Ventricular sepsis and abdominally related complications in children with cerebrospinal fluid shunts.

In a retrospective study of 300 children who underwent placement or revision of cerebrospinal fluid (CSF)-peritoneal shunts during a 10-year period, 15 (5%) developed shunt-related abdominal complications with ventricular sepsis and two developed acute perforated appendicitis. Abdominal complications and associated shunt infections suggested two potential modes of development: (1) descent of contaminated CSF from an infected shunt into the abdomen (CSF ascites--four patients, CSF pseudocysts--four patients, and shunt-induced abscess/peritonitis--five patients); and (2) ascent of bacteria into the shunt from an abdominal source (visceral perforation by the shunt catheter--two patients and acute perforated appendicitis--two patients). Three types of shunt systems were placed during the study period; five of the seven (71%) most serious septic complications were associated with the use of Raimondi spring-reinforced catheters. Bacteria isolated in this series were associated with differing modes of sepsis: those involving descent of bacteria into the abdomen from an infected shunt were predominantly gram-positive, cutaneous microorganisms, whereas those associated with ascent of bacteria from the abdomen into the shunt were mixed, gram-negative intestinal microorganisms. Appendicitis did not result in shunt infections. Aggressive treatment resulted in no operative or complication-related deaths. Removal of the shunt catheter from the abdomen and intravenous antibiotics were essential for eradication of sepsis; laparatomy was required only for cases with suspected peritonitis. In eight of the 17 (47%) patients, reestablishment of CSF-peritoneal shunts was performed after resolution of shunt-related complications. In recent years improved shunting materials and supportive care have reduced the incidence of the most serious of these complications.

Impaired surfactant production in cretin lambs.

Midgestation ovine fetal thyroidectomy resulted in profound congenital hypothyroidism and severe respiratory distress at term. Amniotic fluid obtained at delivery revealed low lecithin: sphingomyelin (L:S) ratios in all animals with a predominantly acidic phosphatide pulmonary phospholipid profile. Surfactant was diminished in the lung effluent of cretins at birth as compared with normal lambs. The acidic phosphatides and low L:S ratios persisted in the pharyngeal aspirates of the cretin lambs following attempted air breathing and the onset of severe respiratory distress. Conversely, normal lambs released considerable surfactant at birth that contained nonacidic phosphatides dominated by dipalmitoyl lecithin and yielding strongly positive L:S ratios. Comparative histologic studies revealed poor alveolar differentiation in certain lambs and persistence of the midgestation canalicular stage of lung development.

Basilar pneumonia simulating acute appendicitis in children.

Twelve children with acute abdominal pain, which was suspected of being acute appendicitis, were subsequently found to have lower lobe pneumonia. Diagnostic barium enema or operative exploration failed to demonstrate any appendiceal abnormality. The abdominal symptoms and the ileus subsided soon after the initiation of antibiotic therapy. Contrary to common belief, it was observed that left-sided pneumonia is capable of mimicking appendicitis almost as frequently as right-sided pneumonia. Since the likelihood of acute appendicitis accompanying pneumonia is small, operative intervention is rarely indicated and should be undertaken only after careful and intensive investigation.

Fat overload with a 10% soybean oil emulsion.

A 10% soybean oil emulsion (Intralipid) has been demonstrated to be an effective means of delivering an adequate caloric intake via a peripheral vein. This emulsion has generally been considered safe and free of significant complications. This is a report of a child who initially thrived on this intravenously administered fat emulsion, then suddenly developed a lifethreatening intolerance to the infusion, which appeared to be the "fat overload syndrome." This syndrome, seen frequently with earlier fat emulsions, has not been reported previously as a complication of the 10% soybean oil emulsion.

Congenital anomalies of the umbilicus.

Knowledge of the embryonic developments of the umbilicus and its contents assists the physician in correctly assessing the various anomalies found in this area. Although some will require specialized facilities and care, the majority of these anomalies can be corrected by simple operative means.

The meconium ileus equivalent following appendectomy.

A child with cystic fibrosis developed the meconium ileus equivalent in the postappendectomy period. This problem has not been emphasized in patients with cystic fibrosis. Operative evacuation only partially relieved the obstruction. Transient upper gastrointestinal bleeding fortuitously produced beneficial effect, which completely resolved the persisting ileus.

Intramural tracheoesophageal fistula (TEF) associated with esophageal web.

This is a report of the fourth known case of intramural TEF with diaphragmatic esophageal atresia. These patients present clinically as a typical esophageal atresia with tracheoesophageal fistula, but in effect have the following unusual features: 1) high TEF entering the trachea in the neck; 2) diaphragmatic-type atresia of the esophagus with uninterrupted muscular coat; 3) the location of this diaphragm is at the level of the carina producing in effect a long intramural fistulous tract. It is believed that faulty recannulization of a segment of the esophagus in association with H-type TEF may explain this uncommon anomaly.

Lymphoid hyperplasia of the bowel and its surgical significance in children.

Twelve children with abdominal complaints had lymphoid hyperplasia of the bowel presenting in an acute or chronic form. The etiology is obscure. An infectious process is thought to precipitate the acute form of the disease. Parasites were identified in two patients with the chronic disease. The acute form, with involvement of the appendix or terminal ileum, presents commonly as acute appendicitis. Because of its self-limiting nature, appendectomy with perservation of the terminal ileum is appropriate. When intussusception is present, resection of the ileum is advisable. The chronic form, which is also common in the terminal ileum, produces disabling symptoms, recurrent intussusception, chronic anemia, and weight loss and is, therefore, amenable to surgical resection.

Agenesis of the dorsal mesentery without jejunoilial atresia ("apple peel small bowel").

Agenesis of the dorsal mesentery with apple peel or Christmas tree deformity but without small-bowel atresia can occur beyond the neonatal period. The recognition of this entity is imperative as it is also associated with a marginal artery which may be the only blood supply to the majority of small bowel. Preservation of this vessel is necessary to avoid catastrophic bowel death.