Meckel's diverticulum in children: a 20-year review.

Meckel's diverticulum occurs in 2% of the population and may present at any age. Its management, when found incidentally at laparotomy, remains controversial, particularly in the pediatric population. From 1970 to 1989, a Meckel's diverticulum was discovered in 164 children at laparotomy. There were 120 boys and 44 girls with a mean age of 5.2 years (range, 0 to 18 years). Forty-seven cases were asymptomatic, representing an incidental finding at laparotomy, 25 were resected, and ectopic gastric mucosa was present in 7 specimens (28%). Three postoperative deaths (6%) that were not related to the resection and 2 complications (4%) (postoperative leak and wound infection) occurred in this group. Of the 117 symptomatic patients, 49 (42%) presented with bowel obstruction, 45 (38%) had rectal bleeding, 16 (14%) had diverticulitis, and 7 (6%) had umbilical pathology. Volvulus (20) and intussusception (19) were the most common causes of obstruction. Predisposing factors for bowel obstruction were fibrous bands to umbilicus or mesentery (37%) and ectopic mucosa (35%). Severe painless rectal bleeding occurred in 45 patients, 30 of whom (67%) required blood transfusion. A nuclear medicine Meckel scan was positive in 32 of 37 patients (85%). Contrast studies were not diagnostic; colonoscopy and gastroscopy ruled out other causes of bleeding. Patients with diverticulitis (16) presented with acute abdominal pain compatible with appendicitis. In the symptomatic group, ectopic mucosa was present in 61% of the resected specimens. Gastric (88%), pancreatic (7%), and gastric with pancreatic (3%) were the most common ectopic tissue. Postoperative morbidity and mortality for symptomatic patients was 8.5% and 0%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Malignant tumors of the middle ear and external auditory canal: a 20-year review

Twenty-four patients with malignant tumors of the external auditory canal and middle ear, originally seen between 1960 and 1980, were reviewed retrospectively. Seventeen patients had epidermoid carcinoma, one had adenocarcinoma, three had rhabdomyosarcoma, and one had osteosarcoma. At presentation, four had disease confined to the external auditory canal, three had superficial invasion of the bony canal, four had deeply invasive disease, and thirteen had disease that extended beyond the temporal bone. Treatment consisted of radiation, surgery, and combination therapy. Four patients with osteosarcoma or rhabdomyosarcoma received adjuvant chemotherapy. Five years after therapy, one of four patients with external auditory canal tumor died of disease, and two died of intercurrent disorders. One of three patients with superficial temporal bone invasion and two of four patients with deeply invasive tumor died of their disease; another died of intercurrent disorder. Twelve of 13 patients with tumor beyond the temporal bone died.     

Spinal meningiomas: a 20-year review

The long-term outcome of 78 patients with spinal meningiomas operated on over 20 years at a single neurosurgical unit was analysed. Age, sex and tumour location were similar to those reported by others. Overall, 95% of our patents were independently mobile postoperatively, despite 25% of the group being unable to walk before operation, including four paraplegic patients. Only two tumours were entirely extradural, and a further two were both intra- and extradural. In all cases, tumour exposure was by posterior laminectomy, without recourse to more complex approaches. Complete tumour resection was achieved in 77 (98%) of cases. The dural attachment was excised in 20 cases and diathermy was applied in 58. There was one recurrence, 14 years after the original surgery. Complex and technically challenging surgical approaches are unnecessary to obtain complete removal even for anteriorly placed tumours. Excision of the dural base would seem unnecessary to attain a low recurrence rate.     

Malignant sacrococcygeal teratoma--endodermal sinus, yolk sac tumor--in infants and children: a 32-year review

Fifteen cases of malignant sacrococcygeal teratoma were treated at our hospital over the last 32 years. These included five cases of endodermal sinus (yolk sac) tumor that arose in otherwise benign or immature teratoma, and ten cases of pure endodermal sinus (yolk sac) tumor. Most were females, and only one was a neonate. The presence of symptoms almost always indicated local extension or distant metastases. According to Altman's classification, all but two of these malignant tumors were Types III and IV. The resectability was low, but with aggressive radiotherapy and chemotherapy, second look operations in five have been possible with increasing optimism for survival. Two of five patients with secondary resections are alive and tumor-free almost two years after therapy was discontinued. So far, only the newborn is a long-term (14 years) cure.     

The late-presenting pediatric Bochdalek hernia: a 20-year review

A 20-year retrospective study was made of children with congenital posterolateral (Bochdalek) hernias presenting more than 8 weeks after birth. The records of 26 patients (16 boys and 10 girls) were evaluated. Sixteen infants and children (62%) were originally misdiagnosed clinically and radiologically as having either infective lung changes, congenital lung cysts, or pneumothoraces; inappropriate thoracentesis occurred in four patients misdiagnosed as having a pneumothorax. Five patients had previously normal chest radiographs. The most useful investigation was a plain radiograph following passage of a nasogastric tube. Coexisting abnormalities (in particular, gut malfixation and malrotation) were common. All patients except one were operated on within days of presentation, and as emergencies if symptoms were acute. More than one third of our patients were left with a smaller than normal ipsilateral lung after their diaphragmatic hernia repair, and these lungs must be considered hypoplastic to some degree. Chest tubes made no difference in the lung's eventual expansion. Two deaths occurred as a result of acute cardiorespiratory arrest in previously well children. Therefore, the symptoms, signs, and radiologic findings of patients with diaphragmatic hernias presenting after the neonatal period may be difficult to interpret, and may result in diagnostic delay, misguided therapy, and a potentially fatal outcome.     

Management of thyroid nodules in children: a 20-year experience

The medical records and surgical slides of 58 patients with the diagnosis of thyroid nodules (solitary nodule in 50 patients) are reviewed. The most common cause of thyroid nodules in this series is follicular adenoma (27 patients or 46%). A nuclear scan (technetium or radioactive iodine) was performed in 55 patients, of which 40 showed a cold nodule. Twelve of the 40 cold nodules were malignant (30%). However, for solitary nodules the incidence of cancer is 27%. This last figure is significantly greater than the one recently reported by Hung et al (18.5%). Available diagnostic methods are reviewed and the clinical management as derived from our experience is presented.     

In-line skating injuries in children: a 10-year review

In-line skating is an increasingly popular recreational activity for both children and adults. As with any high-speed sport, traumatic injury is an associated hazard. It was the purpose of this study to focus on the injuries in children associated specifically with in-line skating with an emphasis on education and prevention. During a 9-year period, 331 injuries were identified, with 105 families completing an in-depth epidemiologic questionnaire. Sixty-one percent of the victims were boys, with an overall average age of 12 years. The upper extremity was most commonly injured (64%); the head and neck area was injured in 16% and the lower extremity in 20%. Fractures represented 38% of all injuries, with inexperience appearing to be the most common cause. An analysis of preventive strategies for childhood in-line skating was undertaken using Haddon's 10 basic preventive principles. Educational programs regarding instruction in in-line skating and the value of protective equipment need to be part of the school curriculum.     

Implications of a positive crossmatch in liver transplantation: a 20-year review

Whether a positive crossmatch result has any relevance to liver transplantation (LT) outcomes remains controversial. We assessed the impact of a positive crossmatch result on patient and graft survival and posttransplant complications. During a 20-year period, 2723 LT procedures with crossmatch results were identified: 2479 primary transplants and 244 retransplants. The rates of positive B cell and T cell crossmatches were 10.1% and 7.4%, respectively, for primary transplants and 14.6% and 6.4%, respectively, for retransplants (P = 0.049 for a B cell crossmatch). Across all primary transplants, females (P < 0.001) and patients with autoimmune hepatitis (P < 0.001) had greater frequencies of positive crossmatches. There was no effect from race or age. For both primary transplants and retransplants, patient survival and graft survival were not affected by the presence of a positive crossmatch. With respect to posttransplant complications, there were no differences in rejection episodes (hyperacute, acute, or chronic) or technical complications (biliary and vascular) between negative and positive crossmatch groups. However, there were significant differences in the pathological findings of preservation injury (PI) on liver biopsy samples taken at the time of transplantation and within the first week of transplantation (P = 0.003 for B cells and P = 0.03 for T cells). In summary, a positive crossmatch had no significant impact on patient survival or graft outcomes. However, there was a significantly higher incidence of PI in primary LT recipients with a positive crossmatch. This finding is important for a broader understanding of PI, which may include a significant immunological component.     

Malignant breast cancer in children: a review of 75 patients

OBJECTIVE: To determine incidence trends and outcomes for pediatric patients with malignant breast disease. METHODS: The Surveillance, Epidemiology, and End Results registry was examined for all females 19 years of age and younger diagnosed with a malignant breast tumor between 1973 and 2004. RESULTS: A total of 75 patients with malignant breast tumors were identified. Overall, 14.5% of patients had in situ tumors, and 85.5% had invasive disease. Tumors were classified as being either carcinomas (n = 41, 54.7%) or sarcomas (n = 34, 45.3%). The majority of sarcomatous lesions were phyllodes tumors (n = 29, 85.5%), whereas most carcinomas were of a ductal etiology (n = 19, 46.3%). The age-adjusted incidence of all malignant pediatric breast tumors in 2003 was 0.08 cases per 100,000 people (0.03 carcinoma and 0.06 sarcoma cases per 100,000 people). In the carcinoma group, regionally advanced disease was present in 11 patients (26.8%), whereas only 3 patients (7.3%) presented with metastatic disease. All patients with sarcomatous tumors presented with localized disease. Adjuvant radiation therapy was administered in only 9.8% of carcinomas and 8.8% of sarcomas, and 85.4% of carcinoma patients and 97.1% of sarcoma patients underwent surgical resection for their primary disease. Subgroup analysis revealed 5- and 10-year survival rates of 89.6% for patients with sarcomatous tumors and 63.1% and 54.3% for carcinomas. CONCLUSIONS: Malignant pediatric breast malignancies remain relatively rare. The two most common histologies of breast neoplasms in children are malignant carcinomas followed by sarcomas. Although uncommon, malignant disease must be considered in the differential diagnosis of the pediatric patient with a breast mass.     

Fracture of the acetabulum in a 14-year-old patient: 20-year review

A case report of 14-year old female with an acetabular fracture involving the anterior column and posterior column-posterior wall is presented here and the findings on 20-year follow-up are described.     

Gastrointestinal surgery in cystic fibrosis: A 20-year review

Objectives

The purpose of this study was to evaluate outcomes of the surgical management for meconium ileus (MI) and Distal Intestinal Obstruction Syndrome (DIOS) in Cystic Fibrosis (CF).

Methods

Children born between 1990 and 2010 were identified using a regional CF database. Retrospective case note analysis was performed. Outcome measures for MI were mortality, relaparotomy rate, length of stay (LOS), time on parental nutrition (TP), and time to full feeds (TFF). Outcome measures for DIOS were: age of onset, number of episodes, and need for laparotomy.

Results

Seventy-five of 376 neonates presented with MI. Fifty-four (92%) required laparotomy. Contrast enema decompression was attempted in nineteen. There were no post-operative deaths. Thirty-nine (72%) neonates with MI were managed with stomas. LOS was longer in those managed with stomas (p = 0.001) and in complex MI (p = 0.002). Thirty-five patients were treated for DIOS. Twenty-five patients were managed with gastrograffin. Ten patients underwent surgical management of DIOS. Overall, MI did not predispose to later development of DIOS. There was a significantly greater incidence of laparotomy for DIOS in children who had MI.

Conclusion

The proportion of neonates with complex meconium ileus was high (49%) and may explain the infrequent utilisation of radiological decompression. Complex MI or management with stomas both significantly increase LOS. Re-laparotomy rate is high (22%) in MI irrespective of the type of management. DIOS is not a benign condition, particularly when the child has had previous abdominal surgery. Early referral to a surgical team is essential in these children.     

The hidden mortality of congenital diaphragmatic hernia: a 20-year review

Aims

The true mortality associated with congenital diaphragmatic hernia (CDH) is hidden because survival analyses do not include fetuses with CDH. A retrospective review of all postmortems (PMs) with a diagnosis of CDH over a 20-year period was carried out to highlight this hidden mortality and also measure the nature and number of associated anomalies.

Methods

Postmortem case record details were reviewed for the period January 1986 to December 2005. Data were collected on live birth, stillbirth, therapeutic abortion, and spontaneous abortion.

Results

There was a decline in the annual number of PMs during the period of the study. The median for the four 5-year intervals being 609 (570-657), 528 (488-565), 515 (413-537), and 373 (357-388). A total of 130 PMs were identified, which included a diagnosis of CDH; 97 (75%) were left sided, 22 (17%) were right sided, and 11 (8%) were bilateral. There were 69 live births, 46 therapeutic abortions, 10 stillbirths, and 5 intrauterine deaths; 22% were right sided/bilateral in the live and therapeutic abortion groups, whereas 53% were right sided/bilateral in the latter 2 groups. Of 130, 82 (63%) had major associated anomalies, and 50% of these had at least 1 further major anomaly. The commonest categories of anomalies were cardiac (30), gastrointestinal/abdominal wall defect (28), and neural tube defects (25).

Conclusions

The true incidence of CDH is considerably higher than that seen in neonatal surgical practice. The decline in number of PMs in our region will exacerbate the underestimation of the true incidence. There is a higher incidence of right-sided/bilateral hernias and more than one major anomaly in those who die in utero.