Supraumbilical skin-fold incision for pyloromyotomy.

We describe our experience with a supraumbilical skin-fold incision for pyloromyotomy in infants. Our technique uses a vertical fascial incision. This approach provides excellent exposure to the pylorus, allows greater operative flexibility, and results in a superior cosmetic outcome compared to the traditional right upper-quadrant incision.

Importance of diarrhea as a presenting symptom of appendicitis in very young children.

BACKGROUND: Appendicitis is an uncommon diagnosis in very young children. It is frequently complicated by delays in diagnosis, perforation, and lengthy hospital stays. OBJECTIVES: To review our recent experience with appendicitis among children younger than 3 years old, and to identify the independent predictors of a prolonged hospital stay. METHODS: A retrospective case series review was performed on all children under age 3 who had an appendectomy for appendicitis between January 1983 and February 1994. Multiple regression analysis was used to identify the independent predictors of a prolonged hospital stay. RESULTS: Sixty-three children were identified. Mean age was 2.2 years (range 11 to 35 months). The mean delay from onset of symptoms to presentation was 4.3 days. Fifty-seven percent were initially misdiagnosed. Diarrhea was reported in 33%. Perforation and/or gangrene were found in 84%. Perforation and/or gangrene at laparotomy and a history of diarrhea at presentation were independent predictors of a prolonged hospital stay. CONCLUSIONS: Appendicitis in children under 3 years old is characterized by delays in diagnosis and perforation. A history of diarrhea is an important factor that confuses the diagnosis, prolongs the observation period, and delays appropriate therapy.

Cholecystectomy in the elderly.

A 4-year retrospective review of 212 patients over 70 years of age who underwent elective and emergency cholecystectomies was undertaken. Elective procedures were performed in 119 patients (76 women, 43 men) whereas 93 patients (43 women, 50 men) underwent emergency surgery. Complications developed in 25 and 34 patients, respectively. In the elective group, the most common complication involved the cardiovascular system, whereas sepsis with multiple organ failure accounted for all of the deaths in the emergency group. Among the 212 patients studied, there was a 3 percent mortality rate in the elective group and a 10 percent mortality rate in the emergency group, with an overall mortality rate of 6 percent. The results indicated that since the risks of elective cholecystectomy are relatively low in the elderly and the risks of cholecystectomy performed as an emergency are considerably higher (10 percent), symptomatic elderly patients with gallstones should be considered good candidates for early elective cholecystectomy.

Use of extracorporeal membrane oxygenation in the septic neonate.

Extracorporeal membrane oxygenation (ECMO) is widely used for cardiopulmonary support in neonates with cardiopulmonary failure secondary to overwhelming sepsis. The purpose of this study was to examine the effects of culture status on the eventual outcome of septic neonates requiring ECMO support. Data from the Extracorporeal Life Support Organization (ELSO) for the tears 1990 through 1992 inclusive were collected and analyzed for all neonates with a primary diagnosis of sepsis. Records were reviewed for gestational age, birth weight, culture status and isolated organism, last arterial blood gas before beginning ECMO, hemorrhagic complications during bypass, and overall survival. Gram-positive sepsis accounted for 85% of positive cultures. Group B streptococcus (GBS) and Escherichia coli were the most commonly isolated organisms (GBS: 95% of all gram-positive sepsis; E coli: 76% of all gram-negative sepsis) from culture-positive patients. Culture-negative patients were found to have a significantly lower mortality rate compared with culture positive patients (16.6% versus 26.9%, P < .001). The incidence of intracranial hemorrhage (ICH) was greater in culture-positive neonates when compared with culture negative (27.6% versus 20.1%, P < .05). There was no difference in the incidence of ICH or eventual outcome between gram-positive and gram-negative sepsis. The culture-positive, septic neonate who requires ECMO support appears to be at an increased risk for intracranial hemorrhage and death. Intracranial hemorrhage appears to be the primary factor affecting survival in these patients. The etiologic organism does not affect the incidence of ICH or outcome. Frequent head ultrasounds and strict control of coagulation parameters are recommended in this patient population.

Should laparoscopic appendectomy be avoided for complicated appendicitis in children?

BACKGROUND/PURPOSE: Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, recent literature on adults suggests that laparoscopic appendectomy may increase the risk for postoperative infectious complications in complicated (gangrenous or perforated) cases. This study was undertaken to compare the results of open versus laparoscopic appendectomy for complicated appendicitis in children. METHODS: A retrospective review from two institutions was performed for all children treated operatively for complicated appendicitis from January 1994 through November 1996. RESULTS: Fifty-six cases were identified. Twenty-seven children underwent laparoscopic appendectomy, whereas 22 underwent open appendectomy. Seven children underwent conversion from laparoscopic to open surgery. Operating times and length of hospital stay did not differ significantly between the laparoscopic and open groups. Postoperative complications developed in 24 children (42.8%). Complications were more frequent after laparoscopic appendectomy compared with open appendectomy (56% v 18%, P = .002). A postoperative intraabdominal abscess (IAA) developed in 14 children (25%). An IAA occurred in two children after open appendectomy compared with 11 children after laparoscopic appendectomy (9% v 41%, P = .01). CONCLUSION: The findings suggest that laparoscopic appendectomy should be avoided in children who have complicated appendicitis because of the increased risk for postoperative intraabdominal abscesses. The authors propose a prospective, randomized trial to verify this finding.

A multicenter trial of 6-aminocaproic acid (Amicar) in the prevention of bleeding in infants on ECMO.

BACKGROUND/PURPOSE: Intracranial hemorrhage (ICH), is a major source of morbidity and the leading cause of death in neonates treated with extracorporeal membrane oxygenation (ECMO). Anecdotal reports have suggested that epsilon-aminocaproic acid (EACA) can decrease the risk of ICH. The purpose of this study was to evaluate, in a multiinstitutional, prospective, randomized, blinded fashion, the effect of EACA on the incidence of hemorrhagic complications in neonates receiving ECMO. METHODS: All neonates (except congenital diaphragmatic hernia) who met criteria for ECMO at three institutions were eligible for enrollment. EACA (100 mg/kg) or placebo was given at the time of cannulation followed by 25 mg/kg/h for 72 hours. Bleeding complications, transfusion requirements, and thrombotic complications were recorded. Post-ECMO imaging included head ultrasound scan computed tomography (CT) scan, and duplex ultrasound scan of the inferior vena cava and renal vessels. RESULTS: Twenty-nine neonates were enrolled (EACA, 13 and placebo, 16). Five (17.2%) patients had a significant (grade 3 or larger) ICH. There was no statistical difference in the incidence of significant ICH in patients who received EACA (23%) versus placebo (12.5%). Septic patients accounted for all of the ICH in the EACA group. Thrombotic complications (aortic thrombus and SVC syndrome) developed in two patients from the placebo group. There was no difference in thrombotic circuit complications between groups. CONCLUSIONS: Our results suggest that the use of EACA in neonates receiving ECMO is safe but may not decrease the overall incidence of hemorrhagic complications.

Renal salvage procedures in patients with synchronous bilateral Wilms' tumors: a report from the National Wilms' Tumor Study Group.

Synchronous bilateral Wilms' tumor accounts for 4% to 6% of all Wilms' tumors. Renal salvage procedures (partial nephrectomy and enucleation) have been recommended to conserve renal parenchyma. The objective of this study was to review the results of renal salvage operations performed in children who had bilateral neoplasms. The authors reviewed the records of 98 children enrolled in the Fourth National Wilms' Tumor Study who had synchronous bilateral tumors and underwent renal salvage procedures. One hundred thirty-four kidneys were managed with renal salvage procedures. Complete excision of gross disease was accomplished in 118 (88%) of the 134 kidneys. Local tumor recurrence in the remnant kidney or tumor bed occurred in 11 cases (8.2%). Overall, 72% of the kidneys were preserved, and the 4-year survival rate was 81.7%. The surgical morbidity after a salvage procedure was comparable to that of a complete nephrectomy in patients with unilateral Wilms' tumor. Although the incidence of positive surgical margins is worrisome, it did not invariably lead to local recurrence in the remnant kidney or the tumor bed.

Complications after surgical intervention for necrotizing enterocolitis: a multicenter review.

Necrotizing enterocolitis (NEC) is a serious condition affecting predominantly the premature infant. The purpose of this study is to report a multicenter experience of complications in 252 infants requiring surgical therapy for NEC. Data from eight institutions for the years 1980 through 1990 were collected and analyzed for infants undergoing surgical therapy for NEC. Records were reviewed for gestational age, birth weight, age at operation, indications for operation, degree of intestinal involvement, operation(s) performed, complications, and 30-day mortality rates. A total of 264 infants underwent surgical intervention for NEC during the study period. Complete information was available for 252 patients. The mean gestational age was 31 +/- 5 weeks and the mean birth weight was 1,552 +/- 823 g. The mean age at operation was 18 +/- 35 days. Pneumoperitoneum was the most common indication for operation (42%). The 30-day survival rate was 72%. Eighty-one percent of patients underwent primary laparotomy, whereas peritoneal drainage was performed in 48 (19%) patients. Postoperative complications were identified in 119 (47%) patients. The most common postoperative complications were sepsis (9%), intestinal strictures (9%), and short gut (9%). Wound infections occurred in 6%, and the incidence of intraabdominal abscess formation was only 2.3%. Gestational age < 27 weeks (P < .005) and birth weight < 1,000 g (P < .005) were associated with significantly increased mortality but no increase in postoperative morbidity. The incidence of complications was similar in the very low birth weight (< 1,000 g) infants (51%) compared with infants > or = 1,000 g (46%).(ABSTRACT TRUNCATED AT 250 WORDS)

Malignant solid tumors in neonates: a 40-year review.

To evaluate the outcome of neonatal malignant solid tumors, we reviewed the records of 222 infants under the age of 1 year with malignant disease who were treated at the University of Texas M.D. Anderson Cancer Center over a 40-year period. Forty-five cases of neonatal (< 30 days old at the time of presentation) malignancies were found. Thirty-two infants had solid tumors and form the basis of this report. Diagnoses included soft tissue sarcoma (13), brain tumor (5), neuroblastoma (6), retinoblastoma (3), malignant melanoma (2), hemangiopericytoma (2), and nephroblastoma (1). The mean age at which initial signs and symptoms were noted was 9 days of life. Fifty-nine percent (19) presented within the first week of life, and 47% (15) presented at birth. The mean age at histological diagnosis was 54 days. The head and neck region was the most common site (18), followed by trunk (9), and extremities (5). Thirty-one patients underwent surgical resection of the primary tumor. Thirteen of those neonates received no additional chemotherapy and/or radiation therapy, whereas 18 received some combination of surgery plus perioperative chemotherapy and/or radiation therapy. Overall survival was 78% (25 of 32) with an average follow-up of 8 years (range, 2 months to 29 years). There were no survivors among those patients with distant metastatic disease at the time of diagnosis. Despite delays, prognosis is excellent in the absence of distant metastatic disease, particularly for extracranial tumors.

Traumatic rupture of a wandering spleen in a child: case report and literature review.

A case of traumatic rupture of a wandering spleen in a 5-year-old girl is presented. To our knowledge, this is the first reported case of such injury in a child. The splenic injury was managed nonoperatively. The etiology and management of wandering spleen is discussed.

Bronchogenic and esophageal duplication cyst in a single mediastinal mass in a child.

We report an unusual case of a mediastinal foregut malformation consisting of complete components of both a bronchogenic and an esophageal duplication cyst in a child. The lesion was identified as an incidental finding during evaluation of a clavicular fracture. Thoracotomy was performed for excision of the mass. A discussion of the pathological findings and the diagnosis and management of foregut malformations is presented.

Venovenous bypass as an adjunct for the management of a retrohepatic venous injury in a child.

We report the successful utilization of venovenous bypass in the case of an 8-year-old-boy who suffered a major hepatic injury with a retrohepatic venous injury after a kick by a horse. Initial nonoperative management was successful, but a delayed hemorrhage required operation. Vascular access was obtained via the peripheral circulation, and venovenous bypass was performed without systemic heparinization. Venovenous bypass improved vascular control and allowed the repairs to be performed in a relatively bloodless field, while not compromising venous return.

Pediatric wound infections: a prospective multicenter study.

OBJECTIVE: Surgical wound infections remain a significant source of postoperative morbidity. This study was undertaken to determine prospectively the incidence of postoperative wound infections in children in a multi-institutional fashion and to identify the risk factors associated with the development of a wound infection in this population. SUMMARY BACKGROUND DATA: Despite a large body of literature in adults, there have been only two reports from North America concerning postoperative wound infections in children. METHODS: All infants and children undergoing operation on the pediatric surgical services of three institutions during a 17-month period were prospectively followed for 30 days after surgery for the development of a wound infection. RESULTS: A total of 846 of 1021 patients were followed for 30 days. The overall incidence of wound infection was 4.4%. Factors found to be significantly associated with a postoperative wound infection were the amount of contamination at operation (p = 0.006) and the duration of the operation (p = 0.03). Comparing children who developed a wound infection with those who did not, there were no significant differences in age, sex, American Society of Anesthesiologists (ASA) preoperative assessment score, length of preoperative hospitalization, location of operation (intensive care unit vs. operating room), presence of a coexisting disease or remote infection, or the use of perioperative antibiotics. CONCLUSIONS: Our results suggest that wound infections in children are related more to the factors at operation than to the overall physiologic status. Procedures can be performed in the intensive care unit without any increase in the incidence of wound infection.