The seroprevalence of cysticercosis, malaria, and Trypanosoma cruzi among North Carolina migrant farmworkers.

A seroprevalence study of cysticercosis, Trypanosoma cruzi, and plasmodia species and screening for active malaria was conducted among a randomly selected group of 138 Hispanic and Haitian migrant farmworkers. A random sample of labor camps in eastern North Carolina was selected. Blood samples were tested by Indirect Fluorescent Antibody techniques for plasmodial antibody and by enzyme-linked immunosorbent assay (ELISA) for cysticerci and T. cruzi antibodies. Questionnaires collected demographic data and medical history of the workers and family. Blood films stained with Leukostat stain were examined for plasmodia species. The seroprevalence of cysticercosis was 10 percent, T. cruzi 2 percent, and plasmodia species 4.4 percent. One case of active malaria (Plasmodium vivax) was demonstrated. The clinical significance of seropositivity was not determined, but these results suggest that a small but significant number of farmworkers are infected with cysticercosis, T. cruzi, and malaria. Migrant health clinicians should be aware of the possible presence of these infections. Greater observance and enforcement of sanitation regulations in farmwork is needed to prevent transmission of cysticercosis.

Acute appendicitis in children with leukemia and other malignancies: still a diagnostic dilemma.

Of 6,099 children treated for malignancy, 16 (ages 3.5 to 18 years) developed acute appendicitis between 1962 and 1989. Fourteen had leukemia (ALL 10, AML 4). One each had rhabdomyosarcoma and Ewing's sarcoma. Active malignancy at diagnosis was noted in 10, 4 of whom had severe neutropenia (absolute neutrophil count less than 500/mm3). Of all the leukemics (2,794/6,099), abdominal pain during induction was a frequent complaint. The incidence of appendicitis, however, was low (0.5%). Nine of the 16 patients presented classically, facilitating prompt diagnosis and treatment. Six diagnoses were delayed. Three of these patients presented atypically with vague, nonlocalized pain, abdominal distention, lack of abdominal guarding, fever, dehydration, diarrhea, and unusual symptoms such as upper gastrointestinal bleeding. In each of these 6 patients the appendix was ruptured. Delays led to complications and deaths. Three patients required perioperative transfusions to treat excessive bleeding and two patients with ruptured appendicitis developed wound abscesses. Two patients died; in one, ruptured appendix was diagnosed only at autopsy. The other patient died of uncontrolled sepsis. Typhlitis occurring during induction chemotherapy may present similarly and is the main differential diagnosis. Typhlitis will usually improve with medical treatment alone. Nausea and vomiting (13/16), right lower quadrant pain (13/16), guarding (14/16), tachycardia (12/16), fever (10/16), and rebound tenderness (10/16) were the most frequent signs and symptoms of appendicitis. Persistent localized abdominal pain and guarding, lack of improvement with medical treatment, clinical deterioration, and the development of a mass were our indications for laparotomy. Despite major improvements in therapy, there is still a 37.5% error rate in our ability to accurately diagnose appendicitis in pediatric cancer patients.

Is there a role for laparoscopic appendectomy in pediatric surgery?

Although laparoscopic procedures are currently in vogue in general surgery, the role of this approach in children has not been prospectively evaluated in the United States using the new instrumentation now available to us. To assess the value of laparoscopic appendectomy (LA) in childhood, we prospectively compared 14 LAs with 50 open appendectomies (OA) over 6 months in a single children's hospital. Antibiotic usage was at the discretion of the surgeon regardless of the procedure performed and was not different between groups. LA was performed under the direction of a single laparoscopy-trained surgeon and patient selection was based on parental consent. A three-puncture LA technique was used; children from this group were allowed to return to full activities as soon as they were comfortable. There were no significant differences between groups for severity of disease, age, weight, hospital cost, or complications. The types of complications that developed were comparable in both groups. The percent of complicated appendicitis (gangrene or perforation) was 32% in the OA group and 36% in the LA group. Patients in the LA group spent significantly fewer days in the hospital and returned to unrestricted activities (school, athletics, etc) faster than patients in the OA group. LA is approximately $1,000 more expensive than OA, the differences being easily explainable by the cost of the disposable supplies necessary for the procedure (laser fibers, trocars, etc), but because of the shorter hospital stay in the LA group the mean total cost for each group was comparable. These data suggest that although there appears to be no cost advantage, LA shortens the hospital stay and allows children to return to unrestricted activity sooner than OA.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of tube gastrostomy on gastroesophageal reflux in patients with esophageal atresia.

Gastroesophageal reflux (GER) occurs frequently in infants with esophageal atresia (EA). The definitive management is primary repair and often includes tube gastrostomy. The recent finding of lower esophageal sphincter (LES) pressure changes with tube gastrostomy suggests that GER might be related to gastrostomy rather than EA per se. To evaluate this thesis, two populations of patients from different children's hospitals were reviewed: EA with and without routine gastrostomy. The two populations were similar with respect to number of infants, associated anomalies, distribution in the Waterston classification, morbidity, and mortality. One hundred sixteen patients were studied. Of the 66 survivors who underwent gastrostomy and repair of EA, 30 were found to have GER (45.5%) and 12 required fundoplication (18.2%). Of 31 surviving patients who underwent repair of EA without gastrostomy, 11 had GER (35.5%) and four required fundoplication (12.9%). These data suggest that tube gastrostomy does not significantly contribute to the GER associated with EA.

Neurenteric cyst: surgery and diagnostic imaging.

Neurenteric cysts are rare, with fewer than 30 cases noted in the literature. We report the case of a newborn infant with respiratory distress caused by a large neurenteric cyst that was identified by prenatal ultrasound. Treatment consisted of excision of the mass through a right posterolateral thoracotomy. The cyst adhered to the spine at the level of the first thoracic vertebra and communicated with the jejunum through a posterior diaphragmatic defect. Postoperative studies with magnetic resonance imaging (MRI) and computed tomography (CT) disclosed an anterior meningocele and tethering of the spinal column. This is the second reported case of a neurenteric cyst demonstrated by prenatal ultrasound. The presence of an intrathoracic cyst associated with spinal abnormalities is characteristic of this anomaly. With imaging techniques such as MRI and CT, we may detect residual intraspinal disease associated with neurenteric cysts.

Late urologic complication of an abdominal gunshot wound.

An unusual late complication of an abdominal gunshot wound is presented. It consisted of an acute hydronephrosis of the left kidney by a BB-type bullet that migrated into the ureter of a 11-year-old boy 1 month after he was injured in the left flank, causing its complete obstruction. A percutaneous nephrostomy was performed and, with the help of a basket-type catheter, the bullet was removed. To our knowledge this is the first case reported of this rare complication treated by this technique.

Twenty-five years' experience with Hirschsprung's disease.

Sixty-three patients with biopsy-proven Hirschsprung's disease were diagnosed at LeBonheur Children's Medical Center, Memphis, TN between 1955 and 1980. Fifty-eight of these patients had pull-through procedures performed by three similarly trained pediatric surgeons. The follow-up was 100 percent, averaging 8 years from initial diagnosis. Demographics, surgical procedures performed, and complications are reviewed. Significant findings are (1) anastomotic strictures occurred most frequently when the level of aganglionosis was at the sigmoid colon; (2) postoperative encopresis was most likely when the endorectal pull-through procedures were performed before the age of 10 months; and (3) with selective use of colostomies or enterostomies performed prior to the pull-through procedure, the incidence of enterocolitis was low, with 0% mortality. On the basis of these findings, we recommend that, when the most proximal level of aganglionosis is the sigmoid colon, it is important to critically inspect the angulation of mesenteric blood vessels and viability of the splenic flexure pull-through colon segment to prevent ischemia and therefore anastomotic strictures. The endorectal pull-through procedure should be delayed until after 10 months of age. Infants with Hirschsprung's disease should have a colostomy or enterostomy prior to a pull-through procedure. Patients diagnosed at 10 months of age or more, who have not had earlier bouts of enterocolitis, are not low percentile weight, and are without signs of severe obstruction, are candidates for pull-through without a prior fecal diversion procedure.

Extralobar pulmonary sequestration and mediastinal bronchogenic cyst.

A child with coexisting mediastinal bronchogenic cyst and extralobar pulmonary sequestration is presented. Two distinct lesions were suggested by barium esophagram and confirmed by a chest computed tomography scan. The diagnostic and embryologic relationship of the two lesions is discussed.

The continued value of angiography in planning surgical resection of benign and malignant hepatic tumors in children.

We assessed the accuracy of angiography or digital subtraction angiography (DSA) in diagnosing malignancy in hepatic tumors in children. In addition, these results were correlated with sonographic and computed tomographic findings of the liver in selected patients. Twenty-seven patients with primary liver tumors were examined with celiac or selective hepatic arteriography. Sonography was performed in 15 and computed tomography in 15 of the 27 patients. Angiographic criteria for malignancy or benignancy were established. These findings were correlated with computed tomographic and sonographic findings of the liver vascularity in selected patients. The final pathologic diagnosis was established surgically or by percutaneous biopsy. Sonography and computed tomography can be used as the initial procedure for evaluating tumor size, location and hepatic vascularity. However, the exact vascular anatomy demonstrated by angiography in children is more accurate and is often needed prior to surgical resection of primary liver tumors.

Effective cisplatin (DDP) based chemotherapy in the treatment of hepatoblastoma.

Nine of 11 patients with hepatoblastoma treated with cisplatin (DDP) based chemotherapy had a complete (CR) or partial (PR) remission. Five of these patients had measurable pulmonary disease and four achieved a CR of pulmonary lesions. The average interval of disease control following DDP was three times that of Adriamycin (ADR). DDP is an effective agent in the treatment of hepatoblastoma.

Limb salvage procedures for children with osteosarcoma: an alternative to amputation.

Amputation remains the standard surgical management for patients with osteosarcoma. However, in carefully selected patients, eradication of the primary tumor can be achieved by En-Bloc resection of the affected bone preserving both anatomical and functional status. Our criteria for limb salvage procedures are that patients must: (1) be age 12 years or older, (2) have no angiographic or clinical evidence of neurovascular involvement, (3) have low-grade osteosarcoma and/or good response to preoperative chemotherapy, and (4) be compliant. Between November 1980 and October 1982, 32 patients with osteosarcoma of an extremity were seen. Eight patients ranging in age from 13 to 21 years underwent limb salvage procedures. Five of these had Tikhoff-Linberg procedures for upper extremity lesions, two had En-Bloc resections for distal femur lesions, and one patient had a segmental arthrodesis for a distal tibial lesion. Of these eight patients, two had low-grade parosteal osteosarcoma. Follow-up ranged from 10 to 28 months (median 16 months). The two patients with parosteal osteosarcoma received no further therapy, while the other six patients received multiple agent chemotherapy. One patient died at 18 months with bilateral pulmonary disease. None have had local recurrences. Two of the eight patients had minor skin necrosis, requiring revision subsequently. Three patients have had transient nerve palsy. All have had good functional results. With careful selection of patients by rigid criteria, limb salvage procedures can be a viable alternative to amputation.

Transmedullary amputation and resection of metastases in combined therapy of osteosarcoma.

The eradication of microfoci of metastatic osteosarcoma by adjuvant chemotherapy permits the surgeon to take a more conservative approach to amputation and to more aggressively resect metastases. In a series of 59 children with osteosarcoma of an extremity, transmedullary amputation carried no greater risk of stump recurrence than either disarticulation or amputation above the joint. We attribute this to careful selection of the level of amputation by use of preoperative bone scans, intraoperative frozen sections of bone stump and intensive postoperative adjuvant chemotherapy. Immediate application of a prosthetic limb has enhanced the physical and emotional rehabilitation of these patients. Resections of pulmonary metastases in 12 patients who were receiving adjuvant chemotherapy has resulted in a median tumor-free survival of 17 mo, with 3 patients still alive without disease for 13, 25, and 72 mo. A more aggressive approach to the resection of pulmonary metastases may substantially improve current rates of tumor-free survival.

Silver nitrate irrigation to control bladder hemorrhage in children receiving cancer therapy.

Silver nitrate irrigations after cystoscopic evacuation of clots stopped intractable hemorrhage from the bladder in 8 of 9 children who had received cyclophosphamide and/or pelvic irradiation for various malignant diseases. This method of management produces fewer adverse side effects yet appears to be as effective as the more drastic measures of control, such as cystectomy or colocystoplasty.

Combined therapy to prevent complete pelvic exenteration for rhabdomyosarcoma of the vagina or uterus.

Three children with rhabdomyosarcoma (sarcoma botryoides) of the vagina or uterus were managed by modified radical resection combined with pre- and/or postoperative chemotherapy and high-dose irradiation. This plan of therapy contrasts sharply with the conventional approach: i.e., pelvic exenteration consisting of cystectomy, hystovaginectomy, and oophorectomy, with urinary diversion by ureteroileostomy or ureterosigmoidostomy. Two patients had complete regressions of tumor following preoperative chemotherapy and irradiation. The third patient received no preoperative therapy, but was given postoperative radium implantation, irradiation, and chemotherapy. The surgical approach consisted of hystovaginectomy and oophorectomy without urinary diversion. These patients are free of tumor for 32, 44, and 54 months, respectively. There were no serious toxic reactions to the drugs, nor any significant postoperative urinary tract problems. The results reported here suggest that hystovaginectomy and oophorectomy coordinated with chemotherapy and irradiation is an acceptable alternative to pelvic exenteration in patients with sarcoma botryoides of the vagina or uterus.

Preoperative therapy for unresectable malignant tumors in children.

Thirty-six children with initially unresectable malignant tumors were managed with pre- and postoperative therapy combined with reduction of primary tumor burden by total or subtotal resection. The proportion of patients achieving long-term tumor-free survival after surgery was 0.48 in the Wilms' tumor group and 0.60 among patients with other regionally unresectable malignant neoplasms. These results are encouraging in an otherwise high mortality situation.

Capsular and vascular invasion: important prognostic factors in Wilms' tumor.

The influence of capsular and vascular invasion on prognosis was determined retrospectively in 52 children with Wilms' tumor. Local recurrence was more prevalent (0.26) in patients with rupture or capsular invasion than in any other group. Inadequate postnephrectomy irradiation or infiltration of the liver by nephroblastoma cells appeared to be predisposing factors in the development of these reccurrences. Of the 26 patients with gross or microscopic vascular invasion, 13 developed metastasis. This proportion was significantly higher than in patients without vascular involvement (p less than 0.05). These observations emphasize the importance of microscopic detection of capsular and vascular invasion in staging of Wilm's tumor.