Pancreaticoduodenectomy for choledochal cyst.

BACKGROUND/AIMS: Choledochal cyst (CDC) is a rare congenital cystic dilatation of the biliary system that can affect children and adults. Standard treatment for CDC includes surgical excision of the cystic bile duct with restoration of bilioenteric continuity by Roux-en-Y hepaticojejunostomy. In rare situations, however, surgical excision of a CDC may require pancreaticoduodenectomy (PD). The goal of this study was to identify instances where a PD may be deemed necessary. METHODOLOGY: We retrospectively reviewed the medical records of all patients treated for CDC at our institution from January 1988 through December 2011. From this cohort, patients who underwent PD were reviewed in detail. Data on preoperative parameters, operative details, cyst type, pathologic diagnosis, and postoperative course were collected. RESULTS: During the 24-year period, 59 patients with CDC were identified and four (7%) underwent formal PD. Final pathology revealed that none of the resected specimens harbored malignancy and all patients are well at follow-up. CONCLUSION: While the standard surgical care for CDC remains complete cyst excision with Roux-en-Y hepaticojejunostomy, there may be particular instances where PD appears more appropriate. While the need for PD in cases of CDC is rare, it is important to consider this possibility when contemplating surgery for CDC.

Gastric tube-pericardial fistula: a remote complication of esophageal replacement for long gap esophageal atresia.

Several short and long-term complications of esophageal replacement have been described in the literature. We report the case of a gastric tube-pericardial fistula occurring 20 years after initial repair of long gap esophageal atresia with a reversed gastric tube.

A practical algorithm for accurate diagnosis and treatment of perinatally identified biliary ductal dilation: three cases that underscore the importance of an individualised approach.

Choledochal cysts (CDCs) identified during the prenatal or immediate postnatal period are unusual with a majority being identified in older children and adults. Although authors advocate surgical resection of these presumed CDCs with reconstruction, there has been no agreement on the optimal timing of such an intervention when the initial diagnosis of CDC is made prenatally or during the newborn period. We present the cases of three children with biliary ductal dilation who were presumed to have CDC by ultrasound and/or magnetic resonance imaging during the perinatal period and who ultimately required different approaches to treatment. The eventual findings in these cases support a period of close postnatal observation followed by carefully planned individualised therapy.

Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child.

Femoral cannulation in pediatric patients requiring extracorporeal membrane oxygenation (ECMO) is commonly associated with distal limb ischemia. Authors have previously reported successful lower limb perfusion using various open techniques to cannulate a distal lower extremity artery at the time of initial ECMO cannulation. These procedures include open femoral artery antegrade cannulation and distal posterior tibial artery retrograde cannulation in older children and adults. Such approaches require ample vessel diameters to accommodate an arteriotomy and catheter insertion and, therefore, are of limited use in smaller children. We hypothesized that after femoral artery cannulation for ECMO, a percutaneous technique of distal limb perfusion might offer unique advantages when treating lower extremity ischemia in small pediatric patients. We report a technique for percutaneous antegrade cannulation in a 4-year-old patient shortly after her primary cannulation for venoarterial ECMO via the femoral artery.

Button-loop feeding jejunostomy.

INTRODUCTION: Post-pyloric feeding via a surgical jejunostomy allows for enteral nutrition in patients that cannot receive oral or gastric feeding. Regardless of the technique used to create a jejunostomy, complications such as tube dislodgement, jejunostomy closure, or bowel obstruction can occur. SURGICAL TECHNIQUE: We present a simple and efficient jejunostomy technique that does not require a sewn anastomosis and employs an easily exchangeable feeding button.