Air encircling the intussusceptum on air enema for intussusception reduction: an indication for surgery?

OBJECTIVES: The prompt identification of children in whom enema reduction of intussusception might fail and surgery is necessary is crucial in order to avoid futile repeat attempts and untoward complications. The purpose of this retrospective review was to determine whether air encircling the intussusceptum in the small bowel during air enema for intussusception reduction could serve as an indication for operation rather than repeat attempts at radiological reduction. METHODS: Imaging studies of 83 children aged 4 to 40 months with idiopathic intussusception who had air enema for intussusception reduction were reviewed for the presence of air encircling the intussusceptum in the distal small bowel. Findings were correlated with clinical course and surgical findings. RESULTS: In 12 of 83 patients, air was seen encircling the intussusceptum in the small bowel, and in 11 of these (88%) air enema failed to reduce the intussusception. In 8 of the 11, delayed repeated attempts using air enema failed to reduce intussusception. Clinical signs and their duration did not differ between those children without and those with air encircling the intussusceptum. CONCLUSION: In the presence of air encircling the intussusceptum in the distal small bowel on air enema, delayed repeated attempts for intussusception reduction are unlikely to succeed, and surgery is indicated.

Perforated appendicitis in the child: contemporary experience.

BACKGROUND: Despite years of research and clinical experience with acute appendicitis, the rate of complications in the pediatric age group continues to be high. OBJECTIVE: To characterize the profile of the child with appendicitis complicated by perforation or intraabdominal abscess. METHODS: Between 1 January 1985 and 31 December 1997 in our department, 581 children under the age of 14 years were clinically diagnosed as suffering from "acute appendicitis." The final diagnoses were: while appendix in 28 cases (4.8%), acute non-complicated appendicitis in 472 (81%), and complicated appendicitis in 81 (13.9%), including 51 cases of free perforation (8.7%) and 30 cases of intraabdominal abscess (5.2%). We retrospectively reviewed the charts of all children with complicated appendicitis and those of 70 randomly selected children with non-complicated appendicitis, and compared patient age, gender, weight percentile, past medical history, and course of the illness. RESULTS: The children with complicated appendicitis were significantly younger (P = 4.8 x 10(-7)), they had higher oral and rectal temperatures (P = 7.9 x 10(-8)), higher platelet count (P = 0.0008) and lower hemoglobin level (P = 0.004). No difference was found in white blood count (P = 0.41). Total delay from symptom onset to surgery was 33 hours (SD 23) in the non-complicated group, 60 hours (SD 38) in the perforated appendicitis group, and 176 hours (SD 107) in the intraabdominal abscess group (P = 4.6 x 10(-8)). No difference in intra-hospital delay was found. CONCLUSIONS: Children with complicated appendicitis are characterized by younger age, longer delay from symptom onset to correct diagnosis, and typical laboratory findings. Delays in diagnosis can be avoided by first considering the diagnosis of acute appendicitis in the differential diagnosis when examining any child with abdominal pain.

Post-pneumonic thoracic empyema in children: a continued surgical challenge.

The optimal treatment of post-pneumonic thoracic empyema in children is controversial. In this retrospective study, we review our seven-year experience with open surgical drainage in this condition. Between July 1, 1989, and June 30, 1996, 20 children (median age 2.7 years, range 1-8 years) underwent thoracotomy for post-pneumonic empyema in our department. The diagnosis of thoracic empyema was established by the combination of exudate in a pleural tap and the demonstration of multi-loculated pleural effusion by either chest ultrasound or computerized tomography of the chest. The surgical approach was through a posterolateral mini-thoracotomy under general anesthesia. Intrapleural debris, gelatinous, and fibrinous material were evacuated and drains were placed, under vision, at the most dependent pleural locations. The mean length of pre-hospital illness was 5 days (S.D. 3.1 days) and the mean hospital length of stay in a pediatric ward prior to surgery, during which all children received intravenous antibiotics, was 9.4 days (S.D. 7.7 days). A causative pathogen was identified in 8 cases: Streptococcus pneumoniae in 6 cases, Streptococcus group A, and H. influenzae each in one case. Cultures from the pus removed during surgery were sterile for all 19 children who received antibiotics for more than 24 hours prior to surgery. Within 48 hours after surgery, fever dropped to < 37.5 degrees C in 85% of the cases. The postoperative course was uneventful in all cases and the children were discharged home 9 days (S.D. 2.8 days) after surgery. We conclude that open mini-thoracotomy and removal of the entire empyema sac is a safe and curative procedure for children with thoracic empyema.

Peritracheal fibrosis induced by sclerosing agents: a putative treatment for tracheomalacia.

Tracheomalacia is a congenital or acquired deficiency of the cartilages of the trachea. Treatment procedures include formation of external support by insertion of cartilage; bone for foreign material into the peritracheal tissue. A sclerosing agent, sodium morrhuate, was injected in the peritracheal tissue, blindly or after skin incision and subcutaneous tissue. In both groups peritracheal granulation tissue and inflammation evolved into peritracheal fibrosis surrounding the cartilage at the site of injection. The reaction was more pronounced following incision of the skin. No fibrosis was observed in a control group following hypertonic saline injection. The results suggest that injection of sclerosing agents might be considered as a conservative mode of treatment in tracheomalacia, by producing peritracheal fibrosis as external support.

Familial combined duodenal and jejunal atresia.

Combined duodenal and jejunal atresia is extremely uncommon. The familial occurrence of congenital duodenal and small bowel atresia is even more unusual. To the authors' knowledge, this is the first report of two siblings with simultaneous duodenal and jejunal atresia who underwent successful surgical repair. The report may support the genetic origin of some forms of high intestinal atresia.

[Hepatosplenic fungal abscesses in the immunocompromised].

A rare, newly recognized variant of systemic fungal infection is the occurrence of focal hepatosplenic microabscesses in the immunocompromised patient. A patient with persistent unexplained fever should have a CT or ultrasound scan of the abdomen. The presence of multiple splenic lesions strongly suggests fungal disease. If antifungal therapy does not result in complete resolution of fever and splenic lesions, splenectomy is recommended.

[Surgical treatment of choledochal cyst].

Our experience with 11 cases of cystic dilation of the biliary tract is reported. 10 children with choledochal cyst were treated by cystduodenostomy (5 cases) and excision of the cyst with hepaticojejunostomy (5 cases). 1 patient who presented with Caroli's disease was not operated. At long term follow-up, all patients except 1 are asymptomatic. A 16-year-old girl who presented with acute pancreatitis 13 years following cystduodenostomy, early in our experience, underwent excision of the choledochal cyst and hepaticojejunostomy, with uneventful postoperative course. We conclude that in the era of modern imaging, accurate preoperative diagnosis may contribute to better planning and outcome of the surgical treatment of these relatively rare congenital biliary anomalies.

[Nonoperative treatment of pancreatic pseudocyst in children].

3 children with pseudocyst of the pancreas resulting from blunt abdominal trauma are described (boys 6 and 8.5 years old, and a 6.5-year-old girl). Based on abdominal ultrasound and CT findings, nonoperative treatment was elected. There was spontaneous resolution in 1 and in the other 2 the pseudocyst was successfully drained. Previous reports and our own results indicate that it is safe to treat pancreatic pseudocysts in children after blunt abdominal trauma.

Gastrointestinal protein loss in children recovering from burns.

Qualitative gastrointestinal protein loss was evaluated in 10 children with second- and/or third-degree burns covering 10% or more of their body surface area (BSA) by using fecal alpha-1-antitrypsin (FA-1-AT) as a marker. Patients were subdivided according to the extent of the burned area: group I (5 patients) had burns covering less than 20% of BSA; group II (5 patients) had burns covering more than 20% of BSA (mean, 37.2% = 24.9%). Results were compared with those of 12 healthy normal controls. Mean maximal FA-1-AT excretion in group II patients (2.71 +/- 1.35 mg/g) was significantly greater than that found in group I children (0.43 +/- 0.26 mg/g; P = .006) and in the controls (0.62 +/- 0.25 mg/g; P = .004). The mean maximal FA-1-AT excretion positively correlated to the percent of BSA covered with burns (r = 0.83). Although the mean septic score (SS) of group I patients (7 +/- 2.9) was significantly greater than that calculated for group II children (3 +/- 2.45; P = .047), only 2 patients in group II had positive microbiological cultures. Patients in both groups had received more than the recommended enteral caloric and protein allowance during the 96 hours prior to the maximal FA-1-AT measurements. Within this range, no correlation was found between the amount of FA-1-AT and the number of calories per kilogram protein consumed. By using the method of FA-1-AT quantification, this study provides the first report on postburn intestinal protein loss in children.

Sarcoma botryoides of the common bile duct: preoperative diagnosis by coronal CT and PTC.

Sarcoma botryoides of the extrahepatic bile ducts is a rare cause of obstructive jaundice in the pediatric population. It is rarely diagnosed preoperatively. We present a case of this tumor which was diagnosed by ultrasound, computerised tomography and PTC. Coronal CT sections were particularly useful in demonstrating the relationship of the tumor to the porta hepatis, pancreas and duodenum.

Complications of suppurative arthritis and osteomyelitis in children.

Three children with suppurative arthritis and osteomyelitis are described to emphasise that delayed or incorrect diagnosis may lead to serious cardiopulmonary complications. In two patients, bilateral bronchopneumonia developed with pneumatocoeles, pneumothorax and empyema. The other had cardiac failure from septic pericarditis. In one case, disarticulation of the knee was needed as a life-saving measure, and the other leg developed an infected pseudarthrosis of the tibia. The causative organism in each case was staphylococcus aureus and no evidence of immunodeficiency was demonstrated.

Necrotizing bowel disease with candida peritonitis following severe neonatal hypothermia.

Peritonitis due to Candida albicans is rare in the newborn infant. Three low birthweight, extremely ill premature infants who were severely hypothermic at the time of admission developed perforation of the gastrointestinal tract. C. albicans was cultured from the peritoneal fluid in each case. In view of the rareness of C. albicans peritonitis in newborns, this cluster of infants suggests a relationship between severe neonatal hypothermia, and bowel perforation with peritonitis due to this fungus.

Comparison of growth, neovascularization, and enzymatic function of fetal intestinal grafts in the omentum and renal capsule.

Fetal tissues are less immunogenic and may be a useful donor source for organ transplantation. This report compares the fate of fetal small bowel segments transplanted in the omentum and renal capsule of recipient syngeneic rats. Two-centimeter segments of fetal jejunum and ileum were obtained from 26 donor 19-day gestational age rat fetuses and transplanted into the subrenal capsule (n = 35) and omentum (n = 40) in syngeneic Fisher rats (weight, 150 g) as free grafts. No immunosuppression was used. At 2 weeks posttransplantation, the recipient rats underwent laparotomy and the grafts were evaluated for viability, growth, enzymatic function, and revascularization. Viable grafts were identified in 27 of 35 renal capsule grafts and 34 of 40 omental grafts. The order of magnitude of fetal growth in the omentum for jejunum was 16 +/- 10 versus ileum 23 +/- 9 (NS). However, in the renal capsule, ileal growth (15 +/- 6) was significantly greater than jejunum (8 +/- 5; P less than .01). Growth for both jejunal and ileal segments was greater in the omentum (P less than .02). The lumen of all omental grafts remained patent; however, 26 of 27 renal grafts had cystic dilatations and areas of obstruction. Microfil casts of the specimens showed vascular connections (neovascularization) between the graft and omentum, a normal serosal vascular pattern, and many submucosal capillary-like vessels. Maltase activity was measured in fetal grafts and compared with control pups bred on the same date as the donor animals. The grafts had a higher maltase level 33.4 +/- 34.6 mumol/min/g than controls 8.3 +/- 2.0 (P less than .005).(ABSTRACT TRUNCATED AT 250 WORDS)

Familial Hirschsprung's disease--a report of 22 affected siblings in four families.

Twenty-two infants, belonging to four families from Gaza, presenting with typical features of Hirschsprung's disease are reported. Eight patients died at home shortly after birth, prior to 1974, due to low intestinal obstruction. Fourteen patients were referred to Hadassah University Hospital after 1974 and diagnosed, by rectal biopsy, as having Hirschsprung's disease. Thirteen underwent laparotomy and multiple intestinal biopsies. Ten had total intestinal aganglionosis, two had total or near total aganglionosis, and in only one patient was the common rectosigmoid aganglionosis found. One patient died prior to surgery. This unusual familial disease, involving very long aganglionic segments, raises the possibility that these infants suffered from a unique variant of Hirschsprung's disease.

Anorectal malformations and Down syndrome.

During 1980 to 1986, 89 children with Down syndrome and 42 with imperforate anus were diagnosed among 64,870 liveborn infants in the Jewish population of Jerusalem. Two of the children had both Down syndrome and imperforate anus. This indicates a high incidence of imperforate anus among children with Down syndrome (2.2%).

Impaired bowel motility following small intestinal transplantation.

Little information is available concerning motility following bowel transplantation and the appropriate timing of offering enteral feedings. Eight Lewis rats (300 g) underwent small bowel transplant as described by R. P. Harmel, Jr., and H. Stanley (J. Pediatr. Surg. 21:214, 1986). Silver oxide electrodes were placed in the native proximal ileum and in the distal segment of the homograft. Four control rats underwent laparotomy and placement of silver oxide electrodes in the jejunum and proximal ileum. Leads were brought out through a stab wound and the abdominal incision was closed. The electrodes were connected to a continuous recorder. Basal electrical rhythm (BER) was recorded periodically and was evaluated daily as the average of three readings per animal per day. Homograft electrical activity was not observed until at least 40 hr post-transplant and never attained the level of BER of the native intestine (P less than 0.05). Myoelectric complex potentials were not observed in the transplanted rats until post-operative day 11. These data suggest that basal electrical activity is significantly impaired following bowel transplantation. This study indicates that intestinal activity can be monitored for extended periods of time and may be a useful method of evaluating recovery of motility post bowel transplant prior to initiating enteral intake.

Pericardial tamponade complicating central venous catheterization in a newborn infant.

Complications of central venous catheterizations are divided into immediate or early complications such as haematoma, pneumothorax and haemothorax, and late complications such as infection and venous thrombosis. One of the rare but life-threatening complications of central venous catheterization is pericardial tamponade. We review the literature and add an additional case, the first reported in a newborn infant.

Unusual parascrotal hernia with ectopic testicle in a neonate. Case report.

A giant indirect inguinal hernia leading to a huge parascrotal mass in a newborn is described. The right scrotum was empty and the ectopic testicle was found in the perineum, close to the anus. To our knowledge this is the first report of the presence at delivery of a parascrotal inguinal hernia in combination with an ectopic testicle.

Colonic complications of ventriculoperitoneal shunts.

Late perforation of the large bowel by the abdominal catheter of a ventriculoperitoneal (VP) shunt is extremely rare. Four of the five reported patients subsequently died. We report here three patients who presented with this complication and were treated successfully. Bowel perforation by a VP shunt catheter should be considered when a shunt infection is secondary to gram-negative enteric organisms. It can occur without evidence of peritonitis, and the abdominal catheter can be removed percutaneously, thus avoiding a laparotomy.

Multiple arterial aneurysms.

An 8 1/2-yr-old boy presenting with excruciating abdominal pain had two abdominal aortic aneurysms excised. Angiography demonstrated additional aneurysms of the right brachial artery, right renal artery, right internal iliac artery and multiple aneurysms of the right popliteal and tibialis posterior arteries. The patient does not suffer from any of the conditions generally recognized to be associated with aortic and multiple arterial aneurysms. No similar case could be found in the English language literature.