Radiologically-guided balloon sialoplasty for treatment of salivary duct stricture: A novel technique in young children.

OBJECTIVES: To describe our experience using radiologically-guided balloon sialoplasty to successfully treat sialadenitis in two children as a single modality intervention. METHODS: A retrospective case series. RESULTS: Both children were successfully treated using balloon sialoplasty with complete and lasting resolution of their symptoms. CONCLUSION: Paediatric sialadenitis secondary to salivary strictures are traditionally managed surgically. We believe that this is the first article to describe this intervention in such a series of children and that balloon sialoplasty is a safe technique and can be repeated as necessary, which should be considered as a management option in such paediatric cases.

A Validated Normative Model for Human Uterine Volume from Birth to Age 40 Years.

Transabdominal pelvic ultrasound and/or pelvic Magnetic Resonance Imaging are safe, accurate and non-invasive means of determining the size and configuration of the internal female genitalia. The assessment of uterine size and volume is helpful in the assessment of many conditions including disorders of sex development, precocious or delayed puberty, infertility and menstrual disorders. Using our own data from the assessment of MRI scans in healthy young females and data extracted from four studies that assessed uterine volume using transabdominal ultrasound in healthy females we have derived and validated a normative model of uterine volume from birth to age 40 years. This shows that uterine volume increases across childhood, with a faster increase in adolescence reflecting the influence of puberty, followed by a slow but progressive rise during adult life. The model suggests that around 84% of the variation in uterine volumes in the healthy population up to age 40 is due to age alone. The derivation of a validated normative model for uterine volume from birth to age 40 years has important clinical applications by providing age-related reference values for uterine volume.

Imaging of congenital lung malformations.

Congenital lung malformations are a heterogeneous group of anomalies that involve the lungs and tracheobronchial tree (congenital airway pulmonary malformation, bronchial atresia, bronchogenic cyst, congenital lobar overinflation, pulmonary cyst, hamartoma, pulmonary isomerism and azygous lobe), vascular abnormalities (arteriovenous malformations, anomalous pulmonary venous return, pulmonary artery sling, interrupted pulmonary artery, pulmonary varix, pulmonary vein stenosis and pulmonary lymphangiectasia), or frequently both entities (pulmonary sequestration, pulmonary maldevelopment and scimitar syndrome). Advances in diagnostic imaging (including sonography, multi-detector computer tomography, magnetic resonance imaging and angiography) have increased their detection during both antenatal and postnatal periods, and radiological characterisation, which in turn influence patient counselling and management stratification. An educational illustration of the clinical application in characterisation of these malformations is presented.

Incidence of clinically silent malrotation detected on barium swallow examination in children.

INTRODUCTION: Duodenojejunal flexure (DJF) orientation is often examined routinely during contrast swallow studies, including those performed for purely oesophageal queries. We examine the radiation burden and the incidence of malrotation in patients undergoing contrast swallow, without clinical suspicion for malrotation. METHODS: Two hundred eighteen consecutive contrast swallow studies were reviewed. Patients whose history may potentially suggest malrotation were identified (n = 90), and remaining children were grouped based on whether DJF was examined (Group 1; n = 88) or not (Group 2; n = 40). Data extracted include demographics, radiographic parameters (dosage, screening time, number of images obtained) and examination findings. Outcome measures comprised: (i) prevalence of clinically incidental malrotation; and (ii) influence of additional evaluation of DJF on patient dosage (mean ± SEM). RESULTS: Malrotation was identified in 2 of 90 patients (2.2%) examined with clinical indications for possible malrotation, but none in Group 1 (13% already had normal DJF confirmed on previous examinations). Groups 1 and 2 were comparable with respect to age and gender (P = ns). Additional evaluation of DJF (Group 1) meant that 54% more images were acquired (48.5 ± 2.9 vs. 31.4 ± 3.4 images in group 2; P = 0.0002) and 24.9% increased screening time (130.8 ± 9.3 vs. 104.7 ± 13.0 seconds in group 2; P = 0.089), resulting in 32.6% increased patient dosage (1.36 ± 0.21 vs. 1.02 ± 0.16 microGym(2) /kg in group 2; P = 0.19). CONCLUSIONS: This study highlights the increased radiation exposures involved with routine screening for DJF position in those patients without clinical suspicion of malrotation, and raises questions about the validity of this practice; however, further research is needed.

Gastroschisis with Hirschsprung's disease: a therapeutic dilemma.

The authors report a case of a neonate with gastroschisis, which, after repair, was further complicated by the diagnosis of Hirschsprung's disease. The authors discuss the diagnostic and management dilemmas posed by the coexistence of these two conditions for the clinician.

A pitfall in the interpretation of plain abdnominal radiographs in neonatal intestinal perforation: a case report.

INTRODUCTION: The recognition of neonatal intestinal perforation relies on identification of free gas in the peritoneum on plain abdominal radiographs and the associated clinical signs. The neonatal bowel takes several hours to fill with gas, potentially obscuring one of the radiological signs of bowel perforation in the neonate. CASE PRESENTATION: We describe the case of a male, Caucasian neonate, born prematurely at 35+2 weeks of gestation, who was suspected before birth to be at risk of intestinal perforation, based on antenatal ultrasound signs of bowel obstruction. However, the diagnosis of intestinal perforation after birth was initially delayed because the first abdominal radiograph, requested by the neonatal team, was taken too early in the clinical progression of the neonate's condition. As a consequence, this delayed referral to the paediatric surgical team and definitive management. CONCLUSION: This case illustrates how consideration of the timing of abdominal radiographs in suspected intestinal perforation in the neonate may avoid misinterpretation of radiographic signs, thereby avoiding delays in referral and treatment in the crucial first few hours of life.

Oxidation of intravenous lipid in infants and children with systemic inflammatory response syndrome and sepsis.

During sepsis in adults, fat becomes a preferred fuel; however, oxidation may be impaired relative to the circulating fatty acid levels. Little is known about the ability of infants and children to oxidize lipids during systemic inflammation (SIRS) and sepsis. The aim of this study was to examine the oxidation of exogenous lipid in these patients. Sixteen patients with SIRS/sepsis and eight controls with no evidence of sepsis were studied by indirect calorimetry during an i.v. lipid utilization test (1 h of 0.3 g/kg/h glucose followed by 3 h of 0.1 g/kg/h glucose plus 0.15 g/kg/h lipid). The respiratory quotient (RQ) (1.0 for carbohydrate utilization and 0.7 for fat utilization) was measured. Results were compared by repeated-measures analysis of variance (ANOVA), paired or unpaired t tests. There was no difference in baseline RQ between controls and patients with SIRS/sepsis (mean +/- SD; 0.82 +/- 0.08 versus 0.82 +/- 0.04). The RQ of controls dropped significantly to 0.78 +/- 0.08 at 240 min (p < 0.001). The RQ of patients with SIRS/sepsis also fell to 0.78 +/- 0.06 (p < 0.01). Infants and children with SIRS/sepsis are able to oxidize i.v. lipid.

The surgical treatment of gastro-esophageal reflux in neonates and infants.

Gastro-esophageal reflux (GER) is a physiological process characterized by the involuntary passage of gastric contents into the lower esophagus not induced by noxious stimuli. It represents a common condition in preterm infants and may occur in healthy neonates. The phenomenon is only considered as GER disease when it causes the patient to be symptomatic or results in pathological complications. Fundoplication is recommended in symptomatic neonates and infants with GER that does not respond to medical treatment. The presence of respiratory symptoms related to GER is the primary indication for fundoplication in this selected population. The Nissen fundoplication is the antireflux procedure of choice and the experience concerning other procedures, including laparoscopic techniques, is limited in this age group. The best results are achieved in newborn infants with isolated GER, as the recurrence rate of GER in infants with associated anomalies is high. Further studies are necessary to evaluate the benefit of laparoscopic fundoplication in this age group.

When can I be proficient in laparoscopic surgery? A systematic review of the evidence.

PURPOSE: The aim of this study was to quantify the learning curve in laparoscopic surgery. METHODS: A systematic review of the evidence using a defined search strategy (PubMed, Medline, OVID, Embase, ERIC, Cochrane databases) was performed. Studies without statistical evaluation of the learning curve and opinion articles were excluded. The authors analysed 7 common laparoscopic procedures: cholecystectomy, fundoplication, colectomy, herniorrhaphy, splenectomy, appendicectomy, and pyloromyotomy. The "initial" and "late" stages of experience were compared with regards to the following outcome measures: operating time, conversion rate, complication rate, and length of stay in hospital. RESULTS: A total of 3,641 articles were reviewed, of which, 37 (25,777 patients) fulfilled the entry criteria (5 in children). In all articles, the definition of proficiency was subjective, and the number of operations required to reach it was highly variable. There were improvements in all 4 outcome measures for cholecystectomy, fundoplication, colectomy, herniorrhaphy, and splenectomy between the "initial" and "late" experience. No data were available for the learning curves in appendicectomy or pyloromyotomy. CONCLUSIONS: The number of procedures required to reach proficiency in laparoscopic surgery has not been defined clearly. These findings are important for training, ethical and medico-legal issues.

Connecting bar for hip spica reinforcement: does it help?

The purpose of this prospective study was to determine if a connecting bar prevented mechanical failure of hip spicas. Eighty-two hip spicas were applied to 70 patients between April 2000 and June 2001 following open or closed reduction for developmental dysplasia of the hip. Bilateral hip surgery was undertaken in 12 patients. Thirty-six spicas were applied with a bar whilst 46 were without. The technique of application was similar in all patients. Overall nine (11%) hip spicas failed (mechanically) prematurely and had to be replaced in hospital under general anaesthesia. All nine were inpatients whose spica did not have a connecting bar (P < 0.005). The rate of spica revision increased with the age of the patient. All parents of failed spica cases (nine cases) preferred the new spica with a bar to the previous one without, because they agreed that the bar made the spica more secure. The bar did not hamper toileting or handling.