Outcomes in pediatric patients with abdominal compartment syndrome following urgent exploratory laparotomy.

BACKGROUND/PURPOSE: Abdominal compartment syndrome (ACS) is a serious condition with high mortality in critically ill children. Our objectives were to characterize the incidence of ACS in pediatric patients who underwent urgent exploratory laparotomy and to compare outcomes of patients with and without ACS. METHODS: This retrospective review examined pediatric patients (0-18years) who underwent urgent exploratory laparotomy over a 2-year period. Primary outcome was mortality; secondary outcomes were achievement of primary fascial closure and necessity of bowel resection. RESULTS: One hundred nineteen patients were included, of which 33 (28%) had ACS, with 27 (23%) being primary ACS and 6 (5%) secondary ACS. Twenty-eight-day mortality was higher in the ACS versus non-ACS group (52% versus 0%, p<0.001) and overall hospitalization (64% versus 2%, p<0.001). Primary fascial closure was achieved less often in ACS compared to non-ACS patients (46% versus 98%, p<0.001). Bowel resection was more frequent in ACS versus non-ACS patients, approaching statistical significance (49% versus 30%, p 0.056). CONCLUSION: During the study period, almost one third of children who underwent urgent exploratory laparotomy had ACS and 64% died. Children undergoing evaluation for acute surgical abdomen may benefit from routine intraabdominal pressure measurement. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Pulmonary hypertension predicts mortality in infants with omphalocele.

OBJECTIVE: The objective of this study was to identify predictors of mortality in infants with omphalocele. METHODS: Medical records of infants with omphalocele born between January 1992 and June 2012, with follow-up toDecember 2012, were retrospectively reviewed. Survivors and non-survivors were compared. Evidence for pulmonary hypertension was sought between the second and seventh day after birth. All included infants had increased right ventricular pressures (RVP >40 mmhg) on echocardiogram on the second day of life with increased oxygen requirements, therefore, the finding of increased pressure was not considered a result of the transitional circulation. Logistic regression was used to evaluate the importance and independence of various factors. RESULTS: Of 51 infants whose records were reviewed, 13 died (25%) and 38 survived (75%). The median time to death was 34 days (range: 4 -408 days). The median follow-up time for those who died was 1.5 years (range: 0.01-15 years) and for survivors was 2.6 years (range: 0.08-15 years). Logistic regression revealed that respiratory insufficiency at birth (OR: 14.8; 95% CI: 2.5-85.0) and pulmonary hypertension (OR: 6.4; 95% CI: 1.1-39.0) were independently associated with mortality. CONCLUSION: Respiratory insufficiency after birth and pulmonary hypertension are independent predictors of mortality in infants with omphalocele.

Farm accidents in children: eleven years of experience.

BACKGROUND/PURPOSE: The aim of this study was to review accidental injuries to children on farms. METHODS: Between January 1988 and December 1999, childhood farm injuries referred to a trauma center were reviewed. RESULTS: Forty-five children under 19 years of age were identified. Mean age was 7.3 years. Male to female ratio was 2:1. A total of 31 of 45 (69%) survived. A total of 14 of 45 (31%) died. The mechanism of injury was tractor in 15 (33%), animals in 13 (29%), other machinery in 9 (20%), falls in 4 (9%), burns in 2 (4%), equipment in 1 (2%), and mechanism not documented in 1 (2%). Twelve deaths involved tractors or machinery (86%), and 2 involved animals (14%). Thirty of forty-five (67%) accidents occurred between June and October. A total of 28 of 45 (62%) occurred between 1 PM and 6 PM. Nine fatalities (64%) were supervised. Predominant injuries were orthopedic in 25 of 45 (56%), neurologic in 19 of 45 (42%), and thoracoabdominal in 10 of 45 (22%). Eighteen (40%) underwent orthopedic surgery. Six patients (13%) had long-term disability. Seven survivors and 7 fatally injured patients (31%) had multiple injuries. Seven of 14 fatalities (50%) had solitary head injuries. The average transport time from scene to rural hospital was 1.5 hours, from rural hospital to trauma center, 2.3 hours. Twelve of fourteen fatalities (86%) were declared dead at the scene, and 2 died en route. CONCLUSION: Efforts must be focused to prevent tractor and animal injuries.

Fibromatoses: clinical and pathological features suggestive of recurrence.

BACKGROUND/PURPOSE: Fibromatoses represent a spectrum of nonneoplastic spindle cell tumors frequently identified in childhood. Although they may be locally aggressive, they do not metastasize. The authors have reviewed their experience of these lesions in an attempt to identify clinical and pathological features suggestive of recurrence. METHODS: Clinical records and pathological specimens from 55 cases of fibromatosis diagnosed and treated at British Columbia's Children's Hospital from 1982 to 1995 were reviewed. RESULTS: Thirty boys and 25 girls with ages ranging from 1 month to 14 years were identified. Eighteen tumors (33%) were congenital. Diagnoses were as follows: musculoaponeurotic fibromatosis (n = 27), infantile myofibromatosis (n = 10), Dupuytren-type fibromatosis (n = 7), fibromatosis colli (n = 7), and digital fibroma (n = 4). Clinical follow-up showed a survival rate of 98%. The single mortality occurred in an infant born with an intraabdominal visceral myofibromatosis, which proved unresectable. Fifteen cases recurred (27%), and nine cases (16%) of infantile myofibromatosis spontaneously regressed. All remaining cases were controlled successfully by surgical resection. CONCLUSIONS: Clinical features suggestive of recurrence included (1) presentation at greater than 5 years of age, (2) extremity location of disease, and (3) incomplete surgical resection. Pathological features suggestive of recurrence were (1) microscopic evidence of tumor at resection margins, (2) mitotic index of 5 or more per 10 high-power fields, and (3) areas of necrosis and inflammation within the tumor.

Neutropenic enteropathy: a 10-year review.

PURPOSE: With the advent of more aggressive chemotherapy, the incidence of neutropenic enteropathy is increasing. This review was performed to (1) determine which children are affected, (2) identify predisposing factors, and (3) assess efficacy of treatment. METHODS: A 10-year (1988 to 1997) review identified 33 children who had 38 episodes of neutropenic enteropathy. Each presented with fever, abdominal pain, and chemotherapy-induced neutropenia. All were treated with fluid resuscitation, bowel rest, and broad-spectrum antibiotics. Surgical intervention was reserved for children with bowel perforation. RESULTS: Neutropenic enteropathy occurred in 24 children with hematologic malignancies and nine with solid tumors. This disease developed in three children after bone marrow transplantation for leukemia. All five patients in whom recurrent episodes developed were receiving chemotherapy for Burkitt's lymphoma. Cytosine arabinoside and VP16 were the most commonly implicated chemotherapeutic agents. Four children required laparotomy and right hemicolectomy, and all survived. Overall survival was 94%. CONCLUSIONS: Although previously described in children receiving chemotherapy for hematologic malignancies, neutropenic enteropathy also occurs in children who have solid tumors and after bone marrow transplantation. The use of cytosine arabinoside and VP16 may predispose patients to this disease. Children receiving chemotherapy for Burkitt's lymphoma are at increased risk for recurrent episodes. Excellent survival rate was attained with supportive care being used as the primary treatment modality.

Laparoscopy as a cause of a false-positive Meckel's scan.

A new cause of a false-positive result of a Meckel's scan is reported. An 11-year-old girl had a 3-week history of constant right lower quadrant pain that was initially managed by laparoscopic appendectomy. A repeated laparoscopy for persistent pain was nondiagnostic. A missed Meckel's diverticulum was considered as the cause of this pain, which prompted a Meckel scan. This scan revealed a periumbilical focus of activity that was interpreted as a Meckel's diverticulum attached to the anterior abdominal wall by a band. The laparotomy showed no Meckel's diverticulum. The false-positive result of the Meckel scan may be the result of inflammation from the periumbilical laparoscopic port site.

Late-presenting congenital diaphragmatic hernia: diagnostic pitfalls and outcome.

PURPOSE: We sought to review the presentation, diagnosis, and outcome of a series of children with late-presenting, congenital diaphragmatic hernias (CDH). METHODS: Bochdalek and Morgagni hernias that were diagnosed after 30 days of age, between January 1989 and December 2009, were reviewed retrospectively. A medical record review and telephone survey were conducted in 2010. RESULTS: Thirty-one subjects, diagnosed with CDH between 45 days and 13 years of age (mean, 16 months), were reviewed. Bochdalek hernias were present in 18 (58%) and Morgagni hernias in 13 (42%). There were twenty (64%) left-sided, eight (26%) right-sided, and three (10%) bilateral CDH. Five (16%) had other congenital anomalies. Eight (25.8%), including a subject with strangulated intestine that required resection, were initially misdiagnosed, due mostly to failure to obtain or correctly interpret a chest radiograph. Thirty (97%) were repaired by an abdominal approach, including seven laparoscopic closures. Follow-up ranged from 1 to 20 years (median, 7 years). All subjects survived without recurrence. Unlike neonatally diagnosed CDH, neither right-sided hernia, patch repair, nor associated esophageal atresia predicted morbidity. CONCLUSION: Although diagnostic delays may lead to morbidity, if late-presenting CDH are expeditiously identified and repaired, their outcome is very good, in contrast to those that present in neonates.

Perforated colonic carcinoma mimicking perforated peptic ulcer: an argument for full exploration of the stomach and duodenum.

Perforated peptic ulcer is one of the commonest types of hollow-viscus perforation. Because many of these ulcers are found at laparotomy to be sealed off, some authors believe it is unnecessary to dissect the surrounding tissue from the presumed site of perforation. A patient with a long history of peptic ulcer disease experienced the sudden onset of signs and symptoms of perforated peptic ulcer. On exploration, the omentum appeared to be densely adherent to the pylorus and duodenum. However, no perforation was found when the omentum was dissected free from the stomach and duodenum. Further exploration revealed a walled-off, perforated carcinoma of the transverse colon adjacent to the mesenteric border. As a result of this experience, the authors emphasize that when the findings at operation do not fit the clinical presentation in a patient with a presumed perforated peptic ulcer, a thorough exploration of the abdominal viscera is mandatory to identify the pathologic process.

Gastroschisis: A sixteen-year review.

PURPOSE: The aim of this study was to examine the incidence of gastroschisis in Saskatchewan over a 16-year period and identify risk factors associated with mortality. METHODS: Information was obtained by retrospective review of all infant charts at the only 2 provincial neonatal intensive care centers from January 1985 through December 2000. Factors recorded were gestational age, birth weight, gender, Apgar score, time to operation, method of closure, time to attain full feedings, presence of sepsis, and length of hospital stay. Live birth data for the province was obtained, and the incidence per 10,000 live births for 3 time intervals was calculated. Analysis was performed with mortality as the dependent variable. RESULTS: Seventy-one infants were identified. Overall survival rate was 93% (66 of 71). During the 3 time intervals examined, the incidence of gastroschisis per 10,000 live births increased from 1.85 in 1985 to 1990 to 3.66 in 1991 to 1995 to 4.06 in 1996 to 2000. The analysis found that intestinal atresia P =.009, OR = 18.3 (95%CI: 2.457-136) and intestinal necrosis P =.050, OR = 10.33 (95%CI: 1.32-80.68) were significantly associated with mortality. CONCLUSIONS: The incidence of gastroschisis is increasing. Intestinal atresia and the development of intestinal necrosis were associated with poor outcome. Patients who had these complications all had short bowel, and full feedings could not be established. They required continuation of total parenteral nutrition and experienced episodes of sepsis.