Anti-TNF-α treatment for post-anastomotic ulcers and inflammatory bowel disease with Crohn's-like pathologic changes following intestinal surgery in pediatric patients.

PURPOSE: To report a previously poorly recognized process of secondary formation of inflammatory bowel disease (IBD)-like process, specifically Crohn's-like changes in pediatric surgery patients who underwent major small bowel and colorectal surgery. We describe potential etiologies, presenting symptoms and treatment approaches. METHODS: Retrospective chart review of patients with history of either chronic, partial gastrointestinal (GI) obstruction or Hirschsprung disease (HD) and subsequent histopathologic findings similar to IBD. Pathology and case histories were reviewed and treatments were compared. RESULTS: Over the last 20 years, a total of nine patients were identified that had the diagnoses of either HD (n = 3) or chronic GI partial obstruction (n = 6) with subsequent development of histopathologic changes similar to those seen in IBD. Overall meantime to diagnosis of IBD-like changes after intestinal resection was 7.70 ± 5.6 years. Half of the patients were also being managed for short bowel syndrome (SBS), and associated GI symptoms may have prolonged the time to identifying these IBD-like changes. When SBS patients were excluded, mean time to IBD changes after pull through for HD was 2.4 ± 0.24 years and after chronic GI partial obstruction was 6.3 ± 2.1 years. Two of the nine patients who underwent a resection of this IBD-like lesion developed a recurrence of this lesion. Anti-TNF-α treatment was used in three of the GI partial obstruction cases: two with complete relief and one with partial response that was supplemented with steroids. Two HD patients were treated with anti-TNF-α and both had marked improvement of symptoms. CONCLUSION: We describe IBD-like intestinal changes following intestinal resection in the pediatric age group. We also present the novel finding that these lesions are responsive to anti-IBD treatment, including anti-TNF-α, and recommend it as part of the medical treatment regiment offered for such patients.

Opportunities and improvisations: a pediatric surgeon's suggestions for successful short-term surgical volunteer work in resource-poor areas.

There is a paucity of trained pediatric surgeons in resource-poor areas, and many children never receive care for debilitating problems that could readily be managed by surgeons with proper training, supplies, and instrumentation. This article, written from the perspective of a surgeon who has been both the recipient of and the provider of volunteer surgical services, is intended to encourage surgeons in technologically advanced locations to volunteer in underserved areas and to assist them in the implementation of such endeavors. Concepts are presented with an emphasis on pediatric surgery, but most are relevant for volunteers in all surgical specialties. Volunteer paradigms include, but are not limited to, the "surgical brigade" model, where a large group of health care professionals take all needed equipment and supplies for the duration of their stint, and the "minimalist" model, where a single volunteer works with local personnel using locally available equipment. For a successful volunteer endeavor the host needs to have a perceived need for the volunteer's services, and the volunteer must be flexible in adapting to meet overwhelming needs with limited resources. It is suggested that appropriate technology, such as the inexpensive anal stimulator presented herein, should be employed whenever possible. With proper planning, realistic expectations, and a cooperative and helpful attitude, volunteer trips can be rewarding experiences for both volunteers and host physicians and lead to lasting relationships that improve children's lives globally.

Survival trends in children with hepatoblastoma.

PURPOSE: Hepatoblastoma (HB) is a relatively rare pediatric malignancy. In this study, we present demographic data and a survival analysis from the largest patient cohort with HB reported to date. METHODS: The surveillance, epidemiology, and end results database was queried from 1973 to 2005 for all patients diagnosed with HB. Kaplan-Meier survival analysis was conducted to determine actuarial survival. Cox regression analysis was performed to determine hazard ratios (HR) for prognostic variables. RESULTS: During the study period, 459 patients with HB were identified. Overall 1-, 3-, and 5-year survival rates for the entire patient cohort were 76, 63, and 60%, respectively. Five-year survival improved over time from 36 (1973-1982) to 63% (1983-2005). Predictors of poor survival include: age 2 years and greater (HR 1.566), black race (HR 1.910), diagnosis prior to 1983 (HR 3.327), inability to perform surgical resection (HR 3.857), regional disease (HR 1.939), and distant disease (HR 3.196). CONCLUSIONS: Hepatoblastoma continues to challenge surgeons and oncologists. Most children are diagnosed early in life and undergo surgical resection whenever possible. With the advent of efficacious chemotherapy, survival has improved. Older children, black patients, and those who present with advanced disease tend to have poor outcomes. Surgical resection is the single most important predictor of survival.

A practical guide for short-term pediatric surgery global volunteers.

INTRODUCTION: The tremendous need for increasing the quantity and quality of global pediatric surgical care in underserved areas has been well documented. Concomitantly there has been a significant increase in interest by pediatric surgeons in helping to relieve this problem through surgical volunteerism. The intent of the article is to serve as a practical guide for pediatric surgeons contemplating or planning a short-term global volunteer endeavor. METHODS: The article is based on the authors' personal experiences and on the published experiences of other volunteers. FINDINGS: The following aspects of volunteerism are discussed: ethical considerations, where and how to go, what and whom to take with you, what to expect in your volunteer locale, and what to do and what to avoid in order to enhance the volunteer experience. CONCLUSIONS: The points discussed in this guide will hopefully make the volunteer activity one that results in greatly improved immediate and long term surgical care for children and improves the chances that the activity will be a meaningful, pleasant, and productive experience for both the volunteer and the host physician.

Significance of 'blush' on computed tomography scan in children with liver injury.

BACKGROUND/PURPOSE: The aim of this study was to determine if the presence of "blush" (an indication of active bleeding) on abdominal CT in children with blunt liver injury adversely affected their clinical outcome as has been reported in adults. METHODS: The authors reviewed the records of 105 children ages 1 to 16 years with blunt liver injury seen on admission IV contrast CT seen over a 6-year period. Demographic characteristics measured were age, mechanism of injury, and injury severity score (ISS). Clinical outcomes included ICU stay, hospital length of stay (LOS), transfusion requirement (milliliters per kilogram), operations performed, and mortality rate. CT scans were evaluated retrospectively by a radiologist blinded to prior reports, for a "blush" and grade of liver injury. No patient underwent arterial embolization. The authors eliminated children with grade I-II injuries (30 patients), because only one had a blush, and analyzed the 75 patients with severe liver injuries (grades III-V). Those patients without a blush (n = 53) seen on CT were the control group, whereas patients with a blush (n = 22) were the study group. Data were analyzed using the Fisher's Exact and Mann-Whitney U test. The level of significance was set at.05. RESULTS: Patients with a blush had a significantly larger transfusion requirement (17.3 +/- 30.5 mL/kg v 5.0 +/- 10.9 mL/kg; P =.02) and mortality rate (23% v 4%; P =.02), but the ISS also was significantly greater (25.8 +/- 14.5 v 17.5 +/- 12.2; P =.019). All other data were similar between the 2 groups. CONCLUSIONS: Children with a blush seen on abdominal CT after blunt liver injury have higher transfusion requirements and greater risk of mortality than those without blush. Mortality is primarily related to the severity of their other injuries.

Tetanus: continuing problem in the developing world.

Despite diligent efforts by the World Health Organization and the governments of developing world countries, tetanus persists as a global health problem. This retrospective study was undertaken to assess the outcome for victims of tetanus presenting to the Baptist Medical Centre in Ogbomoso, Nigeria and to develop better management techniques for future patients. Sixty patients (46 males, 14 females) with nonneonatal tetanus were seen over a 5-year period (1995-1999). The mean age was 26 years, and 74% were 30 years or younger. All patients were treated with antitetanus serum, antibiotics, wound débridement (when a wound was identified), and antispasmodics. No patients underwent tracheostomy or gastrostomy. The mortality rate was 44%. Factors significant for predicting mortality were age greater than 14 years, occupation as a farmer, short incubation period, short symptom duration, high degree of severity on presentation, and high temperature during hospital care. The best hope for improvement in the treatment of tetanus in our institution is more conscientious titration of antispasmodics to control spasms without causing significant respiratory depression. The only real hope for reducing the global mortality for tetanus, however, lies in renewed immunization efforts by all health care providers in developing world countries, not just community health workers.