Recanalization of Chronic Portal Vein Occlusion in Pediatric Liver Transplant Patients.

PURPOSE: To evaluate technical and clinical success and report long-term outcomes of portal vein (PV) recanalization in pediatric orthotopic liver transplant (OLT) patients with chronic PV occlusion. MATERIALS AND METHODS: This is a retrospective review of 15 OLT patients (5 males) with chronic PV occlusion who underwent PV recanalization (33 procedures) between October 2011 and February 2018. Median age was 4.5 years (range, 1-16 years); median weight was 16.6 kg (range, 11.5-57.3 kg). Median time interval from OLT to first intervention was 3.25 years (range, 0.6-15.7 years). Clinical presentations included hypersplenism (n = 12), gastrointestinal bleeding (n = 9), and ascites (n = 3). One patient had incidental diagnosis of PV occlusion. Primary, primary-assisted, and secondary patency at 3, 6, 12, and 24 months were evaluated. RESULTS: Technically successful PV recanalization and reduction of PV pressure gradient to ≤ 5 mm Hg was performed in 13/15 patients (87%). Ten of 15 (67%) patients had successful recanalization with the first attempt. Clinical success, defined as improvement in signs and symptoms of portal hypertension, was achieved in 12/13 (92%) patients. Five of 33 (15%) major complications (Society of Interventional Radiology class C), including perisplenic hematoma (n = 2), hemoperitoneum (n = 2), and hepatic artery pseudo aneurysm (n = 1), were managed with pain medication and blood product replacement. Median follow-up was 22 months (range, 1-77 months). Median primary patency was 5 months. Primary patency at 3, 6, 12, and 24 months was 53.8%, 46.2%, 38.5%, and 30.8%, respectively. Primary-assisted patency was 84.6%, 76.9%, 53.8%, and 46.2%, respectively. Secondary patency was 92.3%, 84.6%, 53.8%, and 46.2%, respectively. CONCLUSIONS: PV recanalization is a safe and effective minimally invasive option in the management of chronic PV occlusion after pediatric OLT.

Generation of patient-derived tumor xenografts from percutaneous tumor biopsies in children with bone sarcomas.

One of the limitations of performing percutaneous biopsies in patients with bone sarcomas is the small amount of tumor that can be obtained for research purposes. Here, we describe our experience developing patient-derived tumor xenografts (PDXs) using percutaneous tumor biopsies in children with bone sarcomas. We generated 14 bone sarcoma PDXs from percutaneous tumor biopsies. We also developed eight bone sarcoma PDXs from surgical resection of primary bone tumors and pulmonary metastases. A multidisciplinary team approach was critical to establish an accurate diagnosis and to provide adequate tumor samples for PDX generation.

Navigating linguistic barriers: a case for and against medical Spanish certification for medical students in border states.

Limited English proficiency poses a significant barrier to health care, particularly in US border states, exacerbated by a nationwide shortage of interpreters. This growing disparity in language-concordant care underscores the need for solutions like integrating Medical Spanish Certification (MSC) into medical school curricula, a topic of considerable debate. Various arguments exist for and against including MSC in medical education, especially considering the increasing Hispanic/Latino patient population. This paper aims to present a balanced perspective on officially including MSC in medical school curricula. After discussing the various arguments, the authors suggest a balanced approach that addresses the challenges while leveraging the potential benefits of MSC in medical education.

Ureteral stricture after pediatric kidney transplantation: Is there a role for percutaneous antegrade ureteroplasty?

INTRODUCTION: Ureteral obstruction following pediatric kidney transplantation occurs in 5-8% of cases. We describe our experience with percutaneous antegrade ureteroplasty for the treatment of ureteral stricture in pediatric kidney transplant patients. METHODS: We retrospectively reviewed all pediatric kidney transplantation patients who presented with ureteral stricture and underwent percutaneous antegrade ureteroplasty at our institution from July 2009 to July 2021. Variables included patient demographics, timing of presentation, location and extent of stricture, ureteroplasty technique and clinical outcomes. Our primary outcome was persistent obstruction of the kidney transplant. RESULTS: Twelve patients met inclusion criteria (4.2% of all transplants). Median age at time of ureteroplasty was 11.5 years (range: 3-17.5 years). Median time from kidney transplantation to ureteroplasty was 3 months. Patency was maintained in 50% of patients. Seven patients (58.3%) required additional surgery. Four patients developed vesicoureteral reflux. Patients with persistent obstruction had a longer time from transplant to ureteroplasty compared to those who achieved patency (19.3 vs 1.3 months, p = 0.0163). Of those treated within 6 months after transplantation, two patients (25%) required surgery for persistent obstruction (p = 0.06). All patients treated >1 year after transplantation had persistent obstruction following ureteroplasty (p = 0.06). CONCLUSION: Percutaneous antegrade ureteroplasty can be considered a viable minimally invasive treatment option for pediatric patients who develop early ureteral obstruction (<6 months) following kidney transplantation. In patients who are successfully treated with ureteroplasty, 67% can develop vesicoureteral reflux into the transplant kidney. Patients who fail early percutaneous ureteroplasty or develop obstruction >1 year after transplantation are best managed with surgical intervention.

Doppler ultrasound for post-angioplasty follow-up in pediatric segmental branch renal artery stenosis: A case report.

INTRODUCTION: Segmental branch renal artery stenosis is an important cause of renovascular hypertension in the pediatric population that is often managed with angioplasty and may require imaging multiple times pre- and post-procedure. Gold standard imaging is angiography, which exposes children to radiation and intravenous contrast. There is not a clear guideline for imaging during follow-up, but patients are monitored for symptom recurrence, which could then trigger repeat imaging. The following case highlights a method of follow-up that has not been broadly studied that may offer benefits over clinical monitoring alone, and how interprofessional cooperation could offer effective surveillance and reassurance for families through a cost-effective method that minimizes potential for harm. CASE AND OUTCOMES: This report describes the clinical course of a child with hypertension secondary to segmental branch renal artery stenosis who was treated with angioplasty and who received follow-up imaging with renal Doppler ultrasound. This method allows the care team to ensure stability of the caliber of the repaired vessel and non-recurrence of stenosis at follow-ups through monitoring for intra-arterial velocity and waveform changes. DISCUSSION: Close follow-up of children with renal artery stenosis is vital following intervention due to high risk of recurrence. Clinical follow-up alone could be sufficient for some patients, however many still require CTA, sometimes even more than once, when symptoms worsen or there is evidence of end-organ damage. During follow-up, collaboration with skilled sonographers to monitor post-repair velocities and waveforms using Doppler ultrasound presents several possible advantages. This includes providing reassurance to patient families, minimizing harmful radiation and contrast exposure, and the potential for early detection of recurrence of stenosis. Especially in cooperative, older pediatric patients with a normal BMI who have a main renal artery stenosis or even in those with a segmental branch stenosis identified through CTA such as in this case. CONCLUSION: This case demonstrates how coordination with sonographers and the use of ultrasound with Doppler could improve the follow-up of pediatric patients with segmental branch renal artery stenosis post-angioplasty to provide further reassurance to families, minimize harm to patients, and ensure post-procedure stability beyond just clinical parameters.

Management of Acute Portal Vein Thrombosis With Serial Mechanical Thrombectomy and tPA in a Pediatric Liver Transplant Recipient: A Case Report.

BACKGROUND: Acute portal vein thrombosis is a major cause of fulminant allograft failure in pediatric liver transplantation. Timely intervention is critical to save the graft and patient. Serial interventional radiologic management of this condition is scarcely reported in the literature. CASE SUMMARY: A recently transplanted 17-year-old male presented to the emergency department with abdominal pain. Rising liver enzymes prompted discovery of a diffuse portal thrombus, which precipitated fulminant liver failure. The adolescent developed respiratory failure, vasodilatory shock, acute kidney injury, and hepatic encephalopathy, complicating treatment. Multiple interventions attempted to clear the thrombus, including interventional radiologic and medical therapies. Uniquely, a continuous infusion catheter was placed at the thrombosis, delivering local tissue plasminogen activator during a 5-day period. Upon thrombus clearance, the patient made a full recovery with no complications during 12 months of follow-up. CONCLUSIONS: When used as a component of multidisciplinary management, continuous locally directed tissue plasminogen activator may be a useful tool for clearance of persistent portal vein thrombosis.

Single-Incision Versus Conventional Technique for Tunneled Central Line Placement in Children.

PURPOSE: A single-incision technique for tunneled central venous access has been described. This study evaluates whether single-incision technique in children is comparable to the conventional method, with regard to procedure time, fluoroscopy time, and complication rate. MATERIALS AND METHODS: This is a retrospective review of 303 internal jugular vein tunneled central catheter placements whose age ranged from newborn to 17 years (median 1.7 years) by pediatric interventional radiologists from January 2014 through December 2015. 223 catheters were placed (181 patients) using the single-incision technique, and 80 catheters were placed (72 patients) using the conventional two-incision technique. Data were obtained from electronic medical records and PACS including procedure time, fluoroscopy time, and complication rates which were compared for both single-incision and conventional techniques. RESULTS: Technical success for the single-incision and conventional technique groups was 99.1 and 98.8%, respectively. Early complication rate was 12.1% for the single-incision technique and 17.5% for the conventional technique (p = 0.254). Overall complication rate was 26% (3.8/1000 line days) for the single-incision technique and 37.5% (4/1000 line days) for the conventional technique (p = 0.085). Median procedure time was 25 min for the single-incision technique and 26 min for the conventional technique (p = 0.427). Median fluoroscopy time was 1.7 min in the single-incision group and 1.3 min in the conventional group (p = 0.085). CONCLUSION: The single-incision technique for central venous access has comparable procedure time and fluoroscopy time with no difference in complication rates between the two techniques in a pediatric population.

Optimal Diagnostic Yield Achieved With On-site Pathology Evaluation of Fine-Needle Aspiration-Assisted Core Biopsies for Pediatric Osseous Lesions: A Single-Center Experience.

CONTEXT: - Image-guided, fine-needle aspiration-assisted core needle biopsy with an on-site evaluation by a pathologist (FNACBP) of osseous lesions is not a common practice in pediatric institutions. OBJECTIVES: - To evaluate the diagnostic adequacy and accuracy of FNACBP for pediatric osseous lesions and to compare the adequacy with procedures that do not use fine-needle aspiration. DESIGN: - Six-year, retrospective review of 144 consecutive children biopsied for osseous lesions with and without fine-needle aspiration assistance. RESULTS: - Pathologic diagnosis was achieved in 79% (57 of 72) of the core biopsies without an on-site evaluation, 78% (32 of 41) of the open biopsies (9 with intraoperative consultation), and 97% (30 of 31) of the FNACBPs as the initial diagnostic procedure. Three FNACBP cases were preceded by nondiagnostic open biopsies. Among 34 lesions sampled by FNACBP, 33 (97%) succeeded with diagnostic tissue, with most (30 of 33; 91%) being neoplasms, including 16 malignant (48%), 13 benign (39%), and 1 indeterminate (3%) lesions. The most-common diagnoses were osteosarcoma (9 of 33; 27%) and Langerhans cell histiocytosis (7 of 33; 21%). In cases with follow-up information available, 93% (28 of 30) of the FNACBP-rendered diagnoses were clinically useful, allowing initiation of appropriate therapy. The FNACBP procedure had 100% specificity, sensitivity, and positive predictive value for all 14 malignant lesions, with the sensitivity being 88% in benign lesions. Most FNACBP procedures (32 of 34; 94%) yielded adequate material for ancillary testing. A gradual upward trend was observed for the choice of FNACBP as an initial diagnostic procedure for osseous lesions. CONCLUSIONS: - The FNACBP procedure yields sufficient material for diagnosis and ancillary studies in pediatric, osseous lesions and may be considered an initial-diagnostic procedure of choice.

Tuberculosis Cervical Adenitis: Management Dilemmas.

Peripheral lymphadenopathy (scrofula) is the second most common site for childhood tuberculosis. Paradoxical reactions are commonly seen even in immunocompetent children after therapy is initiated, and this can lead to draining sinus tracts. We describe a multimodal therapeutic option of antituberculosis therapy, corticosteroids and therapeutic ultrasound-guided nodal aspiration in an adolescent with massive cervical adenopathy.

Traumatic hepatic artery laceration managed by transarterial embolization in a pediatric patient.

While blunt abdominal trauma with associated liver injury is a common finding in pediatric trauma patients, hepatic artery transection with subsequent treatment by transarterial embolization has rarely been reported. We present a case of a child who suffered from a hepatic artery injury which was successfully managed by supraselective transarterial microcoil embolization, discuss management strategies in these patients, and provide a review of currently available literature.

Ectopic cervical thymic tissue: can imaging obviate biopsy and surgical removal?

Thymic tissue rests can be found all along the route of thymic descent from the neck into the anterior mediastinum and are frequently misinterpreted as pathological masses, which leads to biopsy or surgical removal. We present a case of ectopic thymic tissue in the neck and review the imaging characteristics of our patient and those found in the literature to determine if biopsy for this normal variation can be avoided. US findings of ectopic tissue reveal the exact tissue characteristics of normal thymus. The ectopic thymus may have an angulated configuration and mold over adjacent structures rather than displacing or invading them. If further verification is needed, T1-weighted MR images show homogeneous isointense or slightly hyperintense tissue compared with muscle and T2-weighted images show hyperintensity. The mass has the same structure as the normal thymus. We believe, on the basis of these findings, that one can confidently avoid the need for biopsy to prove that the discovered mass is ectopic thymus tissue.

Delayed presentation of malrotation and midgut volvulus: imaging findings.

Midgut volvulus presenting outside the neonatal period often manifests with less than classic findings. One must be ever vigilant for any deviation from normal when imaging the gastrointestinal tract in these patients. Plain films often are noncontributory, and gastrointestinal imaging findings frequently are subtle and not exactly the same as those seen in classic cases in the neonatal period. Cases are presented illustrating the following: abnormal but less than classic small bowel location and configuration, malabsorption and fortuitous spiraling of a nasogastric tube, viral gastroenteritis and pseudo intussusception, intractable vomiting and dehydration with abnormal cecal position, and duodenal obstruction: pseudo SMA syndrome. Fortunately, one now can confirm one's suspicions with computed tomography and ultrasound in terms of determining whether the superior mesenteric artery and superior mesenteric vein positions are normal or reversed.

Sterile fluid collections in acute pancreatitis: catheter drainage versus simple aspiration.

PURPOSE: To compare the clinical outcome of needle aspiration versus percutaneous catheter drainage of sterile fluid collections in patients with acute pancreatitis. METHODS: We reviewed the clinical and imaging data of patients with acute pancreatic fluid collections from 1998 to 2003. Referral for fluid sampling was based on elevated white blood cell count and fevers. Those patients with culture-negative drainages or needle aspirations were included in the study. Fifteen patients had aspiration of 10-20 ml fluid only (group A) and 22 patients had catheter placement for chronic evacuation of fluid (group C). We excluded patients with grossly purulent collections and chronic pseudocysts. We also recorded the number of sinograms and catheter changes and duration of catheter drainage. The CT severity index, Ranson scores, and maximum diameter of abdominal fluid collections were calculated for all patients at presentation. The total length of hospital stay (LOS), length of hospital stay after the drainage or aspiration procedure (LOS-P), and conversions to percutaneous and/or surgical drainage were recorded as well as survival. RESULTS: The CT severity index and acute Ransom scores were not different between the two groups (p = 0.15 and p = 0.6, respectively). When 3 crossover patients from group A to group C were accounted for, the duration of hospitalization did not differ significantly, with a mean LOS and LOS-P of 33.8 days and 27.9 days in group A and 41.5 days and 27.6 days in group C, respectively (p = 0.57 and 0.98, respectively). The 60-day mortality was 2 of 15 (13%) in group A and 2 of 22 (9.1%) in group C. Kaplan-Meier survival curves for the two groups were not significantly different (p = 0.3). Surgical or percutaneous conversions occurred significantly more often in group A (7/15, 47%) than surgical conversions in group C (4/22, 18%) (p = 0.03). Patients undergoing catheter drainage required an average of 2.2 sinograms/tube changes and kept catheters in for an average of 52 days. Aspirates turned culture-positive in 13 of 22 patients (59%) who had chronic catheterization. In group A, 3 of the 7 patients converted to percutaneous or surgical drainage had infected fluid at the time of conversion (total positive culture rate in group A 3/15 or 20%). CONCLUSIONS: There is no apparent clinical benefit for catheter drainage of sterile fluid collections arising in acute pancreatitis as the length of hospital stay and mortality were similar between patients undergoing aspiration versus catheter drainage. However, almost half of patients treated with simple aspiration will require surgical or percutaneous drainage at some point. Disadvantages of chronic catheter drainage include a greater than 50% rate of bacterial colonization and the need for multiple sinograms and tube changes over an average duration of about 2 months.

Imaging of acute appendicitis: US as the primary imaging modality.

BACKGROUND: The investigation of the acute abdomen in infants and children has evolved during the last two decades, placing imagers at the forefront of the evaluation and diagnosis of acute right lower quadrant abdominal problems. US and CT have recently been shown to be equally accurate in the diagnosis of acute appendicitis, but not everyone agrees. OBJECTIVE: To demonstrate the efficacy of triaging patients with acute abdominal problems that suggest appendicitis with US as the primary imaging modality. MATERIALS AND METHODS: We retrospectively reviewed the prospective imaging diagnoses in 622 children who presented to our emergency room (ER) and clinics with acute abdominal symptoms suggestive of appendicitis. We documented whether US or CT was performed and noted the diagnoses made. All of the patients had plain films. In addition, all patients undergoing surgical appendectomy during this time were also documented so as not to miss any cases of appendicitis. None was missed. RESULTS: There were 622 consecutive patients in our study. Three patients, diagnosed as normal, were eventually excluded because of lack of follow-up. In all, 152 patients were evaluated clinically and with plain films only. They were not subject to surgical exploration or further imaging. None returned with appendicitis. Eighty-one patients were directly subject to laparotomy after clinical and plain film evaluation. Of these patients, 20% had a normal appendix. Of the remaining 389 patients, 386 had US and three had CT alone. Four patients had both CT and US because of an inconclusive US examination. Three patients had CT alone because of their size. In total, 137 patients were diagnosed with appendicitis with US and/or CT. Four of these patients (3%) had normal appendices. Forty-two patients (less three lost to follow-up) were diagnosed as normal, and none returned with findings of appendicitis. Nine others had conditions other than acute appendicitis. Three had surgically proven, nonrelated conditions, and of the other six, one had pancreatitis and five nonsurgical adnexal problems. In all, 201 patients were diagnosed (with US) with mesenteric adenitis-enteritis, and none returned with findings of appendicitis. CONCLUSION: We attained a high degree of diagnostic accuracy in patients presenting with findings suggestive of appendicitis using US as the primary imaging modality. Our false-positive appendectomy rate was 3%. Therefore, triage of the acute abdomen with US supported by CT when required has considerable merit, especially when considering that US is noninvasive and does not use ionizing radiation.

Frequently missed fractures in children (value of comparative views).

Fractures in infants and children are different to those seen in adults. Many are very subtle and difficult to detect with certainty. Furthermore, variations in bone contour and epiphyseal plate configuration are endless and at first may suggest pathology. Comparative views are therefore invaluable and are emphasized throughout this communication, which deals with: (1) plastic bending fractures, (2) hairline fractures, (3) impaction fractures, (4) subtle epiphyseal-metaphyseal Salter-Harris fractures, and (5) subtle angle buckle fractures. Helpful points to assist one in detecting these fractures are presented.