Management of major pancreatic duct injuries in children.

BACKGROUND: The operative versus nonoperative management of major pancreatic ductal injuries in children remains controversial. The computed tomographic (CT) scan may not be accurate for determination of location and type of injury. We report our experience with ductal injury including the recent use of acute endoscopic retrograde cholangiopancreatography (ERCP) for definitive imaging, and an endoscopically placed stent as definitive treatment. This has not been reported in children. METHODS: In review of 14,245 admissions to a regional pediatric trauma center over a 14-year period, 18 patients with major ductal injuries from blunt trauma were noted. Records were reviewed for mechanism of injury, method of diagnosis, management, and outcome. RESULTS: There were 10 girls and 8 boys, ranging in age from 2 months to 13 years. The most common mechanisms of injury were motor vehicle and bicycle crashes. Admission CT scan in 16 children was suggestive of injury in 11, and missed the injury in 5. Distal pancreatectomy was carried out in eight patients with distal duct injuries: one died of central nervous system injury. Nonoperative management in three proximal duct injuries suggested by initial CT scan and in three missed distal duct injuries resulted in pseudocyst formation in five survivors; one patient died of central nervous system injuries. Two children with minimal abdominal pain, normal initial serum amylase, and no initial imaging developed pseudocysts. Two of seven pseudocysts spontaneously resolved and five were treated by delayed cystogastrostomy. Two recent children with suggestive CT scans were definitively diagnosed by acute ERCP and treated by endoscopic stenting. Clinical and chemical improvement was rapid and complete and the stents were removed. Follow-up ERCP, CT scan, and serum amylase levels are normal 1 year after injury. CONCLUSION: Pancreatic ductal injuries are rare in pediatric blunt trauma. CT scanning is suggestive but not accurate for the diagnosis of type and location of injury. Acute ERCP is safe and accurate in children, and may allow for definitive treatment of ductal injury by stenting in selected patients. If stenting is not possible, or fails, distal injuries are best treated by distal pancreatectomy; proximal injuries may be managed nonoperatively, allowing for the formation and uneventful drainage of a pseudocyst.

Treatment of pancreatic duct disruption in children by an endoscopically placed stent.

BACKGROUND: Injuries to the pancreas from blunt abdominal trauma in children are rare. Most are minor and are best treated conservatively. The mainstay for treatment of major ductal injuries has been prompt surgical resection. Diagnostic imaging modalities are the key to the accurate classification of these injuries and planning appropriate treatment. Computed tomography (CT) scan has been the major imaging modality in blunt abdominal trauma for children, but has shortcomings in the diagnosis of pancreatic ductal injury. Endoscopic retrograde cholangiopancreatography (ERCP) has been shown recently to be superior in diagnostic accuracy. The therapeutic placement of stents in the trauma setting has not been described in children. METHODS: Two children sustained major ductal injuries from blunt abdominal trauma that were suspected, but not conclusively noted, on initial CT scan. Both underwent ERCP within hours of injury. In case 1, a stent was threaded through the disruption into the distal duct. In case 2, a similar injury, the stent could only be placed through the ampulla, thereby reducing ductal pressure. In both cases, clinical improvement was rapid with complete resolution of clinical and chemical pancreatitis, resumption of a normal diet, and discharge from the hospital. The stents were removed at 10 and 12 days postinjury, and both children have remained well. Follow-up ERCP and CT scans show complete healing of the ducts and no evidence of pseudocyst formation 1 year post injury. CONCLUSIONS: Acute ERCP should be the imaging modality of choice in suspected major pancreatic ductal injury. Successful treatment by placement of an intrapancreatic ductal stent may be possible at the same time. Surgical resection or reconstruction can then be reserved for cases in which stenting is impossible or fails.

Evaluation of malignant biliary obstruction: efficacy of fast multiplanar spoiled gradient-recalled MR imaging vs spin-echo MR imaging, CT, and cholangiography.

OBJECTIVE: Although CT and cholangiography have proven value in the detection of biliary obstruction, determining the extent of biliary tumors and imaging small pancreatic or ampullar tumors remain problematic. We hypothesized that the superior contrast resolution of MR, coupled with contrast-enhanced breath-hold imaging, might increase the sensitivity for tumor detection and improve the depiction of the point of obstruction in patients with malignant biliary disease. SUBJECTS AND METHODS: Twenty-one MRI studies were performed prospectively in patients with malignant biliary obstruction by obtaining breath-hold contrast-enhanced fast multiplanar spoiled gradient-recalled (FMPSPGR) images at 0 and 10 min, conventional spin-echo T1-weighted images, and fast spin-echo T2-weighted images. Findings on MR images were correlated with findings on CT scans (15 cases) and/or cholangiograms (14 cases) by two observers. All MR images, CT scans, and cholangiograms were reviewed to evaluate tumor detection, visualization of dilated bile ducts, and conspicuity of the obstructing tumor. A four-point scale (1 = excellent tumor depiction and conspicuity, 4 = tumor not detected) was used for evaluation. Contrast-to-noise ratios for tumor and bile were calculated for the three MR pulse sequences. RESULTS: The contrast-enhanced FMPSPGR images and CT scans provided excellent depiction of the dilated biliary tree in 95% and 93% of examinations, respectively, with both techniques superior to fast spin-echo and T1-weighted images (p < .005). Tumor detection was best with the immediate FMPSPGR MR images (20/21), compared with fast spin-echo MR images (16/21) (p = .04), T1-weighted MR images (16/21) (p = .04), CT scans (12/15) (p > .05), and cholangiograms (13/14) (p > .05). Of 13 examinations showing proximal biliary obstruction, the mean score for tumor conspicuity was best with the immediate enhanced FMPSPGR MR images (1.38 +/- .65), compared with T1-weighted MR images (2.38 +/- 1.3) and fast spin-echo MR images (2.08 +/- 1.0) (p < .05), but it was not different from the delayed FMPSPGR MR images (1.75 +/- 1.1) or CT scans (1.9 +/- 0.99) (p > .05). For five of six cholangiocarcinomas, the immediate and delayed enhanced FMPSPGR MR images showed excellent tumor conspicuity owing to their enhancement with gadopentetate dimeglumine. Data for contrast-to-noise ratios of tumor showed that the immediate FMPSPGR MR images (15.8 +/- 10.2) were superior to T1-weighted images (6.3 +/- 3.5, p < .01), but were not different from fast spin-echo images (13.5 +/- 6.7) or delayed FMPSGR images (11.5 +/- 8.9). For eight examinations in patients with distal biliary obstruction, the mean score for tumor conspicuity was greater with the immediate FMPSPGR MR images (1.38 +/- 0.52), compared with fast spin-echo images (3.25 +/- 0.71, p < .005), T1-weighted images (2.63 +/- 1.06, p < .05), and delayed FMPSPGR MR images (2.60 +/- 1.5, p < .05), but was similar to that with CT scans (1.40 +/- 0.89, p > .05). Data for contrast-to-noise ratios of tumor showed an advantage for the immediate FMPSPGR MR images (12.0 +/- 7.7) over T1-weighted images (4.0 +/- 2.6, p < .01) and delayed FMPSPGR images (4.3 +/- 2.6, p < .025), but no difference from fast spin echo images (6.6 +/- 8.8, p = .05). CONCLUSION: Contrast-enhanced FMPSPGR MR imaging is sensitive for the detection of tumors causing biliary obstruction. For proximal obstruction, it may be particularly effective for detecting and defining tumor extent of hilar cholangiocarcinomas because of their enhancement with gadopentetate dimeglumine. For cases of distal obstruction, this technique showed improved tumor detection and conspicuity compared with T1- and fast spin-echo T2-weighted images, but showed no advantage over CT.

Endoscopic laser therapy in gastroenterology.

Endoscopic laser therapy has become an important and widely used tool in gastroenterology. It has become important for outpatient palliative therapy for ablating obstructing gastrointestinal neoplasms. This method has often circumvented the need for major palliative surgical resections. Caution must be applied to laser therapy for potentially curable malignant neoplasms because, with vaporization of the target tissue, no tissue specimen is available to assure that local or invasive residual carcinoma is excluded. Therefore, in good surgical candidates, surgical resection of potentially curable cancers is always recommended. In the future, however, the combination of refined endoscopic ultrasonography and laser fluorescence techniques may lead to earlier detection, more precise localization, and even curative ablation of gastrointestinal malignancy.

Epidermolysis bullosa acquisita (EBA) and esophageal webs: a new association.

Epidermolysis bullosa acquisita (EBA) is a well-defined, blistering disorder of the skin associated with autoantibodies to type VII collagen. Although esophageal pathology is common in children with hereditary dystrophic forms of epidermolysis bullosa, esophageal problems have not been reported previously in patients with bona fide EBA. In this report, a 71-yr-old white female with longstanding EBA presented with recurrent dysphagia and multiple esophageal webs that responded to esophageal dilatation.

Trypanosoma lucknowi, a new species of trypanosome from Macaca mulatta with observations on its fine structure.

Trypanosoma lucknowi n. sp. was isolated in culture from one of 126 Macaca mulatta originating from the vicinity of Lucknow, Uttar Pradesh, India. Trypanosoma lucknowi is distinctive because of the large number of epimastigotes and trypomastigotes which, in culture, exhibit no movement or only a slight bending of the flagellar end. This limited motility coincides with a free flagellum which is either completely absent or rudimentary. The microorganism is cloned readily, and the description is based upon such cultures. Trypanosoma lucknowi shows pronounced differences from other trypanosomes of South Asian macaques and from "aflagellar" African trypanosomes. The ultrastructural demonstration of a cytostome and contractile vacuole suggests ultimate grouping with stercorarian trypanosomes. A 3-D reconstruction of the flagellar pocket/cytostome region is included.

Intranuclear cisternal and vesicular structures in canine circumanal gland carcinoma cells.

Intranuclear cisternal and vesicular structures, bound by a single membrane, were observed for the first time in some glandular "bird's eye" cells of canine circummanal gland carcinomas. The role of these intranuclear structures is not clear. It is suggested that they may be involved in cellular adaptation to an environment of nutrient deficiency, as a result of cell overcrowding.

Mitosis in the hemoflagellate Trypanosoma cyclops.

The ultrastructure of interphase and mitotic nuclei of the epimastigote form of Trypanosoma cyclops Weinman is described. In the interphase nucleus the nucleolus is located centrally while at the periphery of the nucleus condensed chromatin is in contact with the nuclear envelope. The nucleolus fragments at the onset of mitosis, but granular material of presumptive nucleolar origin is often recognizable in the mitotic nucleus. Peripheral chromatin is in contact with the nuclear envelope throughout mitosis, and it seems reasonable to assume that the nuclear envelope is involved in its segregation to the daughter nuclei. Spindle microtubules extend between the poles of the dividing nucleus and terminate close to the nuclear envelope. The basal body and kinetoplast divide before the onset of mitosis and do not appear to have any morphologic involvement in that process. Spindle pole bodies, kinetochores, and chromosomal microtubules have not been observed.

Triatomines as experimental vectors of trypanosomes of Asian monkeys.

Systematic surveys of the wild macaques of South Asia by blood culture resulted in the discovery that trypanosomiasis is enzootic in the simians of Indonesia, Malaysia, India, and Thailand. The isolates obtained differ in morphology, metabolism, and ability to multiply in arthropods. Following this discovery, interest focused on possible transmissions of these trypanosomiases. Laboratory-reared and wild-caught insects were studied to determine which are satisfactory intermediate hosts and potential natural vectors. Successful results were obtained with insectary-reared reduviids and Indonesian isolates. In Rhodnius prolixus and Triatoma rubrofasciata the Indonesian trypanosomes multiply for periods which can exceed 40 days. The flagellate infections are in the digestive tract, whereas trypanosomes have never been seen in the salivary glands or in the hemolymph. The feces of trypanosome-carrying reduviids are infective, suggesting a stercoreal method of infection of mammals, and infection was produced in experiments in which feeding by the insects was not possible. The relevance of these findings to natural transmission in Indonesia is not known. Experiments with insects and all other trypanosomal isolates have been negative. The natural transmission mechanism(s) of the simian trypanosomiases in South Asia remains an unsolved problem.

Antibody-independent activation of the alternative complement pathway in human serum by parasitic cells.

The lysis of the monocellular parasite Trypanosoma cyclops by normal human serum (NHS) was found to be complement-dependent and to follow activation of the alternative pathway without apparent requirement for conventional antibodies. Lysis of the organisms was inhibited by heat-inactivating NHS at 56 degrees, preincubation of NHS with cobra venom factor or chelation of divalent cations with EDTA. It took place, however, in human C2-deficient serum and was inhibited by prior heating of NHS at 52 degrees to destroy the activity of factor B of the alternative pathway. Moreover, the lytic reaction was magnesium- but not calcium-dependent. Repeated low-temperature (0 degrees) absorption of either human hypogammaglobulinaemic serum or NHS with the parasite failed to remove or significantly decrease their lytic activities.