Ultrasound markers for prediction of complex gastroschisis and adverse outcome: longitudinal prospective nationwide cohort study.

OBJECTIVES: To identify antenatal ultrasound markers that can differentiate between simple and complex gastroschisis and assess their predictive value. METHODS: This was a prospective nationwide study of pregnancies with isolated fetal gastroschisis that underwent serial longitudinal ultrasound examination at regular specified intervals between 20 and 37 weeks' gestation. The primary outcome was simple or complex (i.e. involving bowel atresia, volvulus, perforation or necrosis) gastroschisis at birth. Fetal biometry (abdominal circumference and estimated fetal weight), the occurrence of polyhydramnios, intra- and extra-abdominal bowel diameters and the pulsatility index (PI) of the superior mesenteric artery (SMA) were assessed. Linear mixed modeling was used to compare the individual trajectories of cases with simple and those with complex gastroschisis, and logistic regression analysis was used to estimate the strength of association between the ultrasound parameters and outcome. RESULTS: Of 104 pregnancies with isolated fetal gastroschisis included, four ended in intrauterine death. Eighty-one (81%) liveborn infants with simple and 19 (19%) with complex gastroschisis were included in the analysis. We found no relationship between fetal biometric variables and complex gastroschisis. The SMA-PI was significantly lower in fetuses with gastroschisis than in healthy controls, but did not differentiate between simple and complex gastroschisis. Both intra- and extra-abdominal bowel diameters were larger in cases with complex, compared to those with simple, gastroschisis (P < 0.001 and P < 0.005, respectively). The presence of intra-abdominal bowel diameter ≥ 97.7th percentile on at least three occasions, not necessarily on successive examinations, was associated with an increased risk of the fetus having complex gastroschisis (relative risk, 1.56 (95% CI, 1.02-2.10); P = 0.006; positive predictive value, 50.0%; negative predictive value, 81.4%). CONCLUSIONS: This large prospective longitudinal study found that intra-abdominal bowel dilatation when present repeatedly during fetal development can differentiate between simple and complex gastroschisis; however, the positive predictive value is low, and therefore the clinical usefulness of this marker is limited. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

[Management of blunt renal trauma in paediatric patients]. / Behandeling van stomp nierletsel bij kinderen.

- In 90% of children, blunt abdominal trauma is the cause of renal, splenic or hepatic injury or an injury affecting a combination of these organs.- Because children's kidneys are anatomically less protected than those of adults, potential renal injury following direct trauma affecting the child's flank, for example by a handlebar or knee should be considered.- Symptoms of renal trauma include excoriations or haematoma on the flank, a 'seatbelt-sign', macroscopic haematuria and fractures of the ribs and vertebra.- As haematuria does not correlate with the severity of renal injury, all children with persistent haematuria should undergo renal imaging.- Children without abnormalities on Doppler ultrasound examination and without macroscopic haematuria can be discharged from the emergency room.- Conservative management of blunt renal trauma is indicated for all haemodynamically stable children. However, haemodynamically unstable children need to undergo an urgent laparotomy. The routine use of bed rest is only indicated for grade V renal injuries.- A DMSA scan is recommended 6-12 weeks after trauma for grade IV-V renal injury.

Isolated abdominal wall defect with complete liver herniation without a covering or remnant membrane: an ominous sign: case report and review of literature.

Complete liver herniation in abdominal wall defects without a membrane is rare and its prognosis is not well documented. We present a case diagnosed at 12 weeks of gestation. At 27 weeks, a C-section was performed for fetal distress. The infant proved impossible to ventilate and died. In literature, 16 similar cases are described of whom 14 died in the neonatal period and two in infancy. This suggests that herniation of the complete liver in isolated abdominal wall defects without a remnant membrane is lethal and counselling should be provided accordingly.

Laparoscopic treatment of gastric and duodenal perforation in children after blunt abdominal trauma.

Minimal invasive surgery has not yet gained wide acceptation for the care of patients that sustained an abdominal trauma. We describe the complete laparoscopic surgical treatment of two patients after a single blunt abdominal trauma. One patient sustained a handle bar injury and presented with a gastric perforation. The other sustained a duodenal rupture by falling on a sharp edge of a table. The patients were assessed and treated laparoscopically. The perforations were identified and closed. Both patients had an uneventful postoperative recovery. Therapeutic laparoscopic treatment of patients with upper gastrointestinal perforation is feasible. We would recommend this approach to experienced laparoscopic surgeons in hemodynamically stable patients.

Minimally invasive pediatric surgery: Increasing implementation in daily practice and resident's training.

BACKGROUND: In 1998, the one-year experience in minimally invasive abdominal surgery in children at a pediatric training center was assessed. Seven years later, we determined the current status of pediatric minimally invasive surgery in daily practice and surgical training. METHODS: A retrospective review was undertaken of all children with intra-abdominal operations performed between 1 January 2005 and 31 December 2005. RESULTS: The type of operations performed ranged from common interventions to demanding laparoscopic procedures. 81% of all abdominal procedures were performed laparoscopically, with a complication rate stable at 6.9%, and conversion rate decreasing from 10% to 7.4%, compared to 1998. There were six new advanced laparoscopic procedures performed in 2005 as compared to 1998. The children in the open operated group were significantly smaller and younger than in the laparoscopic group (p < 0.001 and p = 0.001, respectively). The majority (64.2%) of the laparoscopic procedures were performed by a trainee. There was no difference in the operating times of open versus laparoscopic surgery, or of procedures performed by trainees versus staff surgeons. Laparoscopy by trainees did not have a negative impact on complication or conversion rates. CONCLUSIONS: Laparoscopy is an established approach in abdominal procedures in children, and does not hamper surgical training.

Surgery for necrotising enterocolitis: primary anastomosis or enterostomy?

The ideal surgical management of neonates with necrotising enterocolitis (NEC) is still a matter of debate. The purpose of this study was to compare the results of bowel resection with primary anastomosis with the results of bowel resection with enterostomy. Sixty-three neonates with NEC had a bowel resection in the acute phase of the disease in the period between February 1990 and March 2001. Thirty-four of them (54%) underwent resection of the bowel with primary anastomosis (Group A), and 29 (46%) had resection with enterostomy (Group B). Group A had a lower gestational age and lower birth weight. Mortality, complication rate, and postoperative weight gain were not significantly different between the groups. However, Group B had a significantly longer primary hospital stay (80 +/- 49 days versus 58 +/- 31 days, P < 0.04) and needed a 2nd hospital stay for restoring gastrointestinal continuity. For both reasons, it can be argued that primary anastomosis is superior to enterostomy after resection.

Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: impact of experience on the results in 182 cases.

BACKGROUND: There has been discussion about the value of laparoscopic pyloromyotomy (LP) for the treatment of hypertrophic pyloric stenosis (HPS). In their initial small series, the authors reported a relatively high complication rate. The current study was undertaken to investigate the influence of experience with LP on operative time, complication rate, and postoperative hospital stay for a large number of patients. METHODS: Between October 1993 and March 2002, 182 children underwent LP for HPS. These procedures involved 11 surgeons, 4 consultants, and 7 trainees. The end points of the study were operative time, complications, and postoperative hospital stay. The outcome of 146 LPs performed after July 1996 was compared with the outcome of 36 LPs performed before that period. RESULTS: There was no significant difference in the mean operative time between the two series, but the operative time per surgeon dropped with experience. Mucosal perforation was experienced by 8.3% of the patients in the initial series, as compared with 0.7% in the later series. Insufficient pyloromyotomy occurred in 8.3% of the initial series, as compared with 2.7% of the later series. Other minor complications such as wound infection were infrequent and not influenced by further experience. Major wound-related problems did not occur. The LP procedure was easily learned by novices. After about 15 pyloromyotomies, the operative time was approximately 25 min. The length of postoperative hospital stay also dropped with increasing experience. CONCLUSIONS: The value of LP for the treatment of HPS has been proved. The LP procedure is as quick as the open procedure, has a low morbidity, and is devoid of major wound-related problems. Moreover, the procedure seems to be well teachable.

Early feeding after laparoscopic pyloromyotomy: the pros and cons.

BACKGROUND: Early feeding after pyloromyotomy for hypertrophic pyloric stenosis (HPS) has been advocated because this would lead to earlier discharge. However, some authors remain reluctant to introduce early feeding because of concern about postoperative vomiting. This study aimed to clarify the effects of early versus later feeding after laparoscopic pyloromyotomy on postoperative vomiting, time required to reach full oral feeding, hospital stay, and follow-up evaluation. METHODS: During the period from October 1993 through March 2002, 185 infants underwent laparoscopic pyloromyotomy for HPS. Of these patients, 164 patients were included in the study. The initial feeding was within 4 h after surgery in group A and after 4 hours in group B. The outcome variables were postoperative vomiting subdivided into vomiting requiring adjustment of the feeding schedule or not, time required to reach full feeding, hospital stay, and vomiting as well as weight gain at follow-up assessment. RESULTS: In 23% of the 62 patients of group A and in 6% of the 102 patients of group B (p = 0.003), vomiting was so severe that it necessitated modification of the feeding schedule. Th time required to reach full feeding and the postoperative hospital stay were similar in the two groups. Analysis of the subgroups that required modification of the feeding schedule because of vomiting showed a significant delay in time required to reach full feedings as well as a significant delay in hospital discharge. There was an 11% incidence of ongoing vomiting after discharge irrespective of early or later feeding. Weight gain at follow-up assessment did not differ significantly between the two groups, and did not bear any relations to in-hospital vomiting. CONCLUSIONS: Feeding within 4 h postoperatively leads to more severe vomiting than later feeding. Vomiting leads to discomfort for the child, anxiety for the parents, a prolonged time required to achieve full oral feeding, and a prolonged postoperative hospital stay. However, clinical outcome after discharge is not adversely affected by early feeding. According to this study, it appears that it would be better to withhold feeding for the first 4 h after surgery.

Microbiological factors associated with neonatal necrotizing enterocolitis: protective effect of early antibiotic treatment.

AIM: The incidence of necrotizing enterocolitis (NEC) strongly increased in an neonatal intensive care unit (NICU) in 1997 and 1998 compared with previous years, which coincided with increased incidence of nosocomial sepsis. Specific risk factors related to this NICU and a possible relationship between NEC and nosocomial sepsis were studied retrospectively, including all patients with NEC since 1990 and matched controls. METHODS: Clinical and bacteriological data from the period before the development of NEC and a similar period for the controls were collected retrospectively and corrected for birthweight and gestational age. Statistical analysis was performed by a stepwise regression model. RESULTS: Data of 104 neonates with NEC and matched controls were analysed. The median day of onset of NEC was 12 d (range 1-63 d). Significant risk factors for NEC were: insertion of a peripheral artery catheter [odds ratio (OR) 2.3, 95% confidence interval (95% CI) 1.3-3.9] and a central venous catheter (OR 5.6, 95% CI 3.1-10.1), colonization with Klebsiella sp. (OR 3.4, 95% CI 1.5-7.5) and Escherichia coli (OR 2.1, 95% CI 1.0-4.5), and the occurrence of sepsis, in particular due to coagulase-negative staphylococci (OR 2.6, 95% CI 1.4-5.1). The risk for NEC was decreased after the early use (< 48 h after birth) of amoxicillin-clavulanate and gentamicin (OR 0.3, 95% CI 0.2-0.6). CONCLUSION: Insertion of central venous and peripheral arterial catheters is positively associated with NEC, as is colonization with the Gram-negative bacilli Klebsiella and E. coli and the occurrence of sepsis, particularly due to coagulase-negative staphylococci. Early treatment with amoxicillin-clavulanate and gentamicin is negatively associated with NEC and may be protective against NEC.

[Hypertrophic pyloric stenosis in infants: laparoscopic pyloromyotomy]. / Pylorushypertrofie bij zuigelingen: laparoscopische pyloromyotomie.

OBJECTIVE: To evaluate the results of laparoscopic pyloromyotomy in infants with hypertrophic pyloric stenosis (HPS). DESIGN: Retrospective. METHOD: Data from medical records were collected on all children who underwent laparoscopic extramucosal pyloromyotomy for hypertrophic pyloric stenosis in the period from 1 October 1993 to 31 March 2001 in the Wilhelmina Children's Hospital of the Utrecht University Medical Centre, the Netherlands. RESULTS: A total of 133 children were operated: 108 boys (81%) and 25 girls (19%). The mean age on the day of operation was 35.3 days (SD: 15.4). Of these children, 17 (13%) were ex-prematures and 8 (6%) were ex-dysmatures, and 40 (30%) had a positive family history for HPS. The mean operating time was 29 min (SD: 10); per surgeon, the first 5 operations required over 30 minutes on average and the following operations lasted an average of 26 minutes. Postoperatively, 84 patients (63%) no longer vomited. Four children required a second operation. The mean period from operation to discharge was 61.6 hours (SD: 46.0). Complications included: perforations of the mucosa (n = 4; 3%), wound infections (n = 4; 3%) and small incisional hernias (n = 5; 4%). CONCLUSION: Laparoscopic pyloromyotomy is an efficient and safe operative technique for the treatment of infants with HPS.

Once-daily versus multiple-daily gentamicin in infants and children.

In this prospective randomized trial, the efficacy and safety of once-daily administration of gentamicin were compared with multiple-daily administration in infants and children. In addition, pharmacokinetic variables were calculated. Gentamicin therapy was started at a dose of 5 mg/kg per day under individual dose or dosage interval adjustments to achieve target levels. Fifty-two infants and children aged 1 month (postterm) to 16 years were enrolled. The duration of fever from the start of therapy, the percentage decline of C-reactive protein (CRP) on day 3 of treatment, and the clinical outcome were used as efficacy parameters. Nephrotoxicity was evaluated using creatinine serum levels. Basic characteristics in both groups were comparable. A good clinical response was observed in both groups. Fever may have resolved faster with multiple-daily administration, but this was not statistically significant. The percentage of decline of CRP was also comparable in both groups. Nephrotoxicity occurred in six patients, three per group. Many patients were too ill or too young to perform hearing tests, but no clinical signs of ototoxicity were observed. Mean doses of 6.8 mg/kg per day (multiple-daily administration) and 7.3 mg/kg per day (once-daily administration) were necessary to meet the target gentamicin levels. Triple-daily doses had to be reduced to a twice-daily regimen in 17 of 26 children. Dose and dosage interval adaptations can be performed by Bayesian forecasting using a one-compartment model with one set of K(e) and V(d) parameters. The authors consider both regimens equally effective, with a comparable incidence of nephrotoxicity. A starting dose of 6.5 mg/kg once daily is advised.

Acute dyspnoea resulting from pulmonary oedema as the first sign of a phaeochromocytoma.

The day after undergoing neck dissection, a 42-year-old woman developed acute dyspnoea due to pulmonary oedema. Measurements with a Swan-Ganz catheter revealed not only cardiac depression but also a greatly increased peripheral vascular resistance: 5,400 dyn x s x cm(-5)/m2. A phaeochromocytoma with acute cardiac failure leading to pulmonary oedema was considered. Treatment with alpha- and beta-blockers was complicated by severe hypotension and later ventricular fibrillation. Mechanical ventilation was required for 6 days following resuscitation. Investigation of the urine subsequently showed greatly increased catecholamine concentrations, while imaging revealed bilateral adrenal tumours. Our case history shows that acute pulmonary oedema may be the presenting manifestation of a phaeochromocytoma. The pulmonary oedema resulted partly from backward failure following tachycardia, myocyte necrosis and the greatly increased peripheral vascular resistance, and partly from increased permeability of the capillary network in the lungs.

Laparoscopic management of a paraesophageal hernia with intrathoracic stomach in infants.

Paraesophageal hernia type III in which the stomach lies in the thorax is a rare condition in children. Recently two children presented with a large type III paraesophageal hernia with an intrathoracic stomach. The stomach could be retrieved from the thorax laparoscopically and the procedure was completed with a Thai antireflux procedure.

Record of Aedes albopictus in Nebraska with notes on its biology.

Adult Aedes albopictus were collected in Nebraska on August 10, 1992, at a scrap tire pile in Douglas County. Subsequent collections in 1992 revealed the presence of adult Ae. albopictus at a tire storage yard in West Point, NE. During 1995 and 1996, an ecological study of Ae. albopictus at the West Point site was conducted. Aedes albopictus populations were determined to be able to survive winter conditions in this region.

Laparoscopic management of a large posttraumatic splenic cyst in a child.

Splenic cysts are rare in pediatric surgery. Nowadays management consists of partial splenectomy or decapsulation of the cystic wall. The case reported in this article describes the successful laparoscopic decapsulation of the cystic wall in an 11-year-old child.

Seasonal incidence and geographical variation of Nebraska mosquitoes, 1994-95.

A mosquito survey was conducted in Nebraska during 1994-95. Mosquitoes were collected by CO2-baited CDC light traps at 11 localities throughout Nebraska. Total mosquitoes collected was 685,581 per trap (mean = 790) and 1,163,741 per trap (mean = 1,372) during 1994 and 1995, respectively. Twenty-seven mosquito species representing 8 genera were collected. The most abundant mosquitoes collected statewide were Aedes vexans at 74% of the 2-year total, Culex tarsalis at 11%; Aedes trivittatus, 5%; Aedes melanimon, 1.5%; and Aedes triseriatus, 1%. The floodwater mosquitoes were more prevalent in eastern Nebraska while standing-water mosquitoes, especially Culex tarsalis, were more prevalent in the west.

[A woman with an advanced malignant clear cell hidradenoma]. / Een vrouw met een voortgeschreden maligne 'clear cell'-hidradenoma.

A 67-year-old patient was admitted for diabetes mellitus. Incidentally a large ulcerating tumour was found on the right upper leg. The patient had been suffering from the lesion for six years but had never dared to show it to her physician. Notwithstanding negative outcome of thin needle aspiration oncological dissection was carried out. Histopathological examination proved the tumour to be a malignant clear cell hidradenoma, which is a rare eccrine tumour. This tumour is known to be aggressive and easily spreads to locoregional lymph nodes. Even though it is a rare disease, the aggressive behaviour and the poor prognosis warrant alertness to this neoplasm.

Surveillance for arthropod-borne viral activity in Nebraska, 1994-1995.

A 2-yr arbovirus surveillance program was established in Nebraska following the midwest flood of 1993. CDC light traps were used to collect mosquitoes at 11 localities throughout Nebraska. In 1994, we collected 685,582 mosquitoes, and we tested 1,359 pools of Culex mosquitoes for arbovirus infection, with St. Louis encephalitis virus isolated from 2 pools collected in Scotts Bluff County in western Nebraska. In 1995, 1,163,741 mosquitoes were collected and 2,788 pools tested, with 36 positive for western equine encephalomyelitis (WEE) virus. Thirty of the WEE-positive pools were collected in Scotts Bluff County, 4 pools from the city of Norfolk and 2 from the city of Grand Island. All viruses were isolated from Culex tarsalis Coquillett. The highest minimum infection rate of 3.81 per 1,000 mosquitoes was observed in Scotts Bluff County on 13 September 1995. The seasonal minimum infection rate for WEE was 0.52 in Scotts Bluff County. No human or horse disease attributed to arboviral infection was reported in Nebraska during 1994 and 1995.

Carcino-embryonic antigen--no help with the differential diagnosis.

Two patients who were referred because of an increase in serum carcino-embryonic antigen (CEA) were diagnosed after a number of years as having a medullary thyroid carcinoma. The relationship between CEA and medullary thyroid carcinoma is discussed. The serum level of CEA is neither sensitive nor specific enough to serve as a diagnostic tool. Its determination, however, is useful in the follow-up of patients with carcinoma of the breast, colo-rectal carcinoma and medullary thyroid carcinoma.