Experimental comparison of abdominal drainage systems.

BACKGROUND: In an experimental study the performance of different closed abdominal drainage systems was tested. METHODS: A vacuum bottle designed for Redon Drainage, a flexible plastic bulb designed for Jackson-Pratt drains and a V.A.C.® Negative Pressure Wound Therapy System were used. In a porcine cadaveric study mimicking the abdominal cavity the intrinsic pressure (IP) at one and three minutes (T0, T3) and the amount of evacuated fluid were measured. RESULTS: The Redon and Jackson drainage displayed a rapid decline to IP values of almost zero comparing T0 and T3. Only the V.A.C.® system was able to preserve constant values of negative IP values measured at both time points. Only the V.A.C.® system was able to remove almost the whole amount of inserted fluid. CONCLUSIONS: In an experimental setting the V.A.C.® system was superior to the other two tested systems in delivering constant negative IP and the amount of evacuated fluid.

Ulnar polydactyly - an analysis of appearance and postoperative outcome.

BACKGROUND/PURPOSE: Ulnar polydactylies present with a wide variation in the size and appearance of the affected finger, ranging from small cutaneous appendages to fully formed additional fingers. Since ulnar polydactyly is rarely associated with functional disabilities, psychological and cosmetic reasons are the main rationale for surgical treatment. The aim of this study was to present the appearance, treatment regimen, and outcome of a series of children treated with ulnar polydactylies. METHODS: Data of all pediatric patients treated between 2000 and 2010 were included. For assessing long-term outcome, patients were contacted via mail and asked to complete a questionnaire concerning location and appearance of the scar as well as functional and cosmetic satisfaction (VAS 0-100). RESULTS: In that period, 32 patients (20 male, 12 female) with 53 ulnar polydactylies were treated. In 20 patients the polydactyly occurred bilaterally (63%), in 10 patients on the left side (31%), and 2 patients presented with right-sided ulnar polydactyly (6%). The vast majority of ulnar polydactylies were floating cutaneous appendages. The mean age of the patients at operation was 8.6 months (range 0 to 10 years). 20 patients (63%) responded to the postal questionnaire. Follow-up time was 4.9 years (range 2.1 to 10 years). The majority of patients reported a flat scar (n=18, 90%). Mean overall satisfaction with the postoperative result using a VAS 0-100 score was 89. CONCLUSION: We were able to report a good postoperative outcome of a series of patients suffering from ulnar polydactylies.

Large, segmental, circular vascular malformation of the small intestine (in a female toddler with hematochezia): unusual presentation in a child.

BACKGROUND: Failure to thrive and hematochezia in children may be alarm signs warranting endoscopy. In contrast, vascular malformations of the small intestine are uncommon in this age group. We report on a female toddler in whom various imaging techniques revealed an unusually large segmental vascular malformation of the ileum as the cause of the child's main clinical symptoms. CASE PRESENTATION: A 19 months old girl presented with severe anemia (Hb 3 mmol/l), failure to thrive and chronic diarrhea. Diagnostics for intestinal blood loss and pathogens were negative. The child had duodenoscopy, also for histological diagnosis of celiac disease, with negative results. A dietary protocol was suggestive for inadequate iron intake and she was supplemented. After symptomless four-months the child presented again, now with mild abdominal pain and, for the first time, hematochezia. An orienting abdominal ultrasound (US) study showed a suspicious tumorous bowel condition. A subsequent detailed abdominal US supplemented by a saline enema during investigation (i.e., "hydrocolon", to improve outlining of the formation's localization) revealed a large circumferential cystiform vascular mass of the ileum causing segmental ileal obstruction.Complementing preoperative abdominal hydro-MRI, planned based on the findings of the US study, confirmed the suspected vascular malformation of the ileum and exquisitely outlined the extent, location and anatomy.The patient was successfully operated laparoscopically, the affected ileum segment with the mass was completely removed as proven by histology, and the child recovered well. CONCLUSIONS: The huge segmental vascular malformation of the distal ileum described here is an extreme rarity in young children. Although the reported child's presenting symptoms malabsorption and malnutrition could have been responsible for its severe anemia, this was obviously caused by blood losses from the ileal vascular malformation. It was due to incipient abdominal pain rather than hematochezia that abdominal US was performed and proved crucial for correctly diagnosing this rare malformation. Even in this extensive case detailed imaging work-up including adapted MRI added all information necessary for minimal invasive laparoscopic en bloc resection.

A rare cause for a neonatal cystic abdominal mass.

Intrauterine ovarian torsion is a rare event, but it is a possible cause for unilateral ovarian aplasia. Most commonly the ovary undergoes autolysis after torsion so that no tissue or remnants can be discovered on the involved side. We report a rare case of unilateral intrauterine torsion followed by autoamputation and abdominal reimplantation resulting in an intra-abdominal complex cystic mass with a review of the literature.

Evaluation of fractures in children and adolescents in a Level I Trauma Center in Austria.

BACKGROUND: Injury represents a major concern for children and adolescents worldwide. It is estimated that 10% to 25% of all pediatric injuries will result in fractures. This study aimed to analyze the epidemiology, gender distribution, age, and circumstances of fractures in childhood in a Level I Trauma Center in Austria. METHODS: Children managed with fractures between December 2004 and October 2006 were prospectively evaluated. Patients were divided into four age groups: infants (<1 year), preschool children (1-6 years), school-aged children (6-14 years), and adolescents (>14 years). RESULTS: The study included 3,339 patients younger than 19 years, who presented with 3,421 fractures. There was a male predominance (61.3%, n = 2,096). Girls (38.7%, n = 1,325) had a lower mean age at presentation of 8.2 years (boys, 9.8 years). An increase in the incidences of fractures was observed until a peak of 11 years in girls and 12 years in boys. A majority of fractures occurred in sports facilities (34.7%), followed by those at home (17.6%) and outdoors (16.7%). The most frequent mechanisms were falls on level surface (41.9%), falls from a height <3 m (23.2%), and involuntary contact with persons or objects (18.2%). The most common fractures were those of the distal radius (15.3%), followed by those of the finger (14%) and distal forearm fractures (8%). CONCLUSION: As the Department of Pediatric Surgery in Graz serves as the referral center at least for nearly all major pediatric fractures in the Austrian state of Styria, mechanisms and patterns of major fractures in this study can serve as the basis for state-wide pediatric injury prevention efforts. These prevention strategies should not aim to reduce the level of exposure but should increase the risk awareness and encourage children and their parents to use necessary precautions.

Single-port appendectomy in obese children: an optimal alternative?

INTRODUCTION: The aim of this study was to evaluate our experience with single-port appendectomy (SPA) in obese children. METHODS: From January 2003 to June 2009, 94 SPA (65 women and 29 men, mean age of 12.4 years) were performed in children with appendicitis. Sixty-five of these patients were found to have normal weight, whereas 29 were obese. Patients' records were evaluated regarding operative time, intra- and post-operative complications, initiation of oral intake and histopathological findings. RESULTS: There was no significant difference in operative time between obese and normal weight patients. In the obese group, one wound healing disturbance was documented. In the normal weight group, there were one post-operative bleeding and one wound infection. There was no difference with regards to the introduction of feeds following appendectomy between the groups. Histological examinations revealed 15 normal, 32 acute, 21 phlegmonous, 20 chronic and two perforated cases of appendicitis, three neurogenic appendicopathies and one case of enterobius vermicularis related appendicitis. CONCLUSIONS: Our results indicate that the advantages of single-port appendectomy in the evaluation of the peritoneal cavity, the minimal rate of intra-operative incidents with this technique and superior cosmetics validate this alternative approach of minimal access appendectomy in obese children.

Pin tract infection with external fixation of pediatric fractures.

BACKGROUND: This study aimed to evaluate the incidence and severity of pin tract infections in a series of pediatric trauma patients. METHODS: All pediatric trauma patients with external fixation who were treated at our institution between 1998 and 2003 were included. The charts of 30 children (20 males; 10 females; mean age, 13.2 years; range, 7-19 years) with 37 episodes of external fixation were reviewed. The average duration of external fixation was 17.5 weeks (range, 1-94 weeks). Pin tract infections were graded using the Dahl classification. Bacterial cultures were obtained in case of drainage from the pin site. RESULTS: In 18 (48%) of 37 external fixations, no signs of infection occurred during the treatment period. In the remaining 19 (52%) external fixations, 35 episodes of infection were documented. Most infections were mild or moderate, whereas only 3 (9%) severe deep infections were noted (grade 5). Six (17%) infections healed with local application of rifamycin, whereas 27 (77%) of 35 infections were successfully treated with systemic antibiotics (cefuroxime, clindamycin). The remaining 2 infections (6%) required removal of a pin. CONCLUSIONS: Pin tract infection occurred in half of the patients who were treated with external fixations. Most of the pin site infections in the present series were mild and could be managed by local or systemic application of antibiotics. The occurrence of pin tract infections did not require a change of the method of stabilization.

Role of blood cell-associated AT1 receptors in the microvascular responses to hypercholesterolemia.

OBJECTIVE: Hypercholesterolemia elicits a proinflammatory and prothrombogenic phenotype in the microvasculature that is characterized by activation and adhesion of blood cells. The angiotensin II receptor-1 antagonist Losartan prevents the induction of these responses. The objective of this study was to determine the relative contributions of blood cell-associated versus endothelium-associated AT1a-R to these hypercholesterolemia-induced microvascular alterations. METHODS AND RESULTS: Leukocyte adhesion and emigration and platelet adhesion were quantified by intravital microscopy in postcapillary venules. C57Bl/6 mice were placed on a normal (ND) or high-cholesterol (HCD) diet for 2 weeks. AT1a-R bone marrow chimeras that express AT1a-R on the vessel wall but not blood cells and AT1a-R knockouts were placed on HCD. Venular shear rate was comparable in all groups. Platelet and leukocyte adhesion and leukocyte emigration were significantly increased in HCD mice versus ND. Leukocyte recruitment was significantly reduced in the HCD-AT1a-R bone marrow chimera group, whereas platelet adhesion remained at HCD levels. However, in HCD-AT1a-R knockout mice, platelet and leukocyte adhesion were reduced to ND levels. CONCLUSIONS: These data indicate that the platelet-vessel wall adhesion elicited by hypercholesterolemia is mediated by AT1a-R engagement on the endothelial cell rather than the platelet, whereas leukocyte recruitment is mediated by blood cell-associated AT1a-R.

Modulation of the inflammatory response in cardiovascular disease.

There is a growing body of evidence that inflammation might play an important role in the initiation and progression of cardiovascular diseases (CVDs). The designation of CVD as a chronic inflammatory process is further supported by evidence that the risk factors for CVD cause endothelial cells throughout the vascular tree to assume an inflammatory phenotype. These activated endothelial cells characteristically exhibit oxidative stress and increased adhesiveness for circulating leukocytes. Although initial efforts to define the mechanisms underlying the inflammatory phenotype in diseased endothelial cells have focused on the linkage between oxidative stress and adhesion molecule activation/expression, recent work has implicated a variety of additional factors that can modulate the magnitude and/or nature of the inflammatory responses in CVD. Platelets, angiotensin II, and the CD40/CD40 ligand signaling system are gaining recognition as contributors to the pathogenesis of CVD. These factors appear to converge with known pathways that link oxidative stress with adhesion molecule expression and help to explain the apparent integration of coagulation with inflammation in CVD. These factors also hold the promise of offering multiple sites for therapeutic intervention in CVD.