Pediatric Breast Fibroadenomas: A Systematic Review and Algorithm for Treatment.

BACKGROUND: Pediatric breast masses cause concern for both the patient and their family, although malignancy represents less than 1% of lesions in this population. No studies have systematically described resection and reconstructive methods for different sizes and locations of pediatric breast fibroadenomas. The aim of this study was to perform a recent systematic review of the literature regarding the surgical resection of pediatric breast fibroadenomas and to propose an algorithm for safe and effective treatment that maximizes both therapeutic and aesthetic goals while acknowledging possible future need for nipple-sparing mastectomy. METHODS: A search for the phrase "pediatric breast fibroadenoma" yielded 44 results through the PubMed database. Results were reviewed and filtered to only include pertinent articles published within the last 10 years, yielding 27 results. Application of exclusion criteria resulted in 5 applicable articles. A second search was conducted using the phrase "breast fibroadenoma AND resection," which resulted in 37 studies. Fourteen articles met the inclusion and exclusion criteria from this expanded search. All 19 articles were reviewed for techniques based on the characteristics of the masses in terms of their resection patterns, and a treatment algorithm was designed. RESULTS: Thirty-three female subjects with an average age of 14 years were included in analysis. The average number of fibroadenomas was 1.2. The average diameter of a breast fibroadenoma was 9.1 cm, with a range from 2 to 20 cm. Resection techniques were as follows: 31% (n = 6) periareolar incision, 31% (n = 6) inframammary fold incision, 21% (n = 4) reduction mammoplasty, 10% (n = 2) mastectomy, and 5% (n = 1) mastopexy. Sixteen percent (n = 3) of studies reported the use of implants or myocutaneous flaps when breast reconstruction was warranted. No articles described long-term follow-up with regard to need for eventual mastectomy or skin complications based on prior biopsy. Based on the results of this review, an algorithm was developed to guide treatment of pediatric breast fibroadenomas. CONCLUSION: This is the first time a treatment algorithm for surgical resection has been proposed in the literature. It is our hope that this systematic review will provide guidance to surgeons in the operative management of pediatric breast fibroadenomas.

The surgical management of H-type rectovestibular fistula: a case report and brief review of the literature.

H-type rectovestibular fistula is a rare anorectal malformation with poor consensus on an optimal operative management. We report our management of a recurrent fistula and review previously described operative techniques. Full excision of the tract without apposing suture lines or perineal body dissection simplifies the repair while minimizing complications and recurrence risk.

Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic.

OBJECTIVE: Early presentation and prompt diagnosis of acute appendicitis are necessary to prevent progression of disease leading to complicated appendicitis. We hypothesize that patients had a delayed presentation of acute appendicitis during the COVID-19 pandemic, which affected severity of disease on presentation and outcomes. PATIENTS AND METHODS: We conducted a retrospective review of all patients who were treated for acute appendicitis at Morgan Stanley Children's Hospital (MSCH) between March 1, 2020 and May 31, 2020 when the COVID-19 pandemic was at its peak in New York City (NYC). For comparison, we reviewed patients treated from March 1, 2019 to May 31, 2019, prior to the pandemic. Demographics and baseline patient characteristics were analyzed for potential confounding variables. Outcomes were collected and grouped into those quantifying severity of illness on presentation to our ED, type of treatment, and associated post-treatment outcomes. Fisher's Exact Test and Kruskal-Wallis Test were used for univariate analysis while cox regression with calculation of hazard ratios was used for multivariate analysis. RESULTS: A total of 89 patients were included in this study, 41 patients were treated for appendicitis from March 1 to May 31 of 2019 (non-pandemic) and 48 were treated during the same time period in 2020 (pandemic). Duration of symptoms prior to presentation to the ED was significantly longer in patients treated in 2020, with a median of 2 days compared to 1 day (p = 0.003). Additionally, these patients were more likely to present with reported fever (52.1% vs 24.4%, p = 0.009) and had a higher heart rate on presentation with a median of 101 beats per minute (bpm) compared to 91 bpm (p = 0.040). Findings of complicated appendicitis on radiographic imaging including suspicion of perforation (41.7% vs 9.8%, p < 0.001) and intra-abdominal abscess (27.1% vs 7.3%, p = 0.025) were higher in patients presenting in 2020. Patients treated during the pandemic had higher rates of non-operative treatment (25.0% vs 7.3%, p = 0.044) requiring increased antibiotic use and image-guided percutaneous drain placement. They also had longer hospital length of stay by a median of 1 day (p = 0.001) and longer duration until symptom resolution by a median of 1 day (p = 0.004). Type of treatment was not a predictor of LOS (HR = 0.565, 95% CI = 0.357-0.894, p = 0.015) or duration until symptom resolution (HR = 0.630, 95% CI = 0.405-0.979, p = 0.040). CONCLUSION: Patients treated for acute appendicitis at our children's hospital during the peak of the COVID-19 pandemic presented with more severe disease and experienced suboptimal outcomes compared to those who presented during the same time period in 2019. LEVEL OF EVIDENCE: III.

Right phrenic nerve injury as a complication of tracheoesophageal fistula repair.

OBJECTIVE: To report a rare case of right hemidiaphragmatic paralysis after tracheoesophageal fistula repair, and successful nonoperative management. DESIGN: Case report and literature review. SETTING: Pediatric intensive care unit in an academic, tertiary care medical center. PATIENT: A neonate born to a G1P1Ab0 mother was diagnosed with tracheoesophageal fistula in the immediate postnatal period. He underwent gastrostomy and colostomy with mucous fistula on day 1 of life, and definitive repair of his esophageal atresia and tracheoesophageal fistula via a right posterolateral thoracotomy and a retropleural approach on day 6 of life. The patient failed several attempts at postoperative extubation, and a radiograph on day 11 of life revealed a persistently elevated right hemidiaphragm. INTERVENTION: Nonoperative management with noninvasive positive-pressure ventilation. MEASUREMENTS AND MAIN RESULTS: Restoration of normal diaphragmatic motion. CONCLUSIONS: This case highlights two important points to be considered when tracheoesophageal fistula repair is performed in infants. First, phrenic nerve injury should be included in the differential diagnosis of any patient who has difficulty being weaned from the ventilator in the postoperative period after tracheoesophageal fistula repair. Second, when paralysis of the hemidiaphragm does occur, patients should receive an initial trial of nonoperative management, with diaphragmatic plication reserved for those patients who fail to regain diaphragmatic function after 4 to 6 wks.

Congenital esophageal stenosis: the differential diagnosis and management.

Congenital esophageal stenosis (CES) is a rare congenital abnormality that is difficult to diagnose and often masquerades as other types of structural esophageal disease. We report three cases of CES with different presenting symptoms. We advocate for balloon dilation as the preferred first approach to therapeutic intervention. CES is an important clinical entity in the evaluation of pediatric esophageal disorders and should be suspected in young infants with dysphagia.

Tension pneumoperitoneum in a child resulting from high-frequency oscillatory ventilation: a case report and review of the literature.

An 18-month-old male infant was placed on high-frequency oscillatory ventilation for profound hypoxemia and subsequently developed tension pneumoperitoneum. He underwent a bedside exploratory laparotomy for suspected perforated viscus. No intestinal perforation was identified, and a diagnosis of tension pneumoperitoneum secondary to pneumatosis cystoides intestinalis was made. To our knowledge, this is the only report of a pediatric patient developing tension pneumoperitoneum from high-frequency oscillatory ventilation. A review of the literature examines the differential diagnosis, physiology, and treatment of tension pneumoperitoneum.

Untangling a web: an unusual case of labial necrosis in an adolescent female.

BACKGROUND: Hair tourniquets are commonly described in the pediatric literature. Prompt recognition of a hair tourniquet and treatment with complete removal of the hair by pediatricians, pediatric emergency room physicians, or gynecologists is essential to prevent ischemia and necrosis of affected tissue. CASE: Herein we present the case of a 12-year-old female referred to the pediatric surgery clinic for labial pain and swelling. She was found to have a hair tourniquet of the labia minora caused by pubic hair. The patient was taken to the operating room for examination under anesthesia and removal of the hair. Her post-operative course was unremarkable and she was discharged home the following day. On follow-up visit to the clinic her labial edema had completely resolved and she was pain free. SUMMARY AND CONCLUSIONS: Unlike previous case reports that describe hair tourniquets as originating from hair on the head, our patient had a hair tourniquet caused by pubic hair. In adolescents where personal hygiene of the perineum is difficult, clinicians need to be aware of the possibility of a hair tourniquet forming from pubic hair.

Preoperative angiography with embolization and radiofrequency ablation as novel adjuncts to safe surgical resection of a large, vascular sacrococcygeal teratoma.

Sacrococcygeal teratomas (SCTs) can present a challenging problem and can be associated with significant perinatal morbidity and mortality. A female child was born at 36 weeks' gestation with a large, vascular Type 1 SCT originally identified by prenatal ultrasound. A CT scan showed two large feeding vessels arising from both internal iliac arteries that were successfully embolized during angiography. A radiofrequency probe was then used to ablate a zone between normal tissue and the tumor. The SCT was subsequently surgically excised with minimal blood loss. This case is presented to illustrate two useful and previously unreported postnatal adjuncts to the surgical treatment of massive, hypervascular sacrococcygeal tumors.