Long-term follow-up of tracheal cartilage growth promotion by intratracheal injection of basic fibroblast growth factor

Background

Intratracheal injection of basic fibroblast growth factor (b-FGF) has been shown to enlarge the tracheal lumen 4?weeks after treatment. The objective of this study was to investigate the long-term effect of tracheal cartilage growth promotion by intratracheal injection of b-FGF.

Insulin-like growth factor 2 and its enterocyte receptor are not required for adaptation in response to massive small bowel resection

Purpose

Enhanced structural features of resection-induced intestinal adaptation have been demonstrated following the administration of multiple different growth factors and peptides. Among these, the insulin-like growth factor (IGF) system has been considered to be significant. In this study, we employ mutant mouse strains to directly test the contribution of IGF2 and its enterocyte receptor (IGF1R) toward the adaptation response to massive small bowel resection (SBR).

Methods

IGF2-knockout (IGF2-KO) (n = 8) and intestine specific IGF1R-knockout mice (IGF1R-IKO) (n = 9) and their wild type (WT) littermates (n = 5, n = 7, respectively) underwent 50% proximal SBR. At post-operative day 7, structural adaptation was measured as crypt depth and villus height. Rates of enterocyte proliferation and apoptosis were also recorded.

Results

The successful deletion of IGF2 and IGF1R expression in the enterocytes was confirmed by RT-PCR and Western blot, respectively. Normal adaptation occurred in both IGF2-KO and IGF1R-IKO mice after 50% SBR. Post-operative rates of proliferation and apoptosis in both IGF2-KO and IGF1R-IKO mice were no different than their respective controls.

Conclusion

IGF2 and functional IGF1R signaling in enterocytes are both dispensable for resection-induced adaptation responses. The mechanism for IGF-stimulation of intestinal adaptation may involve other ligands or cellular compartments within the intestine.     

“Trap-door” and “clamshell” surgical approaches for the management of pediatric tumors of the cervicothoracic junction and mediastinum

Background/Purpose

For pediatric tumors of the cervicothoracic junction, an isolated cervical or thoracic surgical approach provides insufficient exposure for achieving complete resection. We retrospectively examined “trap-door” and “clamshell” pediatric thoracotomies as a surgical approach to these tumors.

Methods

We searched our database for pediatric patients with cervicothoracic tumors who underwent clamshell or trap-door thoracotomy between 1991 and 2013, reviewing tumor characteristics, surgical technique, completeness of resection, morbidity, and outcome.

Results

Trap-door (n = 13) and clamshell (n = 4) thoracotomies were performed for neuroblastoma (n = 9), non-rhabdomyosarcoma soft tissue sarcoma (n = 4), germ cell tumor (n = 2), rhabdomyosarcoma (n = 1), and neuroendocrine small cell carcinoma (n = 1). Fourteen of these cervicothoracic tumors were primary, and three were metastatic. Gross total resection was achieved in 15 patients (94%). Operative complications included vocal cord paralysis (n = 2), mild upper-extremity neuropraxia (n = 2), and hemidiaphragm paralysis (n = 1), All but one involved encased nerves. Overall survival was 61% for the series and 80% for patients with primary tumors. Eleven (73%) of 15 patients who underwent gross total resection had no evidence of recurrence. Three patients with metastatic disease died of distant progression within 1.3 years.

Conclusions

Gross total resection of primary cervicothoracic tumors can be accomplished with specialized exposure in pediatric patients with minimal morbidity.     

The most reliable early predictors of outcome in patients with biliary atresia after Kasai’s operation

Background/Purpose

The purpose of this study was to determine reliable predictors of outcome of biliary atresia (BA) after Kasai’s operation.

Patients and Methods

Fifty-four BA cases that underwent Kasai’s operation at our institution over two decades were reviewed. The cases were divided into two groups: Group I: cases that required liver transplantation or died (n = 30) and Group II: cases alive with the native liver. Serum levels of total bilirubin (TB), direct bilirubin (DB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyltransferase (GGT) were measured sequentially after surgery. For cut-off determination, receiver operating characteristic (ROC) analysis was employed.

Results

Serum TB, DB, AST, and ALT in Group I were significantly higher than those in Group II at 1, 2, and 3 months after surgery (p < .05). The most reliable cut-offs determined by ROC analysis were DB of 0.7 mg/dl at 2 months (sensitivity; 93%, specificity; 75%) and AST of 94 IU/L at 2 months (sensitivity; 87%, specificity; 71%). The 54 cases were re-divided into three groups according to the cut-off values: group G (good) with DB and AST < cut-offs (n = 16; Group I:II = 1:15), group M (moderate) with DB or AST > cut-offs (n = 9; Group I:II = 4:5), and group P (poor) with DB and AST ≥ cut-offs (n = 29; Group I:II = 25:4). The 15-year survival rate in groups G, M, and P was 94%, 44%, and 22%, respectively (p < .001).

Conclusion

The combination of serum DB and AST at 2 months after Kasai’s operation is a reliable predictor of long-term BA outcome.     

Is routine chest radiograph necessary after chest tube removal?

Background

Obtaining a chest radiograph (CXR) after chest tube (CT) removal to rule out a pneumothorax is a universal practice. However, the yield of this CXR has not been well documented. Additionally, most iatrogenic pneumothoraces resulting from CT removal are atmospheric in origin, asymptomatic, and can be observed. Recently, we have begun to discontinue routine CXR for CT removal. We evaluated our experience with CT removal to clarify the usefulness of routine post CT removal CXR.

Methods

After IRB approval, a retrospective study was conducted on patients who had a CT placed in the past decade. Cardiac patients requiring a CT were excluded. Patient demographics, diagnosis, treatments, and outcomes were collected. Patients were divided into two groups, those with a CXR after CT removal (Group 1) and those without (Group 2). Percentages were compared with Chi square with Yates correction.

Results

462 patients were identified (group 1 = 327, group 2 = 135). Indications for CT included; empyema (n = 176), lung resection (n = 146), pneumothorax (n = 71), pleural effusion (n = 26), spinal fusion (n = 20), trauma (n = 16), and miscellaneous (n = 7). Seven patients (2.1%) in group 1 required reinsertion for pneumothorax (n = 4), empyema (n = 2), and pleural effusion (n = 1) compared to 1 patient (0.7%) in group 2 who required reinsertion for pleural effusion. This difference was not significant (P = 0.2).

Conclusions

In non-cardiac patients with a CT, tube reinsertion is uncommon and tube replacement is secondary to symptoms. Therefore, routine post CT removal CXR is not necessary. CXR in these patients should be obtained based upon clinical indications after CT removal.     

Tissue specific somatic mutations and aganglionosis in Hirschsprung's disease

Background

RET proto-oncogene intron 1 variations [e.g. SNP1 (rs2506004) and SNP2 (rs 2435357)] have been shown to be etiologically important in the pathogenesis of Hirschsprung's disease (HSCR). Although activating somatic RET rearrangements have been identified in certain tumours, this is the first study to confirm somatic gene variation in HSCR.

Methods

DNA was extracted from 53 paraffin embedded tissue samples (HSCR patients n = 33, multiple levels n = 17), and controls (n = 3). Patients were grouped into aganglionic (Group 1), ganglionated (group 2), and transitional (group 3). PCR products of RET intron 1 were screened for genetic variation by semi-automated bi-directional sequencing analysis and matched to unaffected controls from the general population. Comparison was by Fishers exact test. P < 0.05 was regarded as significant.

Results

HSCR patients included short segment (n = 26), long segment colonic [(n = 4 (24%)], and total colonic aganglionosis (n = 3). RET intronic variations [SNP1 (rs2506004) or SNP2 (rs 2435357)] showed somatic homozygous in affected tissue in 9/12 (75%) Group 1 (aganglionic tissue) compared with 2/5 (40%) and 1/10 (10%) of groups 2 and 3 (P < 0.001). Homozygous SNP2 variation was observed in all long segment versus 4/10 short segment. 50% of the short segment cases showing homozygous SNP 1 variation.

Conclusion

We report somatic mutations in the RET intron 1 region of affected HSCR tissue, confirming for the first time that somatic mutations are present in aganglionic tissue and may promote local aganglionosis through deregulated receptor activity. Detailed understanding of the somatic genetic events that drive congenital aganglionosis may have bearing on diagnosis and therapy.     

A standardised investigative strategy prior to revisional oesophageal surgery in children: High incidence of unexpected findings

Background/Purpose

Revisional oesophageal reconstructive surgery carries uncommon and unusual risks related to previous surgery. To provide maximum anatomical detail and facilitate successful outcome, we report a standardised pre-operative investigative strategy for all such patients.

Methods

Prospective 8-month cohort study following the introduction of this strategy. All patients underwent high resolution thoracic contrast CT scan and micro-laryngo-bronchoscopy by a paediatric ENT surgeon in addition to upper gastrointestinal contrast study, oesophagoscopy, and echocardiogram.

Results

Seven children (median age 5.6 months [range 2.2–60]) completed the pathway. Four were referred with recurrence of a previously divided tracheo-oesophageal fistula (3 congenital, 1 acquired) and 3 (all with oesophagostomy) for oesophageal replacement for congenital isolated oesophageal atresia (OA, n = 1) and failed repair of OA with distal TOF with wide gap (n = 2). Overall, unanticipated findings were demonstrated in 6/7 children and comprised severe tracheomalacia and right main bronchus stenosis requiring aortopexy (n = 1), vocal cord palsy (n = 2), extensive mediastinal rotation (n = 1), proximal tracheal diverticulum (n = 1), severe subglottic stenosis requiring airway reconstruction (n = 1), proximal tracheal diverticulum (n = 1), right sided aortic arch (n = 1) and left sided aortic arch (previously reported to be right sided, n = 1).

Conclusions

This standardised approach for this complex group of patients reveals a high incidence of unexpected anatomical and functional anomalies with significant surgical and possible medico-legal implications. We recommend these investigations during the pre-operative work-up prior to all revisional oesophageal surgery.     

Comparação dos efeitos de remifentanil e remifentanil + lidocaína em intubação de pacientes intelectualmente deficientes

Background and objectives

This is a prospective, randomized, single‐blind study. We aimed to compare the tracheal intubation conditions and hemodynamic responses either remifentanil or a combination of remifentanil and lidocaine with sevoflurane induction in the absence of neuromuscular blocking agents.

Methods

Fifty intellectually disabled, American Society of Anesthesiologists I–II patients who underwent tooth extraction under outpatient general anesthesia were included in this study. Patients were randomized to receive either 2 μg/kg remifentanil (Group 1, n = 25) or a combination of 2 μg/kg remifentanil and 1 mg/kg lidocaine (Group 2, n = 25). To evaluate intubation conditions, Helbo‐Hansen scoring system was used. In patients who scored 2 points or less in all scorings, intubation conditions were considered acceptable, however if any of the scores was greater than 2, intubation conditions were regarded unacceptable. Mean arterial pressure, heart rate and peripheral oxygen saturation (SpO₂) were recorded at baseline, after opioid administration, before intubation, and at 1, 3, and 5 min after intubation.

Results

Acceptable intubation parameters were achieved in 24 patients in Group 1 (96%) and in 23 patients in Group 2 (92%). In intra‐group comparisons, the heart rate and mean arterial pressure values at all‐time points in both groups showed a significant decrease compared to baseline values (p = 0.000)

Conclusion

By the addition of 2 μg/kg remifentanil during sevoflurane induction, successful tracheal intubation can be accomplished without using muscle relaxants in intellectually disabled patients who undergo outpatient dental extraction. Also worth noting, the addition of 1 mg/kg lidocaine to 2 μg/kg remifentanil does not provide any additional improvement in the intubation parameters.     

Antiangiogenic effect of propranolol on the growth of the neuroblastoma xenografts in nude mice

Background

Propranolol has been reported to display an antiangiogenic effect on infantile hemangiomas and also some adult cancers. Little is known, however, about whether propranolol has such effect on pediatric malignancies.

Methods

Nude mice bearing BE(2) C neuroblastoma xenografts were injected intraperitoneally with propranolol and divided into groups of PROP-2 (n = 11), -5 (n = 11), and -10 (n = 10) according to the treating dosages of 2, 5, and 10 mg kg^− 1 day^− 1, respectively. The tumor volume and body weight were recorded every other day. All mice were sacrificed on day 9, and the levels of angiogenic factors were measured in harvested xenografts by immunohistochemistry and western blotting.

Results

The tumor volume and weight of PROP-2 (0.72 ± 0.28 cm³, 0.59 ± 0.21 g) and PROP-5 (0.81 ± 0.35 cm³, 0.61 ± 0.25 g) were significantly decreased when compared with those of CTL (1.22 ± 0.58 cm³, 0.93 ± 0.15 g; P < 0.01). The tumor microvessel density (MVD) scores that PROP-2, -5, and -10 groups had (49.28 ± 17.53, 52.45 ± 17.11, and 51.09 ± 13.18 pixels per picture, respectively) were lower than those from the control group (65.29 ± 17.33 pixels per picture, P < 0.01). Furthermore, vascular endothelial growth factor (VEGF), metalloproteinase-2 (MMP-2), and metalloproteinase-9 (MMP-9) levels were significantly lower in the groups with propranolol treated dosage of 5 and 10 mg kg^− 1 day^− 1 than in the control group.

Conclusions

Propranolol can exhibit an inhibitory effect on the tumor growth and angiogenic factors expression in neuroblastoma xenografts, which may provide some knowledge to the role of β-blockers in the management of NB.     

Open versus needle biopsy in diagnosing neuroblastoma

Background

Open surgical biopsy is traditionally advocated prior to initiating therapy in UKCCLG neuroblastoma protocols. We report a single centre experience comparing the utility of open biopsy vs image guided needle biopsy in aiding the definitive diagnosis and risk stratification of neuroblastoma – (Shimada classification, MYCN expression, cytogenetics – 1p 11q, 17 q).

Methods

Medical records of all new cases of neuroblastoma presenting to a single UKCCLG centre during January 2002–July 2013 were examined.

Results

Thirty nine patients underwent a biopsy of primary tumour for neuroblastoma during the study. Twenty one children had open biopsy and eighteen cases had a needle biopsy. Staging of neuroblastoma revealed - stage 4 (n = 26), stage 3 (n = 7), stage 2 (n = 3) and stage 4S (n = 3). Sites of primary tumour were adrenal gland (n = 20), abdomen (n = 12), thoracic (n = 4), abdomino-thoracic (n = 2) and abdomino pelvic regions (n = 1). All patients (open vs needle) had adequate tissue retrieved for histological diagnosis of neuroblastoma. One needle and one open biopsy case did not have MYCN status determined despite adequate tissue sampling. Seventeen patients (7 open and 10 needle biopsies) had 1p and 17q status reported in MLPA testing (Multiplex Ligation-dependent Probe Amplification). No single patient required a repeat tumour biopsy. Morbidity in the series was minimal with only one child – open biopsy group, requiring emergent laparotomy to control bleeding from an abdominal primary tumour. No complications were recorded with needle biopsy.

Conclusions

Open and image guided needle biopsy appear to yield adequate tissue sampling for diagnosis, risk classification and staging of neuroblastoma. Further larger co-operative studies may usefully guide national and international protocols.     

Botulinum toxin injections in the management of non-neurogenic overactive bladders in children

Introduction

Non-neurogenic detrusor overactivity in children leads to varying degrees of functional impairments (urinary urgency, pollakiuria, urge incontinence, nocturia). Botulinum toxin has shown its effectiveness in the management of detrusor overactivity in neurological patients.

Objectives

To evaluate the relevance of intravesical Botulinum toxin injections for the treatment of non-neurogenic overactive bladders in children. These pediatric patients were resistant to all the usual therapeutics (e.g. bladder/bowel rehabilitation, anticholinergic drugs, management of diet/hygiene habits and constipation, percutaneous posterior tibial nerve stimulation).

Materials and methods

8 children (mean age: 12.5 years), 5 girls, 3 boys with daytime and/or nighttime incontinence and non-neurogenic detrusor overactivity validated by urodynamic testing. Urodynamic testing was conducted before the injections as well as 6 weeks and 1 year post injections. We used Dysport® 8 Speywood Units/kg injected via cystoscopy into 25 different sites.

Results

We noted improvements without any complaints during bladder voiding for all patients, in 6 patients the overactivity disappeared after 1 injection. Compliance was improved early-on in half the cases and at 1 year for all cases (from 12% to 61%, p = 0.01). Noninhibited contractions decreased constantly in both frequency and intensity. Clinical symptoms improved: mean of 7.75 daytime urinary incontinence episodes (IE) per week before the injection vs. 3 after the procedure (p = 0.04). For nighttime IE the improvement was even more noticeable with 7.38 nighttime IE episodes per week before the injection vs. 2.06 after the procedure (p = 0,02).

Conclusion

Intradetrusor Botulinum toxin injections are a potential therapeutic option for the management of non-neurogenic detrusor overactivity in children resistant to the usual treatments.     

Urologic and anorectal complications of sacrococcygeal teratomas: Prenatal and postnatal predictors

Purpose

Anorectal and urologic sequelae are observed in long-term survivors of sacrococcygeal teratoma (SCT). In this study we evaluate the incidence and predictors of anorectal and urologic complications in SCT.

Methods

A retrospective review was performed for all SCT patients who underwent resection at a single institution between 2000 and 2012. Enrollment criteria included a minimum of 12 months follow-up. Categorical variables were analyzed by Fisher’s exact test and continuous variables by Mann Whitney test (p < 0.05).

Results

Forty-five patients were studied. Anorectal complications occurred in 29%, including severe chronic constipation (n = 13) and fecal incontinence (n = 4). Urologic complications occurred in 33%, including neurogenic bladder (n = 12), vesicoureteral reflux (n = 5), and urinary incontinence (n = 7). Prenatal imaging by fetal MRI demonstrated mass effect with obstruction of the bowel (n = 4) or bladder and collecting system (n = 7) in a subset of patients with postnatal complications (anorectal 4/4, PPV 100%; urologic 6/7, PPV 86%). Postnatal complications were associated with obstructive findings on prenatal imaging, prenatal therapeutic interventions, Altman classification, perineal reconstruction, and tumor recurrence. No anorectal or urologic complications occurred in patients with Altman type I tumors.

Conclusions

Urologic and anorectal complications are common in patients with SCT. Higher Altman classification and prenatal imaging suggestive of intestinal or urologic obstruction should prompt focused prenatal counseling and postnatal screening for anorectal and urologic dysfunction.     

Modernized standards in burns management: A comparative study in Komfo Anokye Teaching Hospital,Kumasi, Ghana

Background

Management of burns patients before May 2009 was very difficult at the Komfo Anokye Teaching Hospital (KATH).

Aim

To compile burns patients’ information in the new Burns Intensive Care Unit (BICU), analyze it and draw comparisons to information from the old BICU at KATH.

Methods

This retrospective study involves data from May 2007 to April 2009 (Group 1 – old BICU) and May 2009 to April 2011 (Group 2 – new BICU). The parameters of burn patients recorded included: record of admission, gender, age, aetiology of injury, Total Burns Surface Area (TBSA), the patients’ treatment regime and record of discharge/death. This information was analyzed with SPSS version 18.0.

Results

The total number of patients in the study was 511; Group 1 constituted 47.36% (n = 242) patients; males (n = 307, 61%) outnumbering females (n = 204, 39%). The overall mean, median and interquartile range (IQR) ages of the patients were 12.4 ± 2; 9.5 and 18.0 years respectively. The main aetiology of burns in Group 1 was flame burns (n = 115, 47.5%) and for Group 2 was scald (n = 151, 56.1%). The median TBSA recorded for Groups 1 and 2 were 32% and 41% respectively. A mortality rate of 19.1% (n = 46) and 12.7% (n = 34) were recorded for Groups 1 and 2 respectively which was statistically significant (p < 0.05). We found no differences for age and TBSA (P = 0.7168 and P = 0.8020 respectively). A Chi Square analysis for gender and aetiology of burn revealed no significant difference between Groups 1 and 2. A risk factor analysis for mortality within the Groups (using multiple regression analysis) identified only aetiology of burn in Group 1 to be a factor (P = 0.044).

Conclusion

This comparative study reveals that a significant difference in mortality was recorded for both groups. The mortality difference does not appear to be due to socio-demographic features. This study may demonstrate that modernized and advanced equipment with the adequate personnel play an essential role in burn management in low income countries such as Ghana.     

Undescended testes: Does age at orchiopexy affect survival of the testis?

Purpose

The optimal age at which to perform orchiopexy for cryptorchidism has long been debated. The aim of this study was to determine if age at orchiopexy affected testicular atrophy.

Methods

A retrospective review of patients undergoing orchiopexy from 2000 to 2010 was conducted. An individual testis, rather than patient, was used as the dependent variable. A total of 349 testicles from 1126 charts (ICD-9 = 752.51) were identified. Primary study outcome was testicular survival without atrophy.

Results

Mean follow up for the study was 25 months. There was postoperative atrophy in 27 testes (7.7%). Intraabdominal testicle was independently associated with increased postsurgical atrophy (p < 0.0001). The odds of postsurgical atrophy were 15.66 times higher for an abdominal vs. inguinal location (95% CI: 5.5–44.6). Testicular atrophy was highest for orchiopexy at ages 13–24 months (n = 16 of 133, 12%) vs. those less than 13 months (n = 3 of 64, 5%), and those greater than 24 months (n = 8 of 152, 5%) (p = 0.0024). After adjusting for location, age was not statistically significant with postsurgical atrophy (p = 0.055).

Conclusions

From this study we conclude that there is no increase in testicular atrophy in patients less than 13 months.     

Surgical and anesthetic considerations in histrelin capsule implantation for the treatment of precocious puberty

Background

Precocious puberty treatment traditionally meant anxiety-provoking monthly depot injections until the advent of the annually implanted histrelin capsule. This study is the first to evaluate the surgical and anesthetic aspects of histrelin implantation for precocious puberty.

Methods

All cases from one surgeon at a tertiary pediatric hospital were reviewed for patient age, anesthetic type, technical difficulties, and complications.

Results

From 12/2007 to 3/2013, 114 cases (49% implantations, 25% removals/re-implantations, 25% removals) were performed. Local anesthesia was employed in 100% of non-general anesthesia cases (n = 109, 96%), augmented by inhaled N₂O in 49%. Five patients (4%) underwent general anesthesia: three neurologically-impaired and two coordinated with scheduled MRIs. Procedural difficulties (n = 18, 16%) included implant fracture during removal (n = 16/58 removals, 28%). Fracture never occurred during implantation. Three children (3%) suffered complications. One infection was treated with antibiotics, and two implants were removed for systemic allergic reaction. Six children (5%) had unscheduled post-operative checks for pain (n = 3, 3%), allergy to elastic dressing (n = 2, 2%), or rash (n = 1, 1%). Mean charges for general anesthesia were $10,188 ± 1292 versus $528 ± 147 for N₂O or local alone (p < 0.0001).

Conclusion

While histrelin implantation is straightforward, removal presents technical challenges. Local anesthesia, with possible N₂O supplementation, is well-tolerated and introduces substantial resource and cost savings.     

Primary malignant pancreatic neoplasms in children and adolescents: A 20 year experience

Background

Malignant pancreatic neoplasms in children and adolescents are rare. The clinical presentation, pathologic characteristics, management, and outcomes at two institutions are discussed.

Methods

We retrospectively reviewed all pediatric patients (age < = 18 years) treated for malignant pancreatic neoplasms at two institutions between 1991 and 2011.

Results

Thirty-one patients were identified with median age of 14.7 years (4–18 years). The most common histology was solid pseudopapillary tumor (SPT) (n = 22, 71%) followed by neuroendocrine tumors (n = 4, 13%), pancreatoblastoma (n = 4, 13%), and one unclassified spindle cell neoplasm (3%). Most patients presented with abdominal pain (n = 22, 71%). Complications included pancreatic leak, pseudocyst formation, pancreatitis, pancreatic insufficiency, and small bowel obstruction. The overall 1- and 5-year survival was 96% (95% CI 74%–99%) and 78% (95% CI 43%–93%). Median follow-up among patients alive at the end of follow-up was 20 months (< 1 month–16.2 years). Patients with SPT had better overall survival compared to patients with neuroendocrine tumors or pancreatoblastomas (Log-rank; p = 0.0143).

Conclusion

The majority of pediatric and adolescent patients present with SPTs which are usually resectable and associated with an excellent prognosis. Other histologic subtypes more often present with distant metastases and portend a worse prognosis.     

Incidence and outcomes of unexpected pathology findings after appendectomy

Purpose

Pathologic evaluation of the appendix after appendectomy is routine and can identify unexpected findings. We evaluated our experience in children undergoing appendectomy to review the clinical course of patients with unexpected appendiceal pathology.

Methods

After IRB approval, a retrospective review was conducted on patients who underwent appendectomy from January 1, 1995 to March 1, 2011. Patient demographics, diagnosis, pathological findings, disease outcomes, and treatment were collected only on patients with abnormal pathology.

Results

3602 patients underwent appendectomy. 113 patients had normal appendices, and 86 patients had unexpected findings, including carcinoid tumor (n = 9), pinworm (n = 34), granuloma (n = 14), eosinophilic infiltrates (n = 18), and other (n = 11). All cases of carcinoid tumor were completely resected, with no recurrence or need for reoperation. Of the 34 patients with pinworm infestation, 41.2% underwent antimicrobial therapy, and none had post-operative symptoms. One patient (7%) with an appendiceal granuloma developed Crohn’s disease. Three patients (16.7%) with eosinophilia developed symptomatic intestinal eosinophilia.

Conclusions

Pediatric appendiceal carcinoid is an incidental finding; in this series, none required further intervention. Appendiceal granulomas are not commonly associated with developing Crohn’s disease in the short term. Routine antibiotics for the treatment of pinworms are adequate. Patients with appendiceal eosinophilia may develop symptomatic intestinal eosinophilia.     

A comparison of laparoscopic and open restorative proctocolectomy in children

Aim

Restorative proctocolectomy (RP) is the gold standard for children requiring removal of their colon and rectum. The aim of this study is to contrast conventional (open) and laparoscopic RP.

Methods

All children undergoing RP by one surgeon were prospectively recorded in a customised database. Outcome variables were length of stay in days (LOS), duration of surgery in minutes (DS), blood loss in ml, and complications. Explanatory variables included technique of resection (open or laparoscopic (lap)) and presenting disease. Lap resection was adopted after patient 37. Data are presented as median (range). P < 0.05 was regarded as significant.

Results

Eighty-two (43 girls) children underwent RP at median age 12 (0.5–20) years. RP was performed as Open (n = 37) or Laparoscopic (n = 45). Indications were: colitis (n = 56), polyposis (n = 12), constipation (n = 7), Hirschsprung’s (n = 5), fibrosing colonopathy (n = 2). Significantly, more children had three-stage surgery among the lap group (P = 0.04). LOS was significantly shorter in the lap group [15 (8-114) days vs 17(13– 60) days; P = 0.04], but there was no difference in DS or complication rates between laparoscopic and open surgery. Laparoscopic surgery was associated with significantly lower blood loss [150 (0–840) ml vs. 334 (0-1480) ml; P = 0.02].

Conclusion

Laparoscopic RP is associated with lower blood loss, shorter LOS, but no difference in duration of surgery or complication rate.     

Full thickness abdominal wall defect in growing rats as a model for congenital diaphragmatic hernia prosthetic repair

Background

Large congenital diaphragmatic hernia may require prosthetic correction. Acellular collagen matrices were introduced to avoid complications owing to the use of synthetic patches. We tested 3 different ACM for reconstruction of an abdominal wall defect in an animal model that mimics the fast growth during infancy.

Methods

Pelvisoft® (CR Bard, Covington, GA) and 2 investigational ACM were used for primary reconstruction of a full thickness abdominal wall defect. 3 months-old rats (n = 26) were allowed to survive for 90 days after implantation. Anatomical, tensiometric and histological analyses were performed. Based on good outcomes, we did the same with 1 month-old rats (n = 54). Unoperated rats were used for obtaining reference tensiometric values of selected native tissues.

Results

Major wound complications were exclusively observed in 1 month-old rats. All explants in both groups thinned significantly (p < 0.03) and had an elastic modulus increasing over time, far above that from native tissues at 90 days of life. Both investigational ACM induced a more vigorous foreign body reaction than Pelvisoft^®.

Conclusions

The shift from 3 to 1 month-old rats was associated with wound complications. Pelvisoft® showed a better biocompatibility than the 2 investigational ACM. Passive biomechanical properties of all explants were still not comparable to that of native tissues.     

Esophageal button battery ingestions: Decreasing time to operative intervention by level I trauma activation

Purpose

The incidence of button battery ingestions is increasing and injury due to esophageal impaction begins within minutes of exposure. We changed our management algorithm for suspected button battery ingestions with intent to reduce time to evaluation and operative removal.

Methods

A retrospective study was performed to identify and evaluate time to treatment and outcome for all esophageal button battery ingestions presenting to a major children’s hospital emergency room from February 1, 2010 through February 1, 2012. During the first year, standard emergency room triage (ST) was used. During the second year, the triage protocol was changed and Trauma I triage (TT) was used.

Results

24 children had suspected button battery ingestions with 11 having esophageal impaction. One esophageal impaction was due to 2 stacked coins. Time from arrival in emergency room to battery removal was 183 minutes in ST group (n = 4) and 33 minutes in TT group (n = 7) (p = 0.04). One patient in ST developed a tracheoesophageal fistula. There were no complications in the TT group.

Conclusions

The use of Trauma 1 activations for suspected button battery ingestions has led to more expedient evaluation and shortened time to removal of impacted esophageal batteries.