Letter to the Editor in response to the Position statement and best practice recommendations on the imaging use of ultrasound from the European Society of Radiology ultrasound subcommittee.

This letter to the editor is in response to the consensus statement from the Ultrasound Subcommittee of the European Society of Radiology, the European Union of Medical Specialists (UEMS) Section of Radiology, and the European Federation of Societies for Ultrasound in Medicine and Biology. It highlights the role of the non-medical sonographer in the UK and the evidence underpinning this safe and effective practice.

Tracheobronchial anatomy and the distribution of inhaled foreign bodies in children.

BACKGROUND: Foreign body inhalation is a common and life-threatening emergency, and is most prevalent in young children. The traditional view is that tracheobronchial anatomy determines that an inhaled foreign body is more likely to enter the right main bronchus. This view has been challenged in young children, in whom the distribution of inhaled objects is more evenly distributed between the bronchi. We, therefore, investigated tracheobronchial anatomy relevant to foreign body inhalation in children. MATERIALS AND METHODS: One hundred and fifty-six normal pediatric chest radiographs were selected from a large electronic database. Eight groups of radiographs were identified: supine (n=76) and erect; males (n=84) and females; aged <3 years (median age 12 [0.5-29] months) and > or =3 years (median age 126 [48-180] months). Tracheobronchial widths and angles were determined using a standardized technique with good reproducibility. RESULTS: Overall, children had a proximal right main bronchus that was consistently steeper and slightly wider than the left (P<0.001), becoming more vertical in the erect position (P=0.0001). In most children, the carina was positioned to the left of the mid-trachea, but in 34% of cases (40% of infants), it was to the right of the mid-trachea. The effects of age and gender were otherwise minimal. CONCLUSION: On the basis of tracheobronchial anatomy, an inhaled foreign body is more likely to enter the right bronchial tree than the left in children of all ages. However, the variability in the position of the carina with respect to the mid-trachea may explain why this right-sided preference is less marked in children compared to adults.

Solitary liver cysts in children: not always so simple.

AIM: Liver cysts in children are uncommon. Many are simple and solitary and do not require intervention. However, this series demonstrates a broad range of potential pathologies, some of which are life-threatening. METHODS: All children referred to our unit during an 8-year period (1998-2005) and found to have a solitary liver cyst were prospectively recorded. Clinical, radiologic, and pathologic features were analyzed. Children with an isolated extrahepatic choledochal cyst and polycystic disease were excluded. RESULTS: Twenty-one children with a liver cyst were identified. Two had undergone unsuccessful surgical intervention before referral. There were 11 prenatally detected cysts. Median gestational age at detection was 22 weeks (19-35 weeks); only 1 was specifically characterized as a liver cyst prenatally. Six of these required surgery: 2 large simple cysts, 2 intrahepatic choledochal cysts, 1 giant complex biliary cyst causing respiratory distress, and 1 ciliated hepatic foregut cyst. Of the 5 cysts remaining under ultrasound surveillance, 4 decreased in size or resolved. In 10 children presenting between birth and 15.8 years, a liver cyst was diagnosed postnatally: 3 huge cystic mesenchymal hamartomas, 1 type V choledochal cyst, 1 hydatid cyst, and 5 simple cysts. Four of these required surgical resection. Simple cysts tended to be small and could be distinguished from other pathologies using a combination of imaging techniques (ultrasound, magnetic resonance imaging/magnetic resonance cholangiopancreatography [MRCP], radionuclide scan). Only 2 of 12 children with "simple" cysts required surgery for symptoms. However, a wide range of other cyst pathologies were found in 9 children, and although none was malignant, some were life-threatening and 7 required resection. CONCLUSIONS: Simple solitary nonparasitic liver cysts rarely cause symptoms or require surgery, but the pediatric surgeon should be aware of the wide range of other types of liver cyst in children to ensure appropriate treatment.

Multidisciplinary management of surgical disorders of the pancreas in childhood.

OBJECTIVES: To describe the frequency and range of pancreatic disorders in children requiring surgical intervention and to highlight the importance of multidisciplinary management. METHODS: An audit of all children under 17 years of age referred with surgical disorders of the pancreas or pancreatitis to a regional pediatric gastroenterology unit in the United Kingdom during a 10-year period. A retrospective chart review of clinical features, pathology and outcome was undertaken. RESULTS: Surgical intervention was required for the following pancreatic disorders: persistent hyperinsulinemic hypoglycemia of infancy (n = 4), pancreatic tumors (n = 5), pancreaticobiliary malunion (n = 12), pancreatic trauma (n = 6) and pancreatitis (n = 10). The indications for surgery in acute pancreatitis were a persistent pseudocyst (n = 1) and treatment of an underlying cause of pancreatitis (n = 4); in chronic pancreatitis, surgery was used to treat symptomatic pancreatic duct strictures (n = 4). One child died of a progressive lymphoma but all others who underwent surgery are alive and well. All 33 children with acute pancreatitis, including four with pancreatic necrosis, survived. CONCLUSIONS: Surgery for pancreatic disorders in children is rarely required but may be necessary a) for definitive management of primary pancreatic pathology, b) to treat sequelae of acute or chronic pancreatitis and c) to treat an underlying cause of pancreatitis. There is a broad spectrum of potential pathologies. These patients are best managed by a multidisciplinary team approach.