Ruptured appendicitis presenting as acute scrotal swelling in a 23-month-old toddler.

BACKGROUND: Acute appendicitis is a common disease process in which timely diagnosis minimizes the risk of complications. OBJECTIVES: This case illustrates one example of the range of clinical presentations of young children with acute appendicitis. CASE REPORT: We describe a case in a young child presenting with an inguinal and scrotal mass that was ultimately due to perforated appendicitis with abscess formation. CONCLUSIONS: In the emergency department evaluation of these children with inguinal or scrotal complaints, we maintain that intra-abdominal processes should be included in the differential.

Laparoscopic surface scanning and subsurface targeting: implications for image-guided laparoscopic liver surgery.

Segmental liver resection and locoregional ablative therapies are dependent upon accurate tumor localization to ensure safety as well as acceptable oncologic results. Because of the liver's limited external landmarks and complex internal anatomy, such tumor localization poses a technical challenge. Image guided therapies (IGT) address this problem by mapping the real-time, intraoperative position of surgical instruments onto preoperative tomographic imaging through a process called registration. Accuracy is critical to IGT and is a function of: 1) the registration technique, 2) the tissue characteristics, and 3) imaging techniques. The purpose of this study is to validate a novel method of registration using an endoscopic Laser Range Scanner (eLRS) and demonstrate its applicability to laparoscopic liver surgery. Six radiopaque targets were inserted into an ex-vivo bovine liver and a computed tomography (CT) scan was obtained. Using the eLRS, the liver surface was scanned and a surface-based registration was constructed to predict the position of the intraparenchymal targets. The target registration error (TRE) achieved using our surface-based registration was 2.4 +/- 1.0 mm. A comparable TRE using traditional fiducial-based registration was 2.6 +/- 1.7 mm. Compared to traditional fiducial-based registration, laparoscopic surface scanning is able to predict the location of intraparenchymal liver targets with similar accuracy and rate of data acquisition.

Mechanical abrasion improves early incorporation of small intestinal submucosa.

It has been shown that gross incorporation of porcine-derived small intestinal submucosa (SiS) is limited at 2 weeks. This study evaluates a technique for improving the early incorporation of implanted eight-ply SiS. Six pigs underwent implantation of SiS on the peritoneal surface using three techniques: suture fixation of stock-perforated SiS, suture fixation of manually perforated SiS, and suture fixation of stock-perforated SiS to mechanically abraded peritoneum. Gross incorporation was evaluated and random samples harvested for tensiometric analysis 2 weeks after implantation. SiS placed onto mechanically abraded peritoneum demonstrated significantly greater gross incorporation than both stock-perforated SiS (100% versus 42%, P = 0.015) and manually perforated SiS (100% versus 50%, P = 0.042). There was no difference in gross incorporation between stock and manually perforated SiS. Using tensiometric analysis, the force required to separate the peritoneum from the SiS implant was significantly greater for the SiS placed onto mechanically abraded peritoneum (4.4 +/- 1.7 kg . f/cm2) than for both the stock-perforated SiS samples (1.0 +/- 0.5 kg x f/cm2) and the needle-perforated SiS samples (1.4 +/- 0.9 kg x f/cm2; P < 0.001). There was no difference between stock and manually perforated SiS at 2 weeks. Mechanical abrasion of the peritoneum before SiS onlay leads to improved gross incorporation 2 weeks after implantation in a porcine model of herniorrhaphy. Long-term studies and histologic analysis are needed to validate this method as a means for improving early incorporation of SiS.

Morbidity after procurement of radial arteries in diabetic patients and the elderly undergoing coronary revascularization.

BACKGROUND: The use of radial arteries for coronary revascularization is increasing. There remain concerns regarding alteration of upper extremity function after radial artery procurement. This study evaluates the functional morbidity in higher risk patients. METHODS: Between April 1997 and September 1999, 374 patients underwent unilateral or bilateral radial artery procurement. A questionnaire was used to evaluate symptoms related to motor and sensory function and changes in appearance after radial artery harvest. RESULTS: Two hundred eighty-nine patients were successfully interviewed. The average age was 63 years. Median follow-up was 9.5 months (range, 2 to 23 months). No patient suffered limb loss. Altered gross and fine motor function, residual pain, paresthesias, numbness, pallor, swelling, and altered temperature sensation were compared among diabetic patients, patients older than 70 years, and patients without these characteristics. CONCLUSIONS: Radial artery procurement for elective coronary revascularization can be done with minimal serious morbidity in higher risk patients. The most common symptoms were numbness and paresthesia. Despite the finding of greater residual pain in diabetic patients, we do not believe the use of radial artery conduits is contraindicated in these patients.

Chronic biloma after right hepatectomy for stage IV hepatoblastoma managed with Roux-en-Y biliary cystenterostomy.

We report the complex case of a 12-month-old girl with stage IV hepatoblastoma accompanied by thrombosis and cavernous transformation of the portal vein. After neoadjuvant chemotherapy, she underwent right hepatectomy, which was complicated by iatrogenic injury of her left hepatic duct, and subsequently developed a postoperative biloma and chronic biliocutaneous fistula. Concomitant with multiple percutaneous interventions to manage the biloma nonoperatively while the child completed her adjuvant chemotherapy, she progressed to develop chronic malnutrition, jaundice, and failure to thrive. Once therapy was completed and the child was deemed free of disease, she underwent exploratory laparotomy with Roux-en-Y biliary cystenterostomy for definitive management, resulting in resolution of her biliary fistula, jaundice, and marked improvement in her nutritional status. Roux-en-Y biliary cystenterostomy is a unique and efficacious management option in the highly selected patient population with chronic biliary leak refractory to minimally invasive management.

Laparoscopic nephron-sparing resection of synchronous Wilms tumors in a case of hyperplastic perilobar nephroblastomatosis.

Diffuse hyperplastic perilobar nephroblastomatosis (DHPLN) is a rare precursor lesion of Wilms tumor (WT). Because of the increased risk to develop WT in either kidney, current management algorithms of DHPLN merit nephron-sparing strategies, beginning with chemotherapy and close radiographic monitoring into late childhood. After resolution of DHPLN, subsequent detection of a renal nodule mandates resection to exclude WT. Here, we report the case of a 4-year-old girl who developed 2 synchronous nodules in the right kidney more than 2 years after completion of therapy for DHPLN. Because of the early detection and peripheral location of these 2 nodules, laparoscopic nephron-sparing resection of each was performed using ultrasonic dissection. Both nodules were determined on pathology to be favorable histology WT with negative surgical margins. The child was placed on vincristine and actinomycin D therapy for 18 weeks.

Method to our madness: an 18-year retrospective analysis on gastroschisis closure.

BACKGROUND: The advent of preformed silos has facilitated routine bedside placement often without any attempt of intestinal reduction. It is unclear whether a strategy of routine silo (RS) placement with delayed fascial repair is beneficial over attempted primary repair (aPR) and silo placement only for those patients who cannot be reduced. We retrospectively compared clinical outcomes of neonates having aPR to those having RS placement to determine the impact of routine silo use and silo duration on gastroschisis care. METHODS: Neonatal records from patients with gastroschisis at a single children's hospital between 1990 and 2008 were reviewed. Demographic and outcome data were recorded and subjected to statistical analyses. Documentation of attempted intestinal reduction was used as a surrogate marker for aPR. The remaining patients were placed in the RS group. RESULTS: Two hundred forty-eight neonates with gastroschisis were identified. Thirteen were excluded for congenital or clinical issues which precluded aPR. Of the remaining 235 patients, neonates with RS had significantly more ventilator days (6.2 vs 4.4; P = .0011), more time of total parenteral nutrition (36.5 vs. 28.5; P = .0018), longer length of stay (LOS, 46.5 vs. 40.5; P = .0011), and greater hospital charges ($216,000 vs $172,000; P < .0001) than patients who had aPR. There was no significant difference observed in complications or survival. Linear regression modeling demonstrated that time to closure was significantly related to LOS as an independent variable. Each day to closure was associated with 2.2 extra days of hospitalization and approximately $9557 in hospital charges. CONCLUSION: Although limited by retrospective biases, this study demonstrates that time to closure is the most significant variable related to LOS in gastroschisis. This relationship is intuitive since longer time to closure is probably determined by the severity of gastroschisis. The method of closure, by primary repair or silo, is of secondary importance. Conversely, unnecessarily increasing the time to closure may increase the LOS. The speed of reduction, whether through primary repair or by silo, should be guided by physiologic principles.

Central venous catheter placement at the time of extracorporeal membrane oxygenation decannulation: is it safe?

PURPOSE: Because of concerns for infectious and hemorrhagic complications, methods of obtaining central venous access after extracorporeal membrane oxygenation (ECMO) vary by institution. For infants requiring ECMO, it has been our practice to exchange the venous cannula for a tunneled central venous catheter (Broviac) at the time of decannulation. The purpose of this study is to compare the incidence of catheter-related complications in these patients to a national registry. METHODS: The medical records of all non-cardiac surgery infants, 12 months or younger, requiring ECMO at our institution from 1993 to 2005 (n = 138) were reviewed. Complete information was available for 134. Center for Disease Control criteria was used to identify cases of catheter-related bloodstream infections (BSIs). Data from the National Nosocomial Infections Surveillance system served as a comparative group. Logistic regression was used to determine risk factors for catheter-related BSI. RESULTS: A total of 134 infants spent a mean of 8.1 +/- 4.3 days (range, 1-21 days) on ECMO. At the time of decannulation, a Broviac catheter was placed in the right internal jugular vein of 95 (71%) and remained in place for a mean of 18.2 +/- 17 days (range, 1-109 days). The incidence of BSI related to these catheters was not significantly different than that reported by the National Nosocomial Infections Surveillance system for all central venous catheters over a similar period (6.4/1000 vs 7.3/1000 catheter days; P = .68). The number of days on ECMO and number of catheter days were independent predictors of catheter-related BSI in both bivariate and multivariate logistic regression models (P

Intraband pressure measurements describe a pattern of weight loss for patients with adjustable gastric bands.

BACKGROUND: Individuals with adjustable gastric bands experience plateaus in weight loss. Patients commonly attribute this to a "loosening" of their band with time. We sought to elucidate a physiologic mechanism for this pattern in patient behavior and describe the feasibility of a pressure-based adjustment algorithm for adjustable gastric bands. METHODS: Following IRB protocol, 100 consecutive patients undergoing placement of the Lap-Band (Inamed) were enrolled and followed prospectively for 12 months. Intraband pressure measurements at band volumes 0 to 4 mL were recorded intraoperatively and at each subsequent band adjustment. Band adjustments were made using the currently accepted volume-based postoperative protocol. RESULTS: Seventy-nine patients were included in analysis. Mean percent excess weight loss for the study cohort was 36 +/- 17% at a median followup of 347 days. During the time between adjustments, there was a statistically significant decrease (p < 0.001) in intraband pressure without a corresponding decrease in band volume. This was a result of a substantial change in the pressure-volume relationship of the Lap-Band. As time progressed, the Lap-Band developed less intraband pressure per unit volume. This change was not a result of changes in the elastic properties of the band material itself. CONCLUSIONS: Between adjustments, Lap-Band patients experience gradual loss of satiety and a loosening of their band, despite stable band volume. Their experience is substantiated by degradation in their intraband pressures with time. We have demonstrated that intraband pressures correlate with the patient's clinical history and have thereby established the foundation for a pressure-based adjustment protocol.

A comparative analysis of expanded polytetrafluoroethylene and small intestinal submucosa--implications for patch repair in ventral herniorrhaphy.

BACKGROUND: Small intestinal submucosa and expanded polytetrafluoroethylene are commonly used as adjuncts to repair in ventral herniorrhaphy. Despite their overlapping indications, the physical characteristics of the two materials are quite distinct. This study compares the in vivo properties of two bioprosthetic products, small intestinal submucosa (SiS Gold; Cook Biotech, West Lafayette, IN) and lyophilized small intestinal submucosa (LyoSiS; Cook Biotech), with expanded polytetrafluoroethylene (ePTFE; W.L. Gore and Associates, Flagstaff, AZ). METHODS: Six pigs underwent placement of duplicate samples of each material (SiS Gold, LyoSiS, and ePTFE) within the abdomen as peritoneal onlays (total of six samples per pig). Gross characteristics were evaluated and random samples harvested for histological analysis at 8 wk following implantation. The percentage of contraction was determined by comparing pre-implant to post-implant area. Neovascularity (percent area blood vessels, %A(bv)) was quantitatively assessed by immunohistochemical staining with an endothelial marker, CD-31 antibody. Sites of active collagen deposition were identified and distinguished from pre-existing collagen using a pro-collagen antibody to characterize tissue incorporation and remodeling. RESULTS: Compared with the original area of 22.75 cm(2), significant contraction was observed in SiS Gold, LyoSiS, and ePTFE at 8 wk (post-implant area; 7.6 cm(2), 5.7 cm(2), and 11.2 cm(2) respectively, P < 0.0001). The post-implant areas represent contraction of 67% for SiS Gold, 75% for LyoSiS, and 51% for ePTFE. The ePTFE implants experienced significantly less contraction than both the SiS Gold and LyoSiS implants (P = 0.002). No statistical difference in contraction was noted when SiS was compared with LyoSiS. Compared to SiS Gold, LyoSiS had a higher density of capillary ingrowth (2.7% A(bv)versus 2.2% A(bv), P = 0.01). As expected, vascular ingrowth was absent from the ePTFE samples. Qualitative analysis with pro-collagen antibody revealed new collagen deposition within the lamellar matrix of both SiS Gold and LyoSiS. In contrast, a similar analysis of ePTFE demonstrated a pattern of collagen encapsulation compared with the tissue infiltration and incorporation observed with SIS grafts. CONCLUSION: The host response to ePTFE, SiS Gold and LyoSiS differs at 8 wk following implantation; SiS Gold and LyoSiS undergo tissue ingrowth and remodeling whereas ePTFE undergoes little or no incorporation or morphological change. The physical properties of the materials differ as well; SiS Gold, and LyoSiS experience significantly more contraction than ePTFE. Future comparative analysis may help determine which characteristic, contraction or incorporation, contributes more to long-term success in the patch repair of ventral hernia.