal head CT scan. Children with associated injuries requiring admission were excluded. The endpoints were deterioration in CNS exam, new CT findings, and the need for a prolonged hospital stay. RESULTS: Sixty-two patients were studied with a mean age of 7 years (range, 1 month to 15 years), and 65% were male. The primary mechanisms of injury were fall (45%) and vehicular crash (23%). The mean injury severity score was 4 +/- 2. The mean length of stay was 1.2 days (range, 1 to 3 days). Prolonged hospitalization occurred in 9 patients (15%). No child developed significant CNS sequelae warranting hospital admission. Total charges for these hospitalizations were $177 874. CONCLUSIONS: Children undergoing emergency department work-up of occult head injury, who have a normal CNS exam and a normal head CT scan, do not seem to be at risk for significant CNS sequelae. These patients can be discharged home with parental supervision and avoid unnecessary and costly hospitalization.

Hemophilia presenting in an infant as a radial artery pseudoaneurysm following arterial puncture.

The case presented is of an infant who developed a radial artery pseudoaneurysm following arterial puncture and was subsequently diagnosed with hemophilia. A discussion of radial artery pseudoaneurysms follows.

Partial decapsulation of splenic epithelial cysts: studies on etiology and outcome.

PURPOSE: The presence of squamous epithelium in the cyst wall of children with large splenic cysts has generally been thought to require complete resection of the cyst lining to prevent recurrence. The risks of major bleeding or possible total splenectomy necessitates a simplified procedure to preserve splenic function without cyst recurrence. METHODS: Six patients treated for splenic cyst over a 10-year period underwent partial splenic decapsulation retaining the hilar portion of the spleen. The patient group, including five girls, ranged in age from 6 to 18 years (mean, 13 years). Presenting findings were splenomegaly (n = 4), progressive cyst enlargement (n = 4), left upper quadrant pain (n = 2), ultrasound for unrelated condition (n = 2), and prior history of trauma (n = 1). Cyst location varied from peripheral to deep cortical and ranged in size from 5 to 20 cm containing from 200 to 1,700 mL of sterile straw-colored to dark brown-colored liquid. RESULTS: Palpable splenomegaly resolved in all patients with progressive decrease in size of the splenic remnant, and return of vascularity to normal was confirmed by Doppler ultrasound. Each patient remains asymptomatic without recurrence of the splenic cyst from 1 to 10 years after surgery. Squamous epithelial lining cells found in sheets and clusters were seen within the cyst lining of all patients. Immunohistochemistry of the paraffin-embedded tissue showed that these cells expressed keratin, epithelial membrane antigen (EMA), carcino-embryonic antigen (CEA), but were negative for BerEP4 (conventionally positive in cells of epithelial origin). CONCLUSION: The authors conclude that splenic decapsulation is an effective treatment for splenic epithelial cysts, which both preserves splenic function and prevents recurrence despite retention of hilar cyst lining. Epithelial metaplasia of the mesothelial-mesodermal undifferentiated cells from exposure to an unidentified irritant may explain the histological presence of squamous epithelium within the cyst wall.

Parental presence during induction of anesthesia: the surgeon's perspective.

Parental presence during induction of anesthesia (PPIA) remains controversial and little is known about surgeons' attitudes toward this clinical practice. A questionnaire was mailed to all the United States (US) members of the Surgical Section of the American Academy of Pediatrics and all members of the British Association of Paediatric Surgeons. Questions were asked about attitudes toward PPIA in the operating room and the prevalence of such practice. A total of 275 subjects, constituting 72.4% of the compared groups, responded after three mailings. Sixty percent of the US respondents and 95% of the Great Britain (GB) respondents said they disagree with the statement "parents should never be present during induction of anesthesia". Ninety-two percent of the GB respondents and 69% of the US respondents thought PPIA decreases anxiety (p = 0.001) and increases the cooperation of the child (86% GB, versus 53% US, p = 0.001). Most US respondents (72%) reported that PPIA occurs in less than 25% of their cases, but most GB respondents (80%) reported PPIA in more than 75% of their cases (p = 0.001). These differences in prevalence persisted after logistic-regression models were used to adjust for potential confounding demographic variables. We conclude that the attitudes and practice toward PPIA held by surgeons from the US and GB differ significantly. While a large percentage of the US sample agree that there are benefits in PPIA, only a minority report the routine use of PPIA in contrast to most respondents from GB who report PPIA as routine in their hospital.

Early presentation of metastatic medullary carcinoma in multiple endocrine neoplasia, type IIA: implications for therapy.

A girl 5 years 11 months of age, belonging to an extensive kindred with multiple endocrine neoplasia, type IIA (MEN IIA), was found to have multifocal medullary thyroid carcinoma with metastasis in one paraglandular lymph node after positive findings on a calcium-pentagastrin stimulation test. Her sister, 3 years 8 months of age, also had an elevated calcitonin level, and thyroidectomy revealed C-cell hyperplasia and a focus of medullary thyroid carcinoma. These two cases underscore the need for prophylactic thyroidectomies in MEN IIA patients as young as 5 years of age and strict yearly provocative screening beginning at age 1 year.

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.

Pediatric surgery between 1860 and 1900.

The twentieth century begins the modern era of pediatric surgery, a time of innovation and vastly improved operative survival. Until then, many correctable congenital anomalies had been described in case reports only as medical curiosities, seemingly having no chance for surgical cure, but the challenge was available to those wishing to accept. The first texts devoted to surgical diseases of infancy and childhood were descriptive, emphasizing visible and palpable lesions, tuberculosis, musculoskeletal deformity, and major trauma, but also recognized that "surgical diseases of children by their number, their variety, and their character must, we think, be studied in a special manner and demand a special chapter in surgical books." The construction of Children's Hospitals during the nineteenth century identified the need to provide special facilities for children. Surgical antisepsis was practiced and general anesthesia used. Physicians such as Hirschsprung recognized a wide spectrum of treatable surgical conditions that would soon become the domain of pediatric surgeons. Indeed, at that moment in time at the very beginning of the twentieth century, Roentgen discovered the x-ray, Ladd received his MD degree at Harvard, the first pediatric appendectomies for appendicitis were successfully performed, and Fredet and Ramstedt recognized that pyloroplasty was not the preferred treatment for hypertrophic pyloric stenosis. Modern pediatric surgery had passed from embryo to fetus to newborn.

Infant apnea detection after herniorrhaphy.

STUDY OBJECTIVE: To elucidate risk factors for apnea in preterm infants discharged from the hospital and in full-term healthy infants. To determine the efficacy of real-time cardiopulmonary monitoring versus computerized storage and retrieval for infants at risk. STUDY DESIGN: Prospective study. SETTING: Operating rooms and pediatric patient care units of university medical center. PATIENTS: 27 preterm infants and 20 full-term infants no more than 60 weeks' post-conceptional age, who were admitted for elective herniorrhaphy. INTERVENTIONS: Infants were monitored before and after herniorrhaphy with general anesthesia using an infant apnea impedance monitor, pulse oximetry, and nursing observation. MEASUREMENTS AND MAIN RESULTS: Demographic information and medical history were correlated with postoperative apnea. The sensitivity and specificity of nursing observation and oximetry were compared with computerized apnea monitors. Five patients (11%, four preterm, one full-term) were apneic postoperatively as recorded by computerized pneumocardiography. Previous apnea history, gestational age at birth, and postconceptional age at operation positively correlated with postoperative apnea. Nursing observation failed to detect 4 of 5 patients with documented apnea (sensitivity 20%, positive predictive value 50%). Pulse oximetry failed to detect 3 of 5 patients with apnea (sensitivity 40%, positive predictive value 66%). CONCLUSIONS: Although it is easier to predict postoperative respiratory dysfunction in previously sick or very young infants, absolute predictability for all neonates remains elusive. Clinical monitors with both storage and retrieval capabilities and real-time monitoring increase our ability to detect significant events in children at risk for apnea after herniorrhaphy.

Retrosternal ileocolic esophageal replacement in children revisited. Antireflux role of the ileocecal valve.

The risk of postoperative reflux and pulmonary aspiration with straight colon or gastric tube esophageal replacement in children prompted us to reevaluate the presumed antireflux role of the ileocecal valve with retrosternal ileocolic interposition. This operation was done in eight patients with esophageal atresia (six) and lye stricture (two) from 19 to 50 months of age between 1983 and 1992. There were no operative deaths. The duration of follow-up ranged from 4 to 115 months. Barium swallow obtained in all patients showed unobstructed esophagoileocolic transit without reflux. Two patients with esophageal atresia had localized proximal anastomotic leaks, which healed spontaneously without stricture. In the two patients with lye ingestion ileoesophageal strictures developed that necessitated revision. None of the patients had postoperative respiratory complications or symptomatic gastroesophageal reflux. All eight children have had their gastrostomy tubes removed, are eating a regular diet, and are growing well. In conclusion, the retrosternal ileocolic conduit provides an excellent substitute esophagus in selected pediatric patients, with potential advantages over delayed primary anastomosis or the straight colon or gastric tube interposition because of the antireflux role of the ileocecal valve.

Midgut volvulus. An ever-present threat.

OBJECTIVE: To identify risk factors for midgut volvulus (MGV) and to seek clues to early diagnosis of MGV in children with malrotation. DESIGN: Retrospective patient series. SETTING: Academic medical center. PATIENTS: Sixty-eight consecutive children who had a Ladd operation performed between January 1970 and December 1991. Excluded were three patients whose records were unavailable and patients who had a Ladd operation during the course of repair of an abdominal wall defect or congenital diaphragmatic hernia. RESULTS: Forty of 68 patients had MGV at operation. There was an inverse correlation between age at onset of symptoms and the probability of MGV: 85% (29/34) of patients less than 1 month of age had MGV compared with 43% (10/23) of older children. Patients who had symptoms for less than 4 days were more likely to have MGV (88%; 30/34) than patients who had more chronic symptoms (43%; 10/23). Bilious (green) vomiting was more highly associated with MGV (80%; 35/44) than nonbilious vomiting (38%; 3/8) or pain (50%; 6/12). Roentgenograms of the upper gastrointestinal tract were very accurate for the diagnosis of malrotation but frequently failed to identify MGV (sensitivity, 54%; 13/24). Despite the high proportion of MGV, only three patients had gangrenous bowel. Of these three patients, one died and two have short-gut syndrome. CONCLUSION: Neonates with a short history of bilious vomiting are most likely to have MGV-complicating malrotation, but older children who have chronic intermittent symptoms are also at risk. Since there is no way to predict which patients will develop catastrophic bowel necrosis, early diagnosis and operation are necessary to prevent mortality and short-gut syndrome.

Intestinal rotation and fixation abnormalities in heterotaxia: early detection and management.

Intestinal rotation and fixation abnormalities (IRFA) are known to coexist with heterotaxia (defined as an abnormal arrangement of body organs that is different from complete situs solitus or complete situs inversus), but little is known about the incidence of this association or its clinical management. We have reviewed the records of 34 patients diagnosed with heterotaxia during a 12-year period at Yale-New Haven Hospital in order to develop a plan for the early diagnosis of IRFA and to assess the value of preventive treatment in this complicated group of patients. Of the 34 patients with heterotaxia, all except one presented with complex congenital heart disease. The 34 patients were divided into two groups on the basis of their gastrointestinal workup for suspected IRFA. The 28 patients in group A had no upper gastrointestinal (GI) contrast study performed prior to symptoms suggestive of IRFA. Four of these 28 patients (14%) eventually developed complications of IRFA requiring emergency surgery. Group B consisted of six patients seen during the past 5 years with heterotaxia who had upper GI contrast studies while asymptomatic. All six (100%) were shown to have IRFA and subsequently underwent an uncomplicated elective Ladd procedure once their cardiac condition stabilized. This study confirms the high incidence of IRFA in patients with heterotaxia. We propose that evaluating patients with heterotaxia syndrome for IRFA while asymptomatic may prevent the need for emergency abdominal surgery in patients that have major cardiovascular anomalies.

Diagnosis and treatment of jejunoileal atresia.

A total of 116 cases of intestinal atresia or stenosis were encountered at the Yale-New Haven Hospital between 1970 and 1990. Sites involved were the duodenum (n = 61; 53%), jejunum or ileum (n = 47; 46%), and colon (n = 8; 7%). All but two patients underwent operative correction, for an overall survival rate of 92%. Challenging problems were the management of apple-peel atresia (five patients), multiple intestinal atresia with short-gut syndrome (eight patients), and proximal jejunal atresia with megaduodenum requiring imbrication duodenoplasty (four patients). Major assets in the improved outlook for intestinal atresia are prenatal diagnosis, regionalization of neonatal care, improved recognition of associated conditions, innovative surgical methods, and uncomplicated long-term total parenteral nutrition.

Predictors of postoperative respiratory complications in premature infants after inguinal herniorrhaphy.

There is a significant incidence of inguinal hernia in premature infants and the optimal timing of repair is controversial. A high rate of postoperative respiratory complications has been reported in this group. In this study, the records of 47 premature infants (mean gestational age, 30.3 weeks) who underwent herniorrhaphy while still in the neonatal intensive care unit were reviewed in an effort to define those conditions that are independent risk factors for complications. Forty-three percent of infants had complications, including postoperative assisted ventilation (34%), episodes of apnea and/or bradycardia (23%), emesis and cyanosis with first feeding (6%), and requirement for postoperative reintubation (4%). Although low gestational age and postconceptual age at operation, low birth weight for gestational age, and preoperative ventilatory assistance were significantly associated with postoperative complications, only a history of respiratory distress syndrome/bronchopulmonary dysplasia (odds ratio 2.3), a history of patent ductus arteriosus (odds ratio 2.5), and low absolute weight at operation (odds ratio 3.5 for 1,000-g decrease) were independent risk factors for postoperative complication. Despite previous reports citing postconceptual age as the factor having the greatest impact on postoperative complications, these results indicate that a history of respiratory dysfunction and size at operation may be more important predictors of postoperative respiratory dysfunction in preterm infants.