Pneumatosis intestinalis in a cohort of children with neurological impairment: A patient group with a management dilemma.

AIM: Pneumatosis intestinalis (PI) is uncommon in school-age children. We studied a cohort of neurologically impaired school-age children with PI to formulate an optimum management plan. METHODS: We retrospectively studied all school-age children who were referred to paediatric surgeons with radiological evidence of PI identified between 2011 and 2015. We analysed data on patient demographics, medications, feeding, associated comorbidities, presentation, investigations and treatments. RESULTS: Five patients (3F:2M) with a median age of 7 years (range 5-9) were referred for surgical opinion with the evidence of pneumatosis on their abdominal X-rays. Four of them had associated pneumoperitoneum. All children had neurological impairment significant enough to make them unable to communicate clearly. Four patients were gastrostomy fed, one was jejunally fed. Four children had recurrent episodes of pneumatosis. Four patients had surgery at the initial presentation where colonic pneumatosis was detected; however, there was no evidence of bowel ischaemia or perforation despite of the presence of pneumoperitoneum. Recurrent episodes were successfully managed conservatively even in the presence of pneumoperitoneum. CONCLUSION: In neurologically impaired school-age children, the presence of pneumatosis and pneumoperitoneum does not mandate bowel ischaemia or perforation and therefore could be successfully managed conservatively without the need for surgery.

Laparoscopic retrieval of disconnected shunt catheters from the peritoneal cavity as a day-case procedure in children--early feasibility report.

PURPOSE: The aim of this study was to report our experience with laparoscopic retrieval of disconnected shunt catheters in children. METHODS: Demographic data, indications for shunt insertion, time to disconnection, symptomatology, time to retrieval, operative details, length of stay and complications were recorded retrospectively. Laparoscopy was performed using two 5-mm ports and 10-12-mmHg CO(2) pneumoperitoneum. RESULTS: Seven children (five boys, two girls) had laparoscopic retrieval of disconnected ventriculoperitoneal (VP; n = 6) and lumboperitoneal (n = 1) shunt catheters between 2006 and 2008. Median age was 8 (5-15) years. The indications for shunt insertion were hydrocephalus (n = 4), traumatic subdural haematoma (n = 1), pinealoblastoma (n = 1) and idiopathic intracranial hypertension (n = 1). Median interval from insertion to disconnection was 3 (range 1-10) years. Presenting symptoms were headache (n = 3) and neck swelling (n = 1). Three children were asymptomatic. Median referral-to-procedure time was 69 (range 2-224) days. One child underwent emergency removal of disconnected shunt with laparoscopic-assisted VP shunt insertion under the same anaesthetic. One child had a laparotomy as the catheter tip had penetrated the sigmoid mesocolon close to the bowel and could not be safely removed laparoscopically. Of the remaining five children, four had the procedure performed as day cases. There was no intra- or post-operative morbidity or subsequent shunt infections. CONCLUSIONS: Peritoneally migrated shunt catheters have a risk of viscus injury, particularly bowel perforation. In our experience, laparoscopic retrieval of migrated shunt catheters was safe both as an emergency procedure and electively, when it was performed as a day-case basis in selected patients with excellent outcome.

Laparoscopy and transdiaphragmatic thoracoscopy in management of ruptured amebic liver abscess.

In this paper, we present a case of an amebic liver abscess in a 30-month-old child, which presented to the senior author with a right empyema thoracic. Diagnosis was made with ultrasound of the abdomen and chest and a computed tomography scan. A surgical intervention was done after initial management, including when the chest-drain insertion failed. Laparoscopy was performed. With three working ports in the abdomen, the abscess was deroofed and the pus removed. A 3-cm defect in the diaphragm was identified. An intercostal drain site was utilized to use sponge holders and suction catheters to aid in the deroofing process. A laparoscope was then advanced through the defect and a thoracic toilet performed by using abdominal working ports and a chest-drain insertion site. According to us, this is the first case report of the laparoscopic management of a complicated amoebic liver abscess and the use of abdominal ports to treat empyema thoracic at the same sitting. The use of laparoscopy helped the child to recover faster, thereby avoiding major laparotomy and thoracotomy.

Thyroglossal duct cyst masquerading as a haematoma.

Thyroglossal duct cysts most frequently present in childhood as painless midline swellings around the level of the hyoid. Classically the cyst moves upwards on protruding the tongue. Here we report a novel case of a thyroglossal cyst in an adult in whom the history, examination and fine needle aspiration cytology were typical of a traumatic haematoma. This case is also unique because the thyroglossal duct cyst extended beyond the thyroid gland to the suprasternal notch and actually required two parallel transverse cervical incisions for its complete en bloc removal.

Surgical outcome analysis of paediatric thoracic and cervical neuroblastoma.

OBJECTIVE: To identify factors determining the surgical outcome of primary cervical and thoracic neuroblastoma. METHODS: Twenty-six children with primary thoracic neuroblastoma presented over the last 14 years were analysed for age, mode of presentation, tumour histopathology, biology and outcome. RESULTS: Primary thoracic neuroblastoma was presented in 16 boys and 10 girls at a median age of 2 years (range 6 weeks-15 years). The International Neuroblastoma Staging System (INSS) classified these as Stage 1 (8), Stage 2 (5), Stage 3 (6) and Stage 4 (7). Computed tomography defined the tumour location at the thoracic inlet (11), cervical (2), cervico-thoracic (3), mid-thorax (9) and thoraco-abdominal (1). Twenty-two children underwent surgery that allowed an adequate exposure and resection. Surgical resection was achieved after initial biopsy and preoperative chemotherapy in 15 children, whereas primary resection was performed in 7 children. Four patients with Stage 4 disease underwent chemotherapy alone after initial biopsy; of which, two died despite chemotherapy. Favourable outcome after surgical resection and long-term survival was seen in 19 (86.4%) of the 22 children. Three had local recurrence (14 to 21 months postoperatively), all with unfavourable histology on initial biopsy. The prognostic factors that determined the outcome were age and INSS stage at presentation. In this series, all patients under 2 years of age are still alive, while mortality was seen in five older children. CONCLUSION: Thoracic neuroblastoma in children under 2 years of age irrespective of stage and histology of the tumour results in long-term survival.

Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study.

BACKGROUND/PURPOSE: A randomised controlled trial evaluating the role of video-assisted thoracoscopic surgery (VATS) in childhood empyema reported a failure rate of 16.6%. Our aim is to determine the outcome of VATS in a large series of children managed by 3 paediatric surgeons experienced in endoscopic surgery. METHOD: A retrospective study of all children with empyema admitted under the care of the 3 surgeons between February 2004 and February 2008 was undertaken. Recorded details included demographic data, mode of presentation, preoperative investigations, operative details, antibiotic usage, microbiological data, postoperative course, follow-up data and complications. RESULTS: 114 children (69 boys, 45 girls) had VATS for empyema. Their median age was 5 (0.2-15) years. The pleural cavity was drained for a median of 4 (2-13) days. Median postoperative hospital stay was 7 (4-36) days. Median follow-up was 8 (1-24) months. There were 8 (7%) treatment failures: 5 conversions to thoracotomy and 3 recurrent empyemas. There were 7 complications (6%): air leak (n = 6) and lung injury (n = 1). 104 (91%) children had full resolution of symptoms. There were no deaths. CONCLUSION: Video-assisted thoracoscopic surgery has a better outcome in childhood empyema than reported in a recent randomised trial and it has an important role in the management of this condition.

Mediastinal and pulmonary infantile myofibromatosis: an unusual surgical presentation.

A 4-week-old boy was extensively investigated for stridor and respiratory distress and was found to have a soft tissue mass superior to the left hilum and emphysema of the entire left lung. An exploratory thoracotomy was undertaken for diagnosis and possibly to improve respiratory distress. Intraoperatively, a firm plaquelike mass was identified encasing the entire hilum including left pulmonary artery and left main bronchus. It became apparent that a left pneumonectomy was needed to be performed to resect the tumor completely and achieve hemostasis. Histopathologic examination revealed infantile myofibromatosis with multiple foci within the entire lung parenchyma as well as in the hilar mass. The child is completely recurrence-free and symptom-free after 6 years of follow-up. The literature review was carried out to discuss management of this rare but benign and surgically challenging condition.

Group A streptococcal septicaemia presenting as an acute abdomen in a child.

We present an unusual case of group A streptococcal septicaemia referred to a paediatric surgical unit as acute appendicitis and highlight the importance of remembering this condition as part of a differential diagnosis.