Bicycle-related injuries in children: disturbing profile of a growing problem.

CONTEXT: We observed a changing pattern of bicycle-related injuries in children, with the focus changing from head trauma to thoracic and abdominal injuries, and a trend to increasingly severe injuries. OBJECTIVE: To assess the changing injury pattern, and investigate the development of preventive measures to improve safety. DESIGN, SETTING, AND PARTICIPANTS: Retrospective record review of 142 paediatric patients admitted to our Department of Paediatric Surgery between 1996 and 2005 following bicycle-related injuries. Clinical, laboratory, diagnostic, and therapeutic aspects were analysed. Additional information concerning children's bicycle-related injuries in Israel was obtained from the Gertner Institute (Israel National Center for Trauma and Emergency Medicine Research) and from Beterem (The National Center for Children's Safety & Health, the Safe Kids Israeli Chapter) National Report on Child Injuries in Israel 2006. MAIN OUTCOME MEASURES: The nature and severity of injuries were reviewed, and two 5-year periods compared-from 1996 to 2000 (53 children-Group 1), and from 2001 to 2005 (89 children-Group 2). RESULTS: Head trauma was more common in the Group 1 patients (52.6% vs. 45.2%), but skull fractures and intracranial haemorrhage occurred more frequently in Group 2 (28.5% vs. 16.7%; 21.3% vs. 8.3%, respectively). Injury to the stomach or duodenum, kidneys and liver were all more common in Group 2. Splenic injury occurred with equal frequency in both groups, but more severe injuries were seen in Group 2. More children in Group 2 required intensive care (31% vs. 19.3%). CONCLUSIONS: There is a changing pattern of bicycle-related injuries in children, with chest and abdominal injuries dominating, and an increasing incidence of more severe injury. These findings are important in decision-making regarding preventive measures.

Laparoscopically monitored percutaneous endoscopic gastrostomy (PEG) in children: a safer procedure.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) has now become the preferred technique for facilitating enteral nutrition in children with inadequate caloric intake. Because many problems related to PEG insertion have recently been reported, we were motivated to reassess this established technique. We have therefore added a new step--laparoscopic monitoring--to the classic PEG procedure. METHODS: Fifteen children who required PEG during the previous year were studied. Their ages ranged from 2 months to 18 years. Six children were < 1 year old at the time of operation. In 11 patients, the PEG was performed at the end of a laparoscopic Nissen fundoplication. In the others, it was done as a single procedure. RESULTS: In all 15 children, the PEG was performed safely and quickly, without complications. CONCLUSION: The addition of 'laparoscopic monitoring' to the classic PEG procedure introduced by Gauderer et al. changes the first and last parts of the procedure from an almost 'blind' undertaking to a well-controlled and safer procedure.

Epididymitis in childhood: a clinical retrospective study over 5 years.

BACKGROUND: Acute scrotal pain in children presents a major diagnostic and therapeutic challenge. Epididymitis has been considered uncommon in childhood. The clinical spectrum and therapeutic policy of the acute scrotum in children is continually being reassessed. OBJECTIVES: To determine whether there has been an increase in the incidence of epididymitis in children and to advocate a more selective surgical approach to the acute scrotum. METHODS: We conducted a retrospective review of 65 children admitted to our department of pediatric surgery with the diagnosis of acute scrotum during a 5 year period. RESULTS: Of the 65 children admitted with the diagnosis of acute scrotum, epididymitis was diagnosed in 42 (64.6%). The remaining cases included torsion of the testis in 12 patients (18.5%), torsion of the appendix testis in 5 (7.7%), scrotal pain and minimal physical findings in 4 (6.1%), and scrotal hematoma and idiopathic scrotal edema in one patient each. Doppler ultrasound of the groin, color Doppler ultrasound of the testis and testicular nuclide scintigraphy (Tc-99m scan) examinations were performed on 49, 30 and 57 occasions, respectively; the Tc-99m scan was the most effective tool. All the patients with epididymitis were diagnosed before surgical intervention and were treated conservatively. CONCLUSIONS: We observed an increasing frequency of epididymitis in children admitted with the diagnosis of acute scrotum.

Laparoscopic evaluation and management of nonpalpable testis in children.

We evaluated the outcome of children with nonpalpable testis managed and treated laparoscopically in our department over a 6-year period. One hundred nine boys aged 12 months to 14 years were included in the study; most were between the ages of 12 months and 18 months. Diagnostic laparoscopy and eventual orchiectomy were performed in 50 patients (45.8%) with atrophic testicles. A normal sized intraabdominal testicle was found in 59 patients (54.1%). Seven of the intra-abdominal testicles were bilateral (6.4%), and 12 were located in the vicinity of the inguinal ring (11%). All patients underwent both the first and second stages of the Fowler-Stephens procedure, except for those whose testicles were located in the vicinity of the internal inguinal ring. They underwent an immediate one-stage laparoscopic-assisted orchiopexy without difficulty. Only two patients had atrophic testicles observed in the scrotal area after the complete Fowler-Stephens procedure (3.4%). The good results reported in most series establish the laparoscopic management of the nonpalpable testis as "state of the art," with results superior to those obtained with the open technique regarding morbidity, complication rate, and length of hospital stay.

[Laser treatment of airway obstruction in infants and children].

Airway obstruction during infancy and childhood requiring surgical ablation is rare, and surgical intervention poses a significant challenge. During recent decades, appropriate endoscopic instrumentation, together with advanced laser beam technology have provided new operative modalities for such patients. From 1993 to 1995 we treated 40 infants and children, 26 males and 14 females, 13 days to 11 years old (mean 3.3 years) with Nd-YAG or CO2 laser. Obstructing lesions included granulation tissue or polyps (16 cases), septa or webs (27), or benign tumors (4). 7 had more than a single lesion. All were treated endoscopically under general anesthesia without any operative or postoperative deaths. Surgical intervention removed the obstruction and related symptoms in 34. In 6, laser treatment failed, necessitating additional surgical procedures. 3 had circumferential subglottic web. Operative complications included bleeding during removal of a hemangioma in 1 and recrudescence in another. Postoperative complications were transient respiratory failure and pneumonia in 6, all of which resolved with appropriate treatment. This series proves that laser technology is feasible in the treatment of airway obstruction during infancy and childhood, and is safe and effective.

Giant omental cyst in children presenting as pseudoascites.

An unusual case of omental cyst is described. During a period of 3 years, a child was hospitalized seven times in five different hospitals for evaluation of ascites of unknown origin. Extensive and repetitive diagnostic workup did not reveal the cause of his problem, and recurrent paracentesis improved his condition partially, but for very short periods. A diagnostic laparoscopy, followed by explorative laparotomy, led to the correct diagnosis and appropriate surgical treatment, with complete relief of his complaints.

Acute appendicitis following abdominal trauma.

Acute appendicitis (AA) is generally considered to be a consequence of lumenal obstruction and inflammation of the appendix. At the beginning of the 20th century, trauma was considered to be one of the possible causes of AA but this relationship has not been examined much since then. Our experience with three cases of AA following blunt abdominal trauma led to an extensive review of the world literature on the subject. We believe that abdominal trauma might be causative of AA. The potential for this hazardous and easily missed diagnostic entity should be appreciated in cases of blunt abdominal trauma both for sound clinical decision making and for its potential medical and legal implications.

Subcuticular skin closure as a standard approach to emergency appendectomy in children: prospective clinical trial.

We evaluated the morbidity associated with primary closure by interrupted subcuticular absorbable sutures following emergency appendectomy. In a prospective clinical trial over a 12-month period, 216 children who underwent emergency appendectomy had skin closure using subcuticular interrupted absorbable polyglactin 4-0 sutures. Preoperative prophylactic antibiotics consisting of metronidazole alone or in combination with gentamicin were used in patients with suspected phlegmonous appendicitis; a combination of metronidazole, gentamicin, and ampicillin was used when perforation of the appendix was suspected. Postoperatively, in patients with phlegmonous appendicitis metronidazole was given for 24 hours, whereas in those with peritonitis the triple antibiotics were continued for 7 to 10 days. All patients were assessed for complications resulting from the technique of wound closure. No intraabdominal abscesses or serious complications were recorded. The overall incidence of wound infection was 1.8%. Among children with a perforated appendix the rate of superficial wound infection was 5.7%. There was no difference in the rate of wound infection between patients who received metronidazole alone or metronidazole plus gentamicin preoperatively. All the patients and their families were satisfied with the cosmetic results and with the fact that removal of skin sutures was unnecessary. We conclude that the use of prophylactic antibiotics permits standard skin closure by interrupted absorbable subcuticular suture.

A selective approach to the treatment of acute scrotum in children.

To determine a reliable clinical approach to the problem of acute scrotum (AS) in children and identify patients who require emergent surgical intervention, 65 boys with the diagnosis of AS were studied. The mean age was 11 years. Acute orchitis/epididymitis was diagnosed in 42 (64.6%), torsion of the testis in 12 (18.5%), and torsion of the appendix testis in 5 (7.7%). A testicular radionuclide scan was the most reliable diagnostic tool, being positive in all 12 cases of torsion of the testis. Eighteen patients underwent scrotal exploration. Detorsion and bilateral orchidopexy was performed in 12, excision of a necrotic appendix testis in 5, and evacuation of a scrotal hematoma in 1. The outcome of the involved testis at follow-up examination was excellent, with only 1 child developing testicular atrophy. This study stresses the reliability of the selective approach for the treatment of the AS in children.

Airway obstruction in neonates and children: surgical treatment.

OBJECTIVE: This review of 54 infants and children with airway obstruction who were treated surgically emphasizes the importance of the surgical indications with respect to various anomalies causing airway obstruction and the surgical approach to their management. PATIENTS: There were 4 etiologic groups of airway obstruction. Group A comprised 12 infants with subglottic stenosis; Group B--20 infants with tracheomalacia; 21 patients (Group C) with anatomic narrowing of the trachea; and 1 infant (Group D) with laceration of a main bronchus. METHODS: The surgical procedures performed included anterior laryngotracheal decompression in 12 infants, aortopexy in 19; 1 pulmonary arteriopexy; tracheal stenting with an autologous rib graft in 3 and with Marlex mesh in 1. Tracheal widening, using a free tibia autologous graft, was performed in 3 patients; transbronchoscopic excision in 12; anterior tracheal wedge resection in 4, and segmental tracheal resection and anastomosis in 1 patient. The lacerated bronchus was repaired with fine Dexon sutures. RESULTS: There were no operative deaths. With respect to the original indications for surgery, there were 3 failures--2 in Group A and 1 in Group C. Two patients died from causes unrelated to the procedures--one 10 days postoperatively, and the other 3 months after surgery. CONCLUSIONS: The surgical approach to tracheal obstruction in infants and children offers effective treatment, with no operative mortality, a low complication rate, and good long term survival.

Continuous esophageal pH monitoring during laparoscopic cholecystectomy.

Gastro-esophageal regurgitation (GER) and eventual aspiration is considered a major risk during general anesthesia. High intraperitoneal pressure produced during laparoscopic cholecystectomy (LC) is a possible source of increased GER. We investigated the incidence of GER using continuous esophageal pH monitoring in 14 patients undergoing elective LC. Only two brief episodes of acid reflux (pH < 4) occurred during LC. Apparently the high intraperitoneal pressure during LC carries no increased risk of regurgitation and aspiration.

Peritoneal ventilation: an animal model of extrapulmonary ventilation in experimental adult respiratory distress syndrome.

Adult respiratory distress syndrome (ARDS) is a critical medical problem in which severe arterial hypoxemia is often poorly responsive to conventional modes of mechanical ventilation. We studied the efficiency of mechanical ventilation of the peritoneal cavity in rabbits with experimental ARDS caused by lung lavage. The study shows that peritoneal ventilation is significantly effective in oxygenation of hypoxemic animals with ARDS and is also effective for carbon dioxide elimination. Peritoneal ventilation may be considered as an investigational method for extrapulmonary oxygenation in severe intractable hypoxemia caused by ARDS.

[Nissen fundoplication for gastroesophageal reflux in children].

During a 5-year period 50 children, aged 2 months to 15 years, underwent Nissen fundoplication for the management of severe gastroesophageal reflux and were then followed for from 3 months to 5 years. There were no immediate postoperative deaths. 8 patients (16%) died of serious underlying medical conditions during follow-up. The operation was successful in 86.3% in relation to indications for surgery. Postoperative complications specific for fundoplication occurred in 27 (54%) and other complications in 11 (22%). Of those with complications, 71% were treated successfully. The rest developed dumping syndrome which was diagnosed 1 month to 4 years after operation. They were treated with carbohydrate restriction and a special diet, the results of which will be evaluated later. Although Nissen fundoplication is very successful in resolving the indications for surgery, the high rate of postoperative complications demands re-evaluation of the indications for the operation in children.

Familial intussusception: report of a case with recurrence in the youngest sibling and review of the literature.

The etiology of idiopathic intussusception is unknown. Occurrence of intussusception in more than one patient in a same family is rare. A familial predisposition is suspected. We present a family in which the two children suffered from intussusception with recurrence in the youngest sibling and review the literature.

Oral blast injury caused by an accident.

Blast trauma within the oropharyngeal cavity may be associated with superficial or deep injuries. Superficial injury generally needs only observation; deeper injury that violates the retropharyngeal space may produce dissecting emphysema into the neck and mediastinum followed by prevertebral soft tissue infections and mediastinitis. Injury involving the parapharyngeal space might damage vital cervical vessels. Life-threatening complications may result unless treatment is adequate. Three children who sustained oropharyngeal blast injury are presented. The direct cause was the blast effect of a new, spoiled, orange-flavor beverage just released on the market. The bottle cap of the soft drink and its effervescent liquid "exploded" into their mouths while they were trying to open the bottle with their teeth. Obviously, the failure to observe due precautions, as frequently happens among children, contributed to the occurrence of the accidents. This paper describes the diagnosis, management, and relevant educational and preventive measures of the problem.

Familial thyroglossal duct cyst.

Thyroglossal duct cysts are common congenital abnormalities or developmental field defects, usually detected in early childhood. Despite their frequent occurrence, familial patterns are rare. We report on two new families with thyroglossal duct cysts. In the first family three siblings were involved, while in the second one, father and son were affected. This trait may be autosomal recessive or possibly multifactorial, as the first family would indicate, and also autosomal dominant, as the second family would suggest.

Case report: selective occipital lobe hydrocephalus and agenesis of the left lobe of the liver in congenital myotonic dystrophy.

Myotonic dystrophy (Steinert's disease) is an uncommon familial autosomal dominant disease, characterized by progressive muscular atrophy and myotonia. Mental retardation, frontal baldness, cortical lenticular opacities and testicular atrophy are other prominent features of a disease that involves predominantly striated muscle. There is little information regarding this disease in the radiological literature. The present report introduces two additional findings involving the skull and the liver.