Recurrent Shoulder Tip Pain After Ventriculoperitoneal Shunt Placement Associated with Infectious Peritonitis with Propionibacterium acnes; A Case Report and Review of the Literature.

Ventriculoperitoneal (VP) shunt placement is commonly performed for the treatment of hydrocephalus, and several complications of this procedure are well known. Radiating shoulder tip pain after VP shunt placement has been reported as an unusual complication in a few cases, associated with dislocation of the peritoneal catheter. We described the case of a 9-year-old girl who presented with recurrent radiating shoulder tip pain after VP shunt placement. The pain recurred after peritoneal catheter repositioning because of peritoneal inflammation and adhesion due to peritonitis with Propionibacterium acnes (P. acnes). This bacterium was isolated using 16S ribosomal RNA gene polymerase chain reaction (16S rRNA gene PCR), and anaerobic and prolonged culture tests. After antibacterial treatment, ventriculoarterial (VA) shunt placement was successfully performed. Hemidiaphragm irritation by the peritoneal catheter leads to radiating shoulder tip pain, and peritoneal inflammation and adhesion caused by infectious peritonitis may cause recurrence of this despite catheter repositioning. Clinicians should be aware of shoulder pain as a complication of VP shunt placement, and should consider VA shunt placement as an alternative treatment if this symptom recurs after catheter repositioning. Furthermore, 16S rRNA gene PCR and anaerobic and prolonged culture tests should be considered to detect P. acnes infection.

Jejuno-jejunal intussusception caused by a percutaneous endoscopic gastrojejunostomy tube in a pediatric patient: A case report.

RATIONALE: Although percutaneous endoscopic gastrojejunostomy (PEG-J) tubes are believed to reduce the side effect of aspiration, cautious catheter management is required. Intussusception is a serious complication of these tubes. PATIENT CONCERNS: A 7-year-old boy bedridden with hypoxic encephalopathy owing to drowning at the age of 1 year was admitted our hospital with urinary retention for 1 month. At the age of 4 years, a PEG-J tube was inserted. Concomitant with hyperaldosteronemia, an intestinal intussusception from the duodenum to the jejunum was observed via computed tomography (CT). The patient's condition worsened dramatically; gastrointestinal perforation was suspected, and laparotomy was performed. DIAGNOSIS: Jejuno-jejunal intussusception. INTERVENTIONS: Open surgery was performed to release the intussusception. By assessing the reduced intestinal tract, the intussusception starting from a 50 cm portion from the Treitz ligament had been extended to 100 cm from the Treitz ligament. The oral side jejunum was dilated. No evidence of intestinal perforation or strangulated ileus was observed, and the intussusception was manually remediable. OUTCOMES: Preoperative CT examination showed intussusception from the duodenum to the jejunum. Laparotomy showed intussusception on the anal side of the Treitz ligament. With regard to the CT findings associated with the progression of intussusception to the duodenal site, as a result of the telescope phenomenon extending to the duodenum due to the relaxation of the Treitz ligament through repeated intussusception, it was considered that CT examination revealed intussusception extending from the jejunum to the duodenum of oral side. After 3 postoperative weeks, the patient was finally able to return home. LESSONS: If the ileus is observed during the insertion of a PEG-J, clinicians should consider the possibility of intussusception even in the duodenum.

Neonatal appendicitis mimicking intestinal duplication: a case report.

INTRODUCTION: Acute appendicitis is a common disease in older children but rare in neonates. CASE PRESENTATION: We report the case of a 2-day-old Asian baby who suffered from neonatal appendicitis mimicking intestinal duplication. Laparoscopic appendectomy was successfully performed after the trans-umbilical division of adhesions, and the postoperative course was uneventful. CONCLUSION: There are few reports describing abdominal masses caused by appendicitis mimicking intestinal duplication. The laparoscopic approach for neonatal appendicitis is considered to be a safe and useful therapeutic modality with good cosmetic results.

Double lumbosacral lipomas of the dorsal and filar types associated with OEIS complex: case report.

A female baby was born at 37 weeks and 6 days gestation by vaginal delivery with omphalocele, exstrophy of the cloaca, and imperforate anus, indicating the presence of OEIS complex, a rare combination of defects consisting of omphalocele (O), exstrophy of the cloaca (E), imperforate anus (I), and spinal deformity (S), associated with lumbosacral lipoma. The most common associated spinal deformity is terminal myelocystocele, and spinal lipoma is rare. Constructive interference in steady-state magnetic resonance imaging clearly revealed double lipomas, a dorsal-type lipoma, located dorsal to the low-lying conus medullaris, and a filar-type lipoma, revealed by a thickened and fatty filum terminale. After recovery from abdominogenital repairs, debulking of the dorsal-type lipoma and untethering of the spinal cord by sectioning of the filar-type lipoma were performed at the age of 14 months. Neurosurgical treatment for occult spinal dysraphism should be undertaken after recovery from the initial series of major abdominogenital procedures.

Does small intestinal atresia affect epithelial protein expression in human newborns?

OBJECTIVES: Bowel segments distal to a congenital intestinal obstruction have been suggested to be immature. In other words, luminal components such as amniotic fluid (before birth) and/or enteral nutrition (after birth) may be required to activate intestinal epithelial protein expression, thereby influencing epithelial differentiation. We investigated cell-type-specific protein expression proximal and distal to jejunal and ileal atresias in human newborns. PATIENTS AND METHODS: We immunohistochemically studied intestinal tissue specimens of 16 newborns who had undergone surgery for jejunal or ileal atresia. Sections were taken from both the proximal and distal sides of the atresias. RESULTS: For all patients, the enterocyte-specific markers lactase, sucrase-isomaltase, sodium glucose cotransporter 1, glucose transporters 2 and 5, intestinal fatty acid-binding protein and alkaline phosphatase were expressed at a mean 3 +/- 1 days after birth, both proximal and distal to jejunal and ileal atresias. Expression of goblet cell-specific markers mucin 2 and trefoil factor 3 and that of the Paneth cell marker lysozyme was maintained at either side of the atretic segment. CONCLUSIONS: With respect to the markers used, the human small intestinal epithelium is already differentiated shortly after birth. The absence of intestinal continuity in case of a jejunal or ileal atresia does not affect epithelial protein expression. This would seem to indicate that the developing small intestinal epithelium matures independently of luminal components.

Safe techniques for inserting the hickman catheter in pediatric patients.

The placement of the Hickman catheter in the central veins is thought to be an effective method for providing venous access in various clinical situations in children. The catheter is usually inserted by the percutaneous approach, but in some cases various troublesome complications can occur, such as sheath introducer kinking or damage, in addition to other major ones. Therefore, some modified techniques, using vascular dilators, both to dilate the route and to avoid such complications, have been developed and investigated to obtain a smooth and safe percutaneous insertion of the Hickman catheter in children. A total of 41 Hickman catheters were inserted by the percutaneous method in 41 pediatric patients from 1996 to 2004 in our department. Sixteen catheters were inserted by means of a standard method, using the manufacturer's insertion kit, and 25 catheters were inserted by means of a modified method, namely, using various sized vascular dilators. The length of time for the procedure, the complication rate, and the changes in the serum C-reactive reaction (CRP) levels were then compared between the standard and the modified methods. Those parameters were also compared between a right-side and left-side approach using both methods, to clarify which side was better for the insertion of this catheter. The length of time for the catheter replacement procedure in the standard group was significantly longer than that in modified one. The occurrence rate for both the kinking and small damage to the sheath introducer in the standard group was higher than that in the modified one. The peak of serum CRP in the modified group was significantly lower than that in the standard one. When comparing a right-side and left-side approach, 7 catheters out of 16 were inserted by the right-side approach in the standard group, while 10 catheters out of 25 were done by the right-side approach in the modified group. The length of time for the procedure for the left-side approach was significantly shorter than that for the right-side one in both groups. No difference in technical complications was observed between the two different approaches in the modified group, while complications when using the right-side approach often occurred in the standard group. The peak of serum CRP in the left-side approach was lower than that in the right-side one in both groups. The use of the modified percutaneous method, using various sized vascular dilators and the left-side approach, was therefore found to be useful for the safe and smooth placement of the Hickman catheter in children.

Decrease in hepatic circulation induces hepatic fibrosis in a neonatal piglet model with short bowel syndrome.

BACKGROUND: Regarding the complications associated with short bowel syndrome (SBS), progressive liver failure is one of the most severe complications known to occur: Although several studies have suggested that many factors interactively influence this clinical condition we investigated the relationship between hepatic circulation and hepatic fibrosis using a neonatal piglet SBS model. MATERIALS AND METHODS: This study used the following 4 groups of neonatal piglets: a group with an 80% resection of the small bowel (SBS group), a group with a bypass operation of the small bowel (functional SBS group), a group with only a laparotomy as a sham operation (sham group), and a no operative treatment group (control group). We measured the hepatic circulation just before and after the reconstruction of the intestine, as well as on the 7th and 14th postoperative day. In addition, both blood and hepatic tissue samples were collected to investigate them both biochemically and morphologically. RESULTS: Regarding the biochemical liver function and the tissue blood flow of liver, there were no significant differences among all groups on any investigated days. However, on both the 7th and 14th postoperative days, the portal venous flow in the SBS group was significantly lower than that in other groups. According to a histological analysis, only hepatic samples on the 14th postoperative day showed mild hepatic fibrosis in the SBS group. Regarding the alpha-smooth muscle actin staining findings that expresses active stellate cells, numerous positive cells were found to be distributed in the perisinusoidal space on the 14th postoperative day in the SBS group. CONCLUSION: Based on our data, a decrease in the hepatic circulation, especially in the portal venous flow, after a massive resection of the intestine may cause progressive liver dysfunction because of the activation of hepatic stellate cells.

The efficacy of autologous cord-blood transfusions in neonatal surgical patients.

PURPOSE: Allogenic blood transfusions have a risk of infection owing to unknown organisms, graft-versus-host reaction, and immunosupression; however, the use of autologous blood has been reported to be safe. Cord blood has been reported to be useful as a source of stem cell transplantation for the treatment of leukemia and genetic disease. Furthermore, autologous cord-blood transfusions (ACBT) have been reported to be effective for the treatment of anemia in premature infants. The authors examined the efficacy of ACBT in neonatal surgical patients. METHODS: Autologous cord-blood was stored from 12 infants at delivery, including 2 transvaginal and 10 cesarean section deliveries, from 1998 to 2001. All infants had surgically correctable malformations diagnosed antenatally. The mean gestational age was 37.2 +/- 1.6 weeks, and the birth weight was 2,597 +/- 1.6 g. The results of the blood count, serum electrolyte, and liver function tests of the patients who underwent ACBT only (group 1, n = 7) were compared with those of the 7 neonates who underwent an allogenic transfusion during the same period (group 2, n = 7). RESULTS: The mean volume of the stored blood was 64 +/- 35.6 g (range, 20 to 100). Eleven of the 12 patients underwent transfusions. Ten of 11 patients received autologous cord blood. A mean of 44.1 +/- 37.3 g of cord blood was used. Three of 10 cases also required an allotransfusion because of ECMO circuit preparation and a shortage of the stored blood. One patient underwent allotransfusion only. As a result, 7 of 11 babies (64%) who required transfusion were able to avoid an allotransfusion. The blood potassium levels were lower in group 1 than in group 2. No significant complications were recognized clinically. CONCLUSIONS: ACBT is considered beneficial because it enables neonatal surgical patients to avoid allotransfusions. Therefore, autologous cord-blood storage should be considered in the patients antenatally diagnosed to have surgical malformations. However, the storage volume varies for each case. Improved techniques to obtain an adequate amount of blood also should be developed.

Cortisol and cytokine responses after surgery in different age groups of pediatric patients.

We investigated the cortisol and cytokine responses to surgical stress in the different age groups of pediatric patients. This study included 19 neonates (0-6 days old, group I), 19 infants (1-11 months old, group II), and 20 pre-school children (1-5 years old, group III), undergoing major thoracic and abdominal surgery. We obtained blood samples preoperatively and 0, 3, 6, 12, and 24 h postoperatively to measure the plasma levels of C-reactive protein (CRP), cortisol, interleukin (IL)-6, and IL-10. The plasma CRP level in each group reached a peak value on postoperative day 2; however, the peak value was significantly lower in group I than in groups II or III (I vs II, III; p=0.0134, p=0.0017, respectively). The plasma cortisol level in each group reached a peak value just after surgery; however, the peak value was also significantly lower in group I than in groups II or III (I vs II, III; p<0.001, p=0.0104, respectively). The plasma IL-6 level in each group reached a peak level hours postoperatively; however, the peak values in groups I and II were higher than in group III (I, II vs III; p=0.003, p=0.0458, respectively). The plasma IL-10 level in each group reached a peak value just after surgery and did not differ among the three groups. The endocrine and cytokine responses to the surgical stress vary among the different age groups of pediatric patients.

Roles of nucleosides and nucleotide mixture in small bowel transplantation.

OBJECTIVES: We investigated the effect of nucleosides (NSs) and nucleotides (NTs) on the intestine and intestinal graft in a model of syngenic small bowel transplantation, with the fetal rat intestine as a graft. METHODS: Two-centimeter jejunal segments from Lewis rats at 19 d of gestation were transplanted into the abdominal walls of 5-wk-old Lewis rats by using a non-vascular anastomotic technique. After transplantation, the rats were assigned to one of two groups: group 1 did not receive NS or NT and group 2 was supplemented with NS and NT. The grafts and graft recipients were examined morphologically 14 d after transplantation according to conventional histologic and immunohistochemical studies of neurons and smooth muscles. RESULTS: Group 1 gained little body weight, even though both groups received similar amounts of food. The grafts in group 1 showed poor development in length, diameter, and wet weight. They also showed poor villi development, abnormalities in nerve distribution, and degeneration of muscle layer structure on histologic and immunohistochemical studies. CONCLUSIONS: We found that NS and NT are essential nutrients for intestinal growth and maintenance of structures in fetal small bowel transplantation.

Changing profile of parenteral nutrition in pediatric surgery: a 30-year experience at one institute.

BACKGROUND: Due to technical refinements and steady advances in the development of highly sophisticated nutrient solutions consisting of optimal combinations of macronutrients and micronutrients, parenteral nutrition (PN) is now playing an important role in patient management. However, some PN-associated complications, such as catheter-related sepsis (CRS) and cholestasis, continue at high incidence, particularly in neonates. The objective of this study was to investigate the changing profiles of PN over the past 30 years in our department. METHODS: The medical records of 893 children (225 neonates, 245 infants, 261 preschool-age children, and 162 school-age children) who were placed on PN for >7 days in our department were reviewed, and the following data were extracted: birth weight, underlying disease, indications for PN, PN delivery route, type of catheter used, duration of PN, substrate and energy intake, type of amino acid solution used, and incidence of complications including CRS and liver dysfunction. The results were analyzed by dividing the patients into 3 groups according to their basic stages in management of PN and consisted of group 1 (1970 to 1979), group 2 (1980 to 1989), and group 3 (1990 to 1999). The parameters were compared in each group. RESULTS: The total number of patients in each group showed no significant difference; however, the percentage of low birth-weight neonates increased in group 3. In group 1, 85% of PN was administered through the peripheral vein; in group 2, 51.2%; and in group 3, 9.7%. The total calorie and nutrient intake decreased in groups 2 and 3 compared with group 1, particularly regarding fat intake. In groups 1 and 2, commercially available amino acid solution based on the Food and Agriculture Organization/World Health Organization formula was usually used as the nitrogen source, but in group 3, it was changed to an amino acid solution for children. CRS decreased significantly, particularly in neonates, and occurred at a rate of 45.4% in group 1, 10.7% in group 2, and 1.5% in group 3. The incidence of liver dysfunction also showed a decrease: 35.7% in group 1, 22.3% in group 2, and 18.0% in group 3. A multivariate analysis showed a strong relationship between PN-related liver dysfunction and the duration of PN, the presence of infection, and the type of amino acid solution used. CONCLUSIONS: PN via central venous catheters has been regarded as safe and effective treatment in pediatric surgical patients. Over the past 30 years, the incidence of CRS has decreased. However, PN-related liver dysfunction remains a problem, particularly in patients receiving long-term PN.