The CCSG prospective study of venous access devices: an analysis of insertions and causes for removal.

This is an interval analysis of the 2-year prospective multicenter Childrens Cancer Study Group study of 1,141 chronic venous access devices in 1,019 children with cancer. Device type was external catheter (EC) 72%, totally implantable (TID) 28%, and did not differ for diagnosis or age except more double-lumen devices in bone marrow transplant protocols (77%) and more TIDs in children less than 1 year old (17.7%). Insertion characteristics evaluated in 1,078 (95%) were: operating room placement 99%; general anesthesia 98%; cutdown 67%; percutaneous 33%; atrial position 50%, caval position 50%; and perioperative antibiotics 48%. Vein entry was the external jugular 33%, internal jugular 22%, subclavian 35%, cephalic 7%, and saphenous 3%. Insertion was difficult or very difficult in only 10% and operative complications occurred in only 0.7%. Degree of difficulty bore no relationship to device type or patient age. The reasons for removal in 736 devices (67%) were due to complications in 39%, of which infections were the most frequent. There was some variance between centers ranging from 8.5% to 31% for infection; 2.8% to 24% for dislodgment; and 0% to 13% for occlusion. ECs had a higher risk of dislodgment; elective removals were more frequent in TIDs; there was no difference in infection as a cause for removal between ECs and TIDs. Dislodgment was associated with the shortest distance of the cuff to the skin exit (mean, 4 cm): less than or equal to 2 cm, 49%; greater than 2 cm, 28% (P = .009) and occurred most frequently in the younger patient (18.9%, 0 to 1 years; 0.5%, greater than 8 years.

Human serum albumin-benzo[a]pyrene anti-diol epoxide adduct structure elucidation by fluorescence line narrowing spectroscopy.

Cryogenic (4-10 K) laser-induced vibrationless ground state and vibronic excited state fluorescence emission spectra of the adducts resulting from reaction in vitro of human serum albumin and the carcinogen (+-)-r-7,t-8-dihydroxy-c-9,c-10-epoxy-7,8,9,10- tetrahydrobenzo[a]-pyrene were recorded in order to determine the structures formed. Comparison of these fluorescence line-narrowed (FLN) spectra to those obtained from BaP-7,8,9,10- tetrahydrotetrols, synthetic N-t-BOC-alaninate ester, and N tau- and N pi-histidine amine anti-BaPDE adducts revealed that a mixture of adduct types are formed with the protein. Extensive dialysis of the adducted protein simplified the FLN spectrum, causing it to become nearly identical to the FLN spectrum obtained from the stable peptide adduct. Comparison of the FLN spectra of the synthetic histidine adducts to those obtained from peptide adducts isolated from enzymic digestion of the adducted protein indicated that only one of the imidazole nitrogens is the nucleophile which forms a stable adduct with anti-BaPDE. The FLN studies confirm that N tau-histidine adducts are formed between human serum albumin and the C-10 position of anti-BaPDE.

Conversion of a hemoglobin alpha chain aspartate(47) ester to N-(2,3-dihydroxypropyl)asparagine as a method for identification of the principal binding site for benzo[a]pyrene anti-diol epoxide.

Human hemoglobin was alkylated with (+/-)-7 beta,8 alpha-dihydroxy-9 alpha,10 alpha-epoxy-7,8,9,10-tetrahydrobenzo[a]pyrene (BPDE) and then treated with aqueous (+/-)-3-amino-1,2-propanediol to convert alkylated carboxyl side chains to N-(2,3-dihydroxypropyl) amides. Tryptic peptides produced from the modified protein were subjected to affinity chromatography on phenylboronic acid. The bound fraction was further purified by HPLC on C-4 reverse-phase medium to yield one modified peptide, which was identified as the Thr(41)-Lys(56) peptide of the alpha chain by amino acid analysis, Edman sequencing analysis, and FAB-MS. Limited direct evidence from this study and further indirect evidence from previous work identify Asp(47) alpha as the amino acid reacting with BPDE. The only other likely sites would be the C-terminal carboxyl groups of either the alpha or beta chain. Possible reasons for the site selectivity of the alkylation of human hemoglobin by BPDE are discussed.

Adenocarcinoma of the pancreas in a neonate managed by pancreatoduodenectomy.

A 3-week-old infant presenting with jaundice and an abdominal mass was found to have juvenile adenocarcinoma of the pancreas (pancreatoblastoma). A pancreatoduodenectomy was performed, and the child is alive, well, and free of disease at age 4 years. The operative management and surgical technique are discussed.

Velopharyngeal insufficiency after adenoidectomy: an 8-year review.

The characteristics of 137 patients referred to the Speech Clinic at The Hospital for Sick Children, Toronto, Canada during the past 8 years for the investigation of persistent hypernasality after adenoidectomy are reported. Over 30% of the patients had preoperative factors that are thought to increase the risk, such as submucous cleft palate, fluid regurgitation through the nose, a family history of velopharyngeal insufficiency or clefting, or hypernasality. Fifty percent of the patients required pharyngoplasty to correct hypernasality, 37% required speech therapy alone, and 13% improved with no treatment.

Fat overload syndrome causing respiratory insufficiency.

The fat overload syndrome developed in a 7-year-old girl who was on home TPN which included 20% Intralipid (total lipid dose 3.2 g/kg/d). Acute respiratory insufficiency developed with cough, dyspnea, tachypnea, and cyanosis. The chest x-ray revealed mild cardiomegaly and pulmonary edema. Blood gases showed profound hypoxia (PaO2 29 torr on room air). Spontaneous resolution occurred over the next seven days as the lipemia cleared.

Blunt hepatic trauma in children: experience with operative and nonoperative management.

Between 1974 and 1982, 32 children were treated for blunt hepatic trauma. Twenty-three injuries were secondary to motor vehicle accidents. Twenty-three patients had associated injuries. The hepatic injury was treated surgically in 18 patients. Urgent surgery for massive bleeding was required in 7 patients; 8 underwent laparotomy for continued bleeding after initial stabilization; 2 underwent laparotomy for marked abdominal tenderness, and 1 for an expanding hepatic hematoma. Various excisional, debridement, suture, and drainage procedures were employed. Seven patients died, 5 from uncontrollable bleeding and 2 from associated severe head injury. The eleven survivors did well. The only postoperative complications were two wound infections. Fourteen patients were managed nonoperatively. Liver scan provided the diagnosis in all. Five of these patients required blood transfusion, and the mean volume of transfusion was 33cc/kg. The hospital courses in all cases were uneventful, and there were no late complications. A follow-up liver scan was obtained in 11 patients, showing resolution of the injury in all. We conclude that laparotomy is necessary for hepatic injury when it is associated with continuous massive bleeding. Hemodynamically stable patients can be managed nonoperatively, even when the blood-transfusion requirements are significant.

Surgery for anomalies of the urachus.

Thirty-five children with anomalies of the urachus which have required surgical management have been encountered in this institution over a 20-year period. Of these 35, 19 were classified as patent urachus, 12 as urachal cyst, and 4 as urachal sinus. All cases were treated by excision or drainage. There was one death. Gastrointestinal and other genitourinary anomalies were commonly seen in these patients. Intravenous pyelography was helpful in identifying unsuspected associated genitourinary anomalies while cystography was not. Investigation of the gastrointestinal tract does not appear to be warranted in the absence of symptoms.

Segmental infarction of the greater omentum: a cause of acute abdomen in childhood.

Segmental infarction of the greater omentum is an unusual cause of acute abdominal pain in children. Over 30 years at the Hospital for Sick Children in Toronto, this entity was encountered nine times. All children complained of right lower quadrant pain. They were tender in that area and were thought to have acute appendicitis. At operation, the appendix was found to be normal in all and an area of infarcted omentum was identified as the cause of the acute illness. Torsion of the infarcted omentum was noted in four cases. Excision of the omentum was curative.

The effect of partial splenectomy on experimental pneumococcal bacteremia in an animal model.

The effect of total and partial splenectomy on the blood stream clearance of type 23B Streptococcus pneumoniae was studied in chinchillas 2 wk and 2 mo following surgery to determine the amount of splenic tissue necessary for protection against overwhelming sepsis. Significantly more pneumococci were found in the blood of totally splenectomized chinchillas than in the blood of sham-operated animals throughout the 6-hr sampling period after intravenous inoculation of pneumococci. Animals that had two-thirds of their spleen removed demonstrated a significant delay in clearance of pneumococci compared with sham-operated and hemisplenectomized animals. The rate of pneumococcal clearance was similar for the sham-operated and the hemisplenectomized group, and was significantly prolonged but similar among totally splenectomized and two-thirds splenectomized animals. Pneumococcal opsonic activity was reduced only in the sera of totally splenectomized chinchillas 2 mo after surgery. There was no positive relationship between pneumococcal clearance and change in pneumococcal opsonic activity. These results suggest that the impaired clearance of circulating pneumococci in splenectomized animals is due to the loss of splenic reticuloendothelial cells as a mechanical filter, rather than deficient serum opsonic activity. There appears to be a critical splenic mass required for optimal bacterial clearance, and hemisplenectomy may protect against overwhelming postsplenectomy sepsis.

Surgical management of islet-cell adenoma in infancy.

Persistent neonatal hypoglycemia is a potentially serious condition which should be recognized promptly, investigated thoroughly, and treated expeditiously. Islet-cell adenoma causing hypoglycemia in infancy is very unusual. Only 23 cases have been reported in the literature. This report documents eight cases of our own and summarizes diagnostic methods, proper medical preparation, and fundamental surgical management. Prompt surgical intervention is emphasized, as this will relieve hypoglycemia and may be important in preventing irreversible central nervous system damage. We are of the opinion that any infant with unremitting hypoglycemia, a high corrected insulin/glucose ratio, and failure to respond to maximum diazoxide therapy will require partial pancreatectomy. Identification of the adenoma at the time of operation is unlikely, and blind pancreatectomy and/or reoperation is not unusual.

Open thoracotomy and pleural abrasion in the treatment of spontaneous pneumothorax in cystic fibrosis.

The various treatments of spontaneous pneumothorax in cystic fibrosis are examined over a 15-yr period. Open thoracotomy with pleural abrasion is compared to observation, tube thoracostomy, and tube thoracostomy with instillation of quinacrine. Open thoracotomy with pleural abrasion has been performed 31 times in 20 patients. Discussion centers around selection of patients, preoperative preparation, operative technique, and postoperative care and follow-up, including analysis of pulmonary function studies. In our experience, open thoracotomy with pleural abrasion is a safe and effective method that should be utilized in the management of pneumothorax in patients with cystic fibrosis.

Replantation of the upper extremity in children.

Since Malt and McKhann performed the first successful replantation of a traumatically amputated extremity in 1962, there has been a flurry of case reports and articles debating the pros and cons of the various technical aspects of replantation. There have been three case reports of children, under the age of 15, who have successfully undergone replantation of the upper extremity transected throught the humerus. The first case report in this article is the fourth. The factors involved in selecting replantation or amputation, and the technical aspects of the operation which are felt to be important, are briefly reviewed. Because the mechanics of limb replantation are rather straightforward, we feel that the pediatric surgeon should be familar with the preoperative and intraoperative factors to be weight, and that this alternative to stump closure be carefully considered when one is presented with an upper extremity transection.