Early start of clean intermittent catheterization versus expectant management in children with spina bifida.

PURPOSE: We instituted early clean intermittent catheterization (CIC) in 1997 for all newborn infants with spina bifida (SB). We compared this group to a historical group managed expectantly to see if early catheterization was associated with a reduction in renal scar rate as determined by DMSA scanning. METHODS: Data were studied retrospectively on all infants with SB over a recent 13-year period who were treated with early universal CIC in a regional pediatric urology department. These were compared to our previously published outcomes in a historical group (1985-1994) that was managed expectantly [Brown et al. Chronic pyelonephritis in association with neuropathic bladder. Eur J Pediatr Surg 1999;9 Suppl 1:29-30.] RESULTS: 114 infants were born with SB from 1997 to 2010, of which 13 were excluded from this analysis. Mean follow-up was 11.4 years. In the historical cohort there were 126 infants born from 1985 to 1994, with 26 exclusions; follow-up then ranged from 4 to 13 years. DMSA scan showed renal scarring in 19/101 (18.8%) of the recent cohort versus 39/100 (39%) of the previous group (P = 0.002). Renal scarring at a later age also appeared to be a feature of the recent group, with first detection occuring by 4 years in only 9/19 (47%) in the latest cohort compared to 28/39 (72%) in the historical cohort. CONCLUSION: Based on these renal protective data, we recommend indwelling and then intermittent catheterization from birth in all patients with SB. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective, cohort comparison study.

Vascular access survival in children and young adults receiving long-term hemodialysis.

BACKGROUND: The delivery of long-term hemodialysis therapy in children is complicated by smaller vascular caliber and the potential lifelong requirement for hemodialysis access. Various factors have resulted in the increased use of cuffed central venous catheters (CVLs) in preference to autologous arteriovenous fistulae (AVFs) and arteriovenous synthetic grafts (AVGs). The aim of this study is to compare CVL, AVF, and AVG survival and determine factors affecting their survival. METHODS: A 20-year retrospective study was undertaken of pediatric patients receiving long-term hemodialysis therapy. Age, height, weight, body mass index, and sex were noted at each procedure, in addition to the presence of hypoalbuminemia, underlying diagnosis, type and site of vascular access, and effect of previous access surgery. The grade of operator also was noted. RESULTS: Three hundred four vascular access procedures were performed on 114 patients, with a median age at initial access formation of 12.0 years (range, 4 weeks to 21.9 years). The most common procedure was CVL insertion (182 procedures) and then AVF formation (107 procedures), with only 15 AVGs created. Median censored survival was 3.14 years (95% confidence interval, 1.22 to 5.06) for AVFs and 0.6 years (95% confidence interval, 0.20 to 1.00) for CVLs. Factors adversely affecting vascular access survival were younger age, trainee operator, presence of hypoalbuminemia, and type of access undertaken, with AVF better than CVL. CONCLUSION: This study shows increased survival of AVFs over CVLs and AVGs. Vascular access in children and adolescents may impact on future dialysis accessibility and should be undertaken by those most experienced in each technique.

Heterotopic gastric mucosa in a duplicate gallbladder.

A 7-year-old girl presented with recurrent acute pancreatitis. Detailed investigations, including endoscopic retrograde cholangiography, suggested a poorly defined biliary tract abnormality. At laparotomy, this was discovered to be a duplicate gallbladder each with a separate cystic duct but contained within a single serosal envelope. Both gallbladders were removed, and histologic examination found the inferior organ to be lined by heterotopic fundic-type gastric mucosa. Despite the absence of any remaining structural biliary abnormality and no evidence of residual ectopic gastric mucosa, the patient experienced a few further episodes of self-limiting mild acute pancreatitis during the following 3 years. The presence of heterotopic gastric mucosa in a duplicate gallbladder has not been described previously.