Enterostomy tube placement in children with spinal muscular atrophy type 1.

OBJECTIVE: To determine the major complication rate in the first 30 days after enterostomy tube insertion in infants with spinal muscular atrophy (SMA) type 1. STUDY DESIGN: A retrospective case review of all children with SMA type 1 who had a gastrostomy or gastrojejunostomy tube placed by the image-guided technique at the Hospital for Sick Children from 1994-2004. Major complications were classified as peritonitis, aspiration pneumonia, respiratory failure, nonelective admission to the pediatric intensive care unit, and death. RESULTS: Twelve children were identified as having SMA type 1 with an enterostomy tube insertion. The median age at tube insertion was 6.1 months (range 2.2 to 15.8 months). Major complications in the first 30 days after the procedure included aspiration pneumonia (5/12 patients [41.6%]), respiratory failure requiring admission to the pediatric intensive care unit (4/12 [33%]), and death (2/12 [16.7%]). Children with development of aspiration pneumonia were significantly older at time of tube insertion (P < .05) than those with no aspiration. CONCLUSIONS: Major complications including death are seen in children with SMA type 1 in the first 30 days after enterostomy tube insertion.

Membranous duodenal stenosis: initial experience with balloon dilatation in four children.

INTRODUCTION: We present a novel approach to the treatment of membranous duodenal stenosis (MDS). To our knowledge this is the first paper to describe balloon dilatation for this entity. MATERIAL AND METHODS: Four children, 2 boys and 2 girls, aged between 8 and 28 days, underwent duodenal balloon dilatation. Balloon dilatation was performed under general anaesthesia using standard angiography balloons per os. Balloon diameters ranged from 6 to 14 mm. RESULTS: All balloon dilatations were successful. None of the procedures showed procedural or post-procedural complications. None of the patients subsequently required surgical intervention. To date all children are doing well. DISCUSSION: The initial experience with balloon dilation of MDS showed a 100% success rate, without procedural or post-procedural complications. The results obtained in this small group of patients suggest that the use of balloon dilatation in cases of MDS may be a safe technique that can be readily performed by an experienced interventional radiologist.

US-guided core biopsy of the spleen in children.

PURPOSE: To evaluate the safety, diagnostic yield, and clinical benefits of performing ultrasonography (US)-guided percutaneous splenic core biopsy in children. MATERIALS AND METHODS: US-guided splenic core biopsy was performed in 30 children aged 6 months to 15.3 years (mean, 7.0 years), with focal lesions in 27 patients and homogeneous splenomegaly in three. Four patients underwent repeat biopsy to identify changes in splenic disease. Four types of biopsy needles were used in this series. General anaesthesia was used in 21 patients and conscious sedation in nine. Medical records were reviewed to assess diagnostic accuracy, influence on treatment, and biopsy-related complications. RESULTS: All biopsies were performed without complication. Among the 30 biopsies, an accurate diagnosis was obtained in 25 (83%), a false-negative result was obtained in two (7%), and three (10%) were nondiagnostic. All conclusive results influenced treatment decisions. The mean number of needle passes was 2.7 per patient (range, 2-5 passes). Use of needles was 50%-100% successful in the acquisition of adequate tissue cores. Use of the 18-gauge needle was always successful in the safe acquisition of adequate tissue, with a maximum of three passes. CONCLUSION: US-guided splenic core biopsy is a minimally invasive, simple, and safe procedure for use in children. It provides relatively high diagnostic accuracy while minimizing complications when compared with alternative, more invasive procedures.

Further report of small-bowel intussusceptions related to gastrojejunostomy tubes.

BACKGROUND: The use of gastrojejunostomy (GJ) tubes for feeding pediatric patients who have inadequate oral intake, cannot tolerate gastric feeding, or have significant gastroesophageal reflux may present problems. OBJECTIVE: To report our experience of intussusception associated with GJ tubes, with emphasis on risk factors. MATERIALS AND METHODS: Clinical histories and imaging studies were reviewed for all patients with GJ tube-associated intussusceptions at our institution from January 1995 to March 1999. RESULTS: Of 251 GJ tubes inserted, 40 (16%) intussusceptions occurred in 30 patients (20 males). They ranged in age from 3 months to 17 years (mean 2.6 years) and in weight from 3 to 90 kg (mean 12.5 kg). The underlying diagnosis varied. The main symptom was bilious vomiting. The initial diagnosis was made by sonography in 19 cases and fluoroscopy in 21. Intussusceptions recurred eight times in patients with a distal pigtail (n = 17) but only twice in patients without the distal pigtail (n = 18). CONCLUSIONS: GJ-tube related intussusception is a common, easily diagnosed problem. Predisposing factors appear to be male sex, young children, and presence of a distal pigtail on the tube. Awareness of intussusception is imperative for prompt diagnosis to achieve feeding tolerance.

CT-guided percutaneous needle biopsy of small lung nodules in children.

Malignant pulmonary nodules in a patient with neoplasia alters clinical staging and therapy. Although it may be difficult, it is imperative to obtain a tissue diagnosis of such nodules. We describe a coaxial technique using controlled respirations, which we have found useful for biopsy of small pulmonary nodules in children. Clinical records, imaging and pathology (histology and cytology) were reviewed for 17 children who had 18 nodules biopsied in the method described. A diagnosis of malignant or benign tissue was made in 15 nodules. One biopsy was inadequate and there was one false-negative. Adequate cores were obtained in 15 nodules, cytology in 2 and inadequate material in 1. There was no significant morbidity.

Ureteral opening pressure: a novel parameter for the evaluation of pediatric hydronephrosis.

PURPOSE: The antegrade nephrostogram is an important tool in the evaluation of the upper urinary tract. However, the information currently provided by a nephrostogram is largely limited to anatomical details. To establish a meaningful pressure-flow parameter that may be incorporated into a routine nephrostogram, we evaluated the ureteral opening pressure (defined as the pressure at which contrast material is first seen beyond the suspected site of obstruction) and correlated these findings with the results of pressure-flow studies performed with an external infusion and/or furosemide induced diuresis. MATERIALS AND METHODS: A total of 52 renal units were studied under a prospective pressure-flow study protocol. All patients had grade 3 or 4 hydronephrosis (Society of Fetal Urology classification) and patient age range was 0.2 to 12 years (median 1.1). The suspected sites of obstruction were the ureteropelvic and ureterovesical junctions in 42 and 10 renal units, respectively. With the patient under general anesthesia 22 gauge percutaneous nephrostomy needles were inserted. Pressure-flow studies with an external infusion and/or furosemide induced diuresis were then performed. As the renal pelvic pressure progressively increased during the course of the pressure-flow studies, the renal pelvic pressure at which contrast material was first seen to appear distal to the suspected site of obstruction was recorded as the ureteral opening pressure. Ureteral opening pressures were compared to the results of the pressure-flow studies. RESULTS: With a positive test defined as renal pelvic pressure greater than 14 cm. water, positive ureteral opening pressures were associated with positive pressure-flow study results in 100% of the cases, regardless of which form of pressure-flow study was used or where the suspected site of obstruction was located. In contrast, negative ureteral opening pressures had specificities and negative predictive values of only 19 to 57%, depending on the form of the pressure-flow study and the suspected site of obstruction. CONCLUSIONS: An elevated ureteral opening pressure was 100% predictive of obstruction and may obviate the need for more elaborate pressure-flow analyses. However, if the ureteral pelvic pressure remained low, the possibility of a potentially significant obstruction could not be definitively eliminated and further evaluation was required.

Non-operative management of traumatic pancreatic pseudocysts associated with pancreatic duct laceration in children.

Objective. To assess the successful non-operative management in traumatic pancreatic pseudocysts (TPP) associated with duct laceration in children. Surgical therapy (cystogastrostomy or distal pancreatectomy with splenic salvage) has been classically considered the treatment of choice for those pseudocysts. Materials and methods. This report presents the clinical and imaging findings in two children with TPP and pancreatic duct disruption observed either on endoscopic retrograde cholangiopancreatography or injection via catheter drainage. Results. Both children responded to long-term cyst drainage. Conclusion. Although the experience is limited, the authors suggest that pancreatic injury associated with duct laceration can respond to non-operative management.

Recognition of intussusception around gastrojejunostomy tubes in children.

OBJECTIVE: We describe antegrade intussusceptions of duodenum and jejunum around gastrojejunostomy tubes seen on sonography and fluoroscopic contrast tube studies. Reduction of the intussusception was achieved by bolus injection of air or contrast medium through the tube or exchange over a wire. CONCLUSION: Sonography and fluoroscopic contrast tube studies permit diagnosis of intussusception around gastrojejunostomy tubes.

Interventional drainage of appendiceal abscesses in children.

OBJECTIVE: This study was undertaken to validate the outcome of interventional drainage and IV antibiotics for the treatment of appendiceal abscesses in children. MATERIALS AND METHODS: Between March 1991 and March 1995, 46 children with one or more intraabdominal appendiceal abscesses were seen at a tertiary care referral center. The children received IV antibiotics and underwent interventional drainage of their collections. All procedures were performed in the radiology intervention suite using IV sedation and, in one patient, a general anesthetic. All patients were followed up for at least 1 year. RESULTS: The 46 patients underwent 64 procedures. These included the insertion of 34 percutaneous drainage catheters, the insertion of 25 transrectal drainage catheters, and five needle aspirations. Four patients did not respond to their initial treatment and required surgery. One patient developed a colonic fistula that resolved spontaneously. CONCLUSION: Successful treatment of 42 patients (91%) justifies image-guided drainage and IV antibiotics as appropriate management for appendiceal abscesses in children.

Fecal incontinence in children: treatment with percutaneous cecostomy tube placement--a prospective study.

PURPOSE: To evaluate the technique used for and long-term results of percutaneous cecostomy tube placement for the treatment of fecal incontinence in children. MATERIALS AND METHODS: After an initial pilot study in 15 patients, 42 additional patients with fecal incontinence aged 2-20 (mean, 11.5) years and weighing 9.9-109.0 (mean, 39.2) kg underwent percutaneous cecostomy tube placement. Twenty-nine patients had spina bifida, nine had imperforate anus, three had cloacal anomalies, and one had Hirschsprung disease. Mean follow-up was 265 days (range, 8-503 days). RESULTS: Tube placement was successful in all patients. One patient developed local inflammation after accidental early retention-suture removal, which was treated with suture replacement and intravenous antibiotics. Another developed postprocedural ileus, which resolved. Late complications included constipation in one patient (treated with diet alteration), granulation tissue in seven patients (treated with silver nitrate cautery), and accidentally dislodged tubes in three patients (two successfully replaced at home and one replaced at the radiology suite). Vomiting related to the phosphate enema occurred in two patients. Resolution of soiling was achieved in all patients. CONCLUSION: Percutaneous cecostomy and antegrade enemas are very successful in achieving fecal continence and patient independence and acceptability, with minimal early and late complications.

The cecostomy button.

Percutaneous insertion of a cecostomy tube, performed under local anesthesia, to facilitate antegrade colonic cleansing, has been an invaluable advance in the management of fecal incontinence. However, the patient is left with a length of tubing (2 to 4 inches) protruding from the cecostomy site that has to be taped down to the abdominal wall. Available devices for insertion in place of the cecostomy tube are cumbersome and have a relatively high profile, projecting more than 1 cm from the surface of the abdominal wall. Worn under a swimsuit, they are clearly discernible. The inflated balloon within the cecum can occasionally break. Furthermore, in the individual with a relatively thick abdominal wall, such devices are too short to reach from the skin to the cecum. A new form of low-profile trapdoor device has been developed that overcomes the above shortcomings of other available "buttons." It has been successfully used in a clinical setting in 49 patients.

Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.

PURPOSE: To evaluate a technique of retrograde insertion of gastrostomy and gastrojejunostomy tubes with radiologic guidance in children. MATERIALS AND METHODS: During a 4 1/2-year period, 511 patients underwent attempted insertion of gastrostomy or gastrojejunostomy tubes. Patients' ages ranged from premature to 18.6 years (mean age, 3.8 years), and weight range was 0.8-86.0 kg (mean weight, 12 kg). The charts of 453 patients were reviewed. RESULTS: Placement was unsuccessful in six patients because of colonic interposition (n = 2), microgastria (n = 2), or hepatosplenomegaly (n = 2). Initial placement was a gastrostomy tube in 436 patients and a gastrojejunostomy tube in 69 patients. Sixty-eight gastrostomy tubes were converted to gastrojejunostomy tubes. Early complications (< 30 days) included skin infection (n = 11), stoma irritation (n = 20), and tube dislodgment (n = 6). Late complications included stoma irritation (n = 29), skin infection (n = 23), tube leakage (n = 14), and discomfort during feeding (n = 15). Two complications necessitated surgery: extragastric misplacement and small-bowel transgression. There were no tube-related deaths. CONCLUSION: Percutaneous retrograde placement of gastrostomy or gastrojejunostomy tubes safely and effectively provides long-term nutrition for children. A team approach is essential to provide service to this cumulative population.

Percutaneous cecostomy: a new technique in the management of fecal incontinence.

A pilot study on the percutaneous introduction of a cecostomy tube for colonic irrigations in the treatment of children with fecal incontinence is described. The results were good, and the technique is recommended for certain patients.

Pressure decay half-life: a method for characterizing upper urinary tract urine transport.

PURPOSE: We examined the pressure dynamics of hydronephrotic kidneys after elevated renal pelvic pressure developed. MATERIALS AND METHODS: A total of 40 patients (44 renal units) 0.2 to 12 years old was evaluated. Transiently elevated renal pelvic pressure was induced with a percutaneous nephrostomy infusion. After renal pelvic pressure increased the infusion was stopped and the subsequent decrease in pressure with time was plotted as a pressure decay curve. The rapidity of the decrease in renal pelvic pressure was then quantitated as a half-life for each pressure decay curve. Pressure decay half-lives were compared to corresponding pressure flow study results and diuretic nuclear renography half-lives. RESULTS: Renal units without elevated renal pelvic pressure during infusion at a high physiological flow rate were associated with relatively rapid pressure decay, whereas those with elevated renal pelvic pressure during infusion were associated with much slower pressure decay (p < 0.0001). Diuretic nuclear renography half-lives had no correlation with collecting system pressure dynamics. CONCLUSIONS: Pressure decay half-life provides an objective quantitative measure of the relative tendency for elevated renal pelvic pressure to persist. When used in conjunction with other diagnostic modalities, it may be a useful parameter for a comprehensive assessment of the risk of pressure induced injury in hydronephrotic kidneys.

Deep pelvic abscesses in children: transrectal drainage under radiologic guidance.

PURPOSE: To compare the effectiveness of radiologically guided transrectal drainage (TRD) of deep pelvic abscesses (DPAs) in children with that of percutaneous and surgical techniques. MATERIALS AND METHODS: Treatment results in 57 children with DPAs were retrospectively evaluated. The following procedures were performed: TRD alone (n = 21), TRD and percutaneous drainage (PD) of multiple abscesses (n = 5), PD alone (n = 19), and open surgical drainage (SD) (n = 8). Four patients were treated medically. Most abscesses were due to either perforated appendix or recent appendectomy. Patients believed to have a perforated appendix underwent interval appendectomy 4-6 weeks after TRD or PD. RESULTS: All patients recovered fully. TRD was tolerated better than PD or SD. Patients were usually ambulatory within 24 hours of the TRD procedure and required minimal analgesia. The average hospital stay was 4.2 days with TRD, 8 days with TRD and PD, 6 days with PD, and 10.5 days with SD. CONCLUSION: Radiologically guided TRD is effective in the treatment of DPAs.

Effect of puberty on markers of glomerular hypertrophy and hypertension in IDDM.

Epidemiological data implicate puberty as a factor in the initiation of diabetic nephropathy. However, the mechanism remains unclear. We hypothesized that puberty would result in an increase in glomerular hypertrophy and hypertension; these two early concomitant events are seen as pivotal to the pathophysiology of diabetic nephropathy. We studied the effect of pubertal duration on three surrogate markers of glomerular hypertrophy/hypertension: kidney volume (KV), microalbuminuria (MA), and Na-Li countertransport (CT). We recruited 177 subjects (87 female and 90 male; aged 6.2-22.1 years) with IDDM of 5 to 10 years' duration (6.8 +/- 1.6 years) into three groups with different pubertal duration: prepubertal since IDDM diagnosis; prepubertal at diagnosis, now pubertal; or early puberty at diagnosis, now postpubertal. KV was measured by ultrasound and corrected for body surface area; MA was defined as urinary albumin excretion of 15-200 micrograms/min in two of three 24-h samples, and Na-Li CT was measured in erythrocytes. As pubertal duration increased, there was a disproportionate increase in mean KV (prepubertal, 247 +/- 6 [SE] ml/1.73 m2; pubertal, 282 +/- 7/1.73 m2; postpubertal, 295 +/- 7/1.73 m2, P = 0.001), prevalence of nephromegaly (KV > 300 ml/1.73 m2) (14, 31, and 45%, respectively, P = 0.001), and prevalence of MA (0, 9.7, and 20.5%, respectively, P = 0.003). Subjects with KV > 300 ml/1.73 m2 were eight times more likely to have MA than those with KV < 300 (odds ratio 8.1, 95% confidence interval 2.4-27.4, P = 0.0001). There was no effect of pubertal duration on Na-Li CT. Multiple regression with KV as the dependent variable found an association with pubertal duration, MA, Na-Li CT, and current HbA1c (P < 0.0001). Our findings indicate that pubertal duration is an important determinant of both KV and MA and suggest that nephromegaly precedes microalbuminuria. We postulate that these effects are attributable to the influence of the pubertal milieu on glomerular hypertrophy/hypertension.

Peripherally inserted central catheters in children.

PURPOSE: To assess the feasibility and complications of peripherally inserted central catheters (PICCs) in pediatric patients. MATERIALS AND METHODS: The authors attempted to place PICCs in 122 patients aged 9 days to 19 years (mean, 6.82 years; median, 5 years). Catheters were placed to allow prolonged administration of antibiotics or chemotherapeutic agents (n = 50), provide total parenteral nutrition (n = 41), and establish prolonged intravenous access for blood draws and fluid administration (n = 31). Silicone catheters measuring 3, 4, and 5 F were inserted in either basilic or cephalic veins and positioned at the junction of the superior vena cava and right atrium under fluoroscopic guidance. Patients were monitored for complications until devices were removed. RESULTS: Fluoroscopically guided PICC placement was successful in 137 of 148 attempts. Postinsertion complications included mechanical defects of the catheter, PICC-related infection, occlusion of the PICC, and venous stasis. Complications occurred at a rate comparable to those seen with blind insertion. CONCLUSION: Fluoroscopically guided PICC placement is feasible and safe in pediatric patients.

Evaluation of pediatric hydronephrosis using individualized pressure flow criteria.

In pursuit of a diagnostic modality better able to assess collecting system urine transport characteristics while operating within physiological ranges, a new set of guidelines for the pressure flow study was proposed. An infusion rate individualized for each patient was chosen based on a calculated estimate of the maximum physiological urine output, adjusted for patient size and age. The upper limit of normal renal pelvic pressure used was 14 cm. water. We evaluated 37 renal units with grade 3 or 4 hydronephrosis with the individualized pressure flow study. Patient age ranged from 0.2 to 12 years (median 1.1). Calculated individualized infusion rates ranged from 1.3 to 12.5 ml. per minute and resulting renal pelvic pressures ranged from 7 to greater than 40 cm. water. In each patient the corresponding renal pelvic pressure resulting from a fixed 10 ml. per minute infusion rate was uniformly equal to or higher than the corresponding individualized study pressures (p < 0.0001). Disagreement between the individualized and fixed rate pressure flow studies was highest in the younger patients. The correlation coefficient between diuretic nuclear renography half-times and individualized pressure flow results was 0.09, indicative of a random association between the 2 variables. By using individualized infusion rates based on the calculated estimate of the maximum physiological urine output, much of the falsely high pressures induced by nonphysiologically high fixed infusion rates in pediatric patients can be avoided.

Posttraumatic arterial priapism in children: management with embolization.

PURPOSE: To evaluate selective embolization for management of posttraumatic priapism in preadolescent boys and color Doppler sonography for diagnosis of the causative lesion and for planning embolization. MATERIALS AND METHODS: Five preadolescent boys with posttraumatic priapism underwent selective angiography and embolization. Color Doppler sonography was performed in the last three patients. RESULTS: Selective angiography showed an intracavernosal arteriovenous fistula in two patients, pseudoaneurysm of the cavernosal artery in two patients, and asymmetric cavernosal arterial flow in the other patient. After successful embolization, detumescence was achieved in all patients. Color Doppler sonography enabled localization and characterization of the lesion causing the priapism in the three patients. CONCLUSION: Angiography with selective embolization is a safe and effective method to correct posttraumatic priapism in children. Color Doppler sonography is a valuable preangiographic study, as it allows for characterization and localization of the causative lesion and obviates diagnostic cavernosal aspiration.