Surgical management of coccidioidomycosis in children.

BACKGROUND/PURPOSE: Operations for Coccidioides immitis infection in children have received little study. The authors perceived an increase in the number of patients requiring operations for coccidioidomycosis at Phoenix Children's Hospital. The authors therefore reviewed the surgical management of children with C immitis infection in Phoenix, Arizona. METHODS: The medical records of all children hospitalized from 1994 to 1999 with a confirmed laboratory diagnosis of coccidioidomycosis were reviewed. Age, gender, race, immune status, laboratory data, operations, and outcome were recorded. RESULTS: Of 39 children with proven coccidioidomycosis, 21 patients (54%) underwent a total of 49 operations. Boys represented 72% of all children reviewed. Sixteen patients (29% of the operative cohort) were immunocompromised. Thoracic procedures (19 cases) were most frequent. CONCLUSIONS: Over half the children hospitalized for coccidioidomycosis required at least 1 operation. Most were immunocompetent boys with thoracic disease. Pediatric surgeons, who provide the bulk of operative care, should expect to encounter coccidioidomycosis in endemic areas, and increasingly in nonendemic areas.

Foreign body aspiration in children: value of radiography and complications of bronchoscopy.

PURPOSE: The authors undertook a 10-year review of bronchoscopies for airway foreign bodies in children to test assertions in previous reports that (1) characteristic abnormalities in chest radiographs are important indicators of the need for bronchoscopy and (2) experienced operators incur negligible complications. METHODS: The medical records of 293 children who underwent bronchoscopies by experienced pediatric surgeons for suspected airway foreign bodies were reviewed for patient age, symptoms, duration of symptoms before bronchoscopy, prebronchoscopy radiographs, type of foreign body, anatomic location of foreign body, success of bronchoscopic removal, length of hospital stay, and complications. RESULTS: Of the 293 bronchoscopies, 265 showed airway foreign bodies. A choking episode was recorded in 228 of the 265 patients with foreign bodies and 5 of the 28 with negative bronchoscopy. The surgeon thought that radiographs were normal at the time of bronchoscopy in 110 patients who had foreign bodies. Nine patients with foreign bodies had atypical radiographs; three had bilateral emphysema and six had upper lobe or bilateral atelectasis or pneumonia. There were three complications: one vocal cord injury requiring temporary tracheostomy, one tracheal laceration from removal of an aspirated tooth, and one severe postoperative subglottic edema requiring a 4-day hospital stay. The age of the patients, symptoms, types of foreign bodies, locations of foreign bodies, management, and outcomes were similar to those of previous reports. CONCLUSIONS: In children with airway foreign bodies, chest radiograph findings are frequently normal and can display abnormalities uncharacteristic for foreign body aspiration. Children witnessed to choke while having small particles in their mouths and noted subsequently to have raspy respiration, wheezing, or coughing should undergo prompt bronchoscopy regardless of radiographic findings. Complications of bronchoscopy for foreign body aspiration are uncommon but occur even in experienced hands.

Undescended testicle associated with spigelian hernia.

The authors encountered a patient with a spigelian hernia (SH) and undescended testicle (UDT), making the fourth reported case with this combination. This patient provides further evidence that congenital SH predisposes neonates to UDT.

A 3-year survivor of near-total intestinal aganglionosis.

A newborn girl had no ganglion cells beyond 2 cm distal to the ligament of Treitz. The proximal jejunum was dilated. A jejunostomy constructed 46 cm distal to the ligament of Treitz functioned. A 28-cm jejunal segment was myectomized to augment enteral feeding. For almost 1 year she has been on enteral feedings only, and her body size has been in the 75th percentile.

Survival of nonpalpable undescended testicles after orchiopexy.

Among 496 boys who underwent operations for the preoperative diagnosis of undescended testicle, 41 patients had high undescended testicles that were not palpable preoperatively. Four of the 41 were bilateral, for a total of 45 high undescended testicles. Eight of the 45 were lost to long-term follow-up. Thirty-seven testicles were followed for over 1 year, and 30 (81%) of the 37 survived orchiopexy long term. No testicles atrophied later if they survived the first few postoperative months. Twenty-nine (64%) had vascular pedicles long enough to reach the scrotum without dividing the testicular artery. Our findings confirm long-standing impressions of most pediatric surgeons: (1) 81% survival warrants continuation of standard orchiopexy through a groin incision for nonpalpable undescended testicles in patients who will be able to ejaculate and engage in coitus; (2) most nonpalpable undescended testicles can be brought safely into the scrotum while preserving the testicular vasculature through a groin incision; (3) if it is necessary to divide the testicular artery in order to bring the testicle into the scrotum, our results confirm previous reports that preservation of the testicular collaterals will often allow the testicle to survive in a normal scrotal location; and (4) the need for testicular autotransplantation with microvascular anastomosis should rarely arise.

Obstruction of the neonatal airway from teratomas.

Most neonates with cervical or oral-pharyngeal teratomas have airway obstruction and an obvious mass. In previous reports, obstruction of the airway had caused 49 deaths in 164 newborns with cervical teratomas and five deaths in 24 newborns with oral-pharyngeal teratomas. Most were reported before the era of prenatal ultrasound. Cervical and oral-pharyngeal teratomas can now be diagnosed prenatally to allow preparation for the neonatal airway obstruction that so often occurs. Three infants with cervical teratomas, one infant with an oral-pharyngeal teratoma and one with a combined cervical and oral-pharyngeal teratoma were born in Phoenix over a one year period of time, and all had airway obstruction. These five patients demonstrated the value of prenatal planning and prompt postnatal surgical care by an ultrasonographer, a perinatologist, a neonatologist, maternal and pediatric anesthesiologists and a pediatric surgeon.

Surgical management of neonatal interstitial emphysema.

In the past 6 years, 50 patients with interstitial emphysema in our newborn nursery were treated with open operative procedures to remove interstitial air. Thirty-one were critically ill newborns with severe progressive pulmonary interstitial emphysema treated with pleurotomies. Five underwent pleurotomies on both sides, for a total of 36 operations in the 31 patients. All of the 31 patients underwent aggressive medical management to reduce airway pressure before resorting to operation. Ventilator manipulations, selective bronchial intubation, Forgerty catheter occlusion of the bronchus, and percutaneous lung needling were among the methods used to reduce emphysema in these patients. The operation for all 31 patients consisted of multiple linear pleurotomies to lyse blebs. The hilum was skeletonized to release perihilar blebs. A downhill course was reversed by the operation in over 50% of patients. The operation almost always permanently cured the tension emphysema on that side. Seventeen of the 31 patients lived. Eight of ten patients with unilateral disease lived. All of those patients who died had either very low birth weight, severe preoperative hypoxia, shock, or a combination of these problems.

Indomethacin versus immediate ligation in the treatment of 82 newborns with patent ductus arteriosus.

In the past 10 years, echocardiography and prostaglandin inhibition have changed the management of the patent ductus arteriosus (PDA) in newborns with respiratory distress syndrome (RDS). To judge the results of our present management for morbidity and survival, we analyzed data retrospectively on 82 newborns who were treated from 1977 to 1983 for PDA. We compared their hospital courses and outcomes with a similar group of 45 infants reported by us 10 years ago who were treated by early ductal ligation. The 82 recent patients were divided into two groups, A and B. Group A, 62 consecutive newborns with PDA, was treated primarily with indomethacin. A subsequent group of 20 newborns was treated for PDA primarily with early ductal ligation, group B. There was a 67.8% survival in group A versus 66.7% in the original group of patients 10 years ago--no significant improvement in survival in recent patients using indomethacin. Group B, with early ductal ligation similar to the original patients, had a survival rate of 75%. We identified a group of high-risk infants under 1500 grams with severe RDS whose prognoses varied significantly, depending on the treatment. In the original patients 10 years ago, 41.2% of newborns under 1500 grams with severe RDS survived; 33.3% survived in group A whereas, 71.4% survived in group B. In this high-risk group, treatment for PDA with indomethacin had the worst prognosis, and treatment with ductal ligation combined with modern supportive measures had the best prognosis.

Pneumoperitoneum in infants without gastrointestinal perforation.

Pneumoperitoneum signals gastrointestinal perforation and, as a rule, requires prompt laparotomy. However, we have recently encountered infants with severe respiratory distress who developed pneumoperitoneum without any gastrointestinal leak. These 10 patients were managed without operations. Three patients survived the respiratory distress and subsequently manifested no gastrointestinal disturbances. Five patients who died of pulmonary disease after conservative management of pneumoperitoneum had autopsies that revealed no gastrointestinal disease. We found no clinical or radiographic signs of peritonitis in these patients. Paracentesis and gastrointestinal x-rays revealed no gastrointestinal perforation. These critically ill newborns were thereby spared an unnecessary laparotomy. This experience confirms previous reports in the literature that, by clinical and radiographic correlations, "medical" pneumoperitoneum can often by distinguished from "surgical" pneumoperitoneum in critically ill infants with respiratory distress who may not easily tolerate an unnecessary laparotomy.

Intrapericardial teratoma--neonatal cardiorespiratory distress amenable to surgery.

Intrapericardial teratoma in early infancy produces critically severe cardiorespiratory distress and often results in the death of the infant. A recent patient in our newborn nursery displayed the distinctive combination of cardiorespiratory distress and enlargement of the "cardiothymic" silhouette. The echocardiographic demonstration of pericardial effusion and cardiac displacement suggested the diagnosis. Our patient's mass received the early recognition necessary for a successful surgical outcome.

Extremity swelling in an infant with copper and zinc deficiency.

A female infant born with jejunal atresia and a severely shortened bowel acquired progressive thickening of her thighs at 7 mo of age. While receiving parenteral nutrition, all four extremities rapidly became massively thickened and tender, and the child made no effort to move them. X-rays revealed large subperiosteal hematomas encompassing each femur, tibia, and humerus as the cause of the swelling. Ascorbic acid levels in the serum were not diminished, but copper and zinc levels were extremely low. Treatment with a trace element solution that included copper reversed the extremity thickening and the pseudoparalysis.

Emergency splenectomy for idiopathic thrombocytopenic purpura in children.

Splenectomies were performed in 30 children out of a total of 183 with idiopathic thrombocytopenic purpura (ITP). Of these 30, ten splenectomies were performed on an emergency basis. Significant spontaneous gross hematuria, gastrointestinal bleeding or epistaxis appear to represent harbingers of intracranial hemorrhage and constitute indications for emergency splenectomy.

Jejunal atresia with absent mesentery and a helical ileum.

Of 59 infants with jejunoileal atresia, seven presented with absence of mesentery, the main superior mesenteric artery ceasing to exist beyond the origin of the right colic or ileocolic artery, and a helical ileum. This distinctive form of jejunal atresia has been recognized with increasing frequency in recent years. Distal to the atresia, the small bowel receives its blood supply retrograde from an artery derived from the ileocolic or right colic arcades, and the ileum coils around its nutrient artery in an "apple peel" or "Christmas tree" deformity. The first three patients in this report died. The lastion, but they recovered as their malabsorption gradually disappeared. The treatment includes resection of the dilated bowel, as in other atresias. Resection of part of the distal bowel may be required for additional atresias or for poor vascularity with questionable viability. Postoperative malabsorption generally requires intravenous hyperalimentation.

Jejunoileal atresia: a proposed classification.

An experience with 59 infants with jejunal and ileal atresia is presented along with a proposed classification based on a combination of morphology and clinical characteristics. It would appear that the characteristics of each type are sufficiently distinct as to render this worthwhile classification.