Distal fragmented port catheter: case report and review of literature

BACKGROUND: Insertion of long-term central venous catheters (CVC) plays a vital role in providing continuous venous access for therapy in children. CVC line fractures are most commonly seen after long-term periods of therapy during removal. Usual place of rupture is proximal, at the point of entrance of the catheter into the vein, when the subclavian approach is utilized. We discuss a case that shows that CVC can also fracture in places different than the most common location and is possible not to detect that a fracture has occurred if a substantial portion of catheter is removed. METHOD: We report a two-year-old child that was incidentally found to have a distal fragmented piece of CVC left after previous "successful" removal on simple chest films. At time of removal the catheter length was deemed properly. A CT Scan confirmed the suspected diagnosis. Fragment of catheter was successfully removed via femoral percutaneous endovascular technique. RESULTS: CVC fractures can be suspected when there is resistance during removal or the length retrieved is too short. In this case the ease of retrieval and unusual site of rupture was the cause of not noticing that a part of catheter remained fixed to the vessel wall. Different potential mechanisms of CVC rupture include mechanical trauma, manufacturing defect or material degradation. Ruptures should be detected early to prevent complications such as sepsis, endocarditis, thrombosis, embolization, vessel stenosis and dysrhythmia. Best method to remove the fragmented catheter is via percutaneous endovascular retrieval method. After catheter removal a hyperdensity silhouette on a CXR can mimic the fragmented portion of a catheter known as a calcified cast or "ghost". To differentiate a "ghost" from an actual fragmented portion of catheter a CT Scan or echocardiogram is needed. CONCLUSION: Most important single step in preventing such complication is to keep record of the patient length of catheter that was inserted...

Malrotation of the intestine and preduodenal portal vein associated with abdominal situs inversus: a case report

Abdominal situs inversus is a rare condition usually associated with malformations of asymmetric organs such as the heart, liver, spleen and malrotation of the intestines. A case of abdominal situs inversus with intestinal malrotation and preduodenal portal vein is reported. Patient underwent prophylactic Ladd's procedure and preduodenal portal vein was left undisturbed during surgery. This case highlights the importance of rigorous investigation of anatomic features prior to surgery in a patient with heterotaxia. The authors advocate radiological investigation of patients with heterotaxia and prophylactic Ladd's procedure in those with intestinal malrotation.

Duodenal duplication with accessory papilla causing recurrent pancreatitis in a child: a case report

We discuss a 16-year-old male patient who presented with three episodes of recurrent pancreatitis within the last 6 months. Preoperative imaging studies suggested a choledochal cyst within the second portion of the duodenum. Patient was taken to surgery and the lesion was removed. Pathology examination of the cyst revealed a duodenal duplication. The accessory pancreatic papilla entering the closed duplication cyst was the main cause of the pancreatitis in this child.

Renohepaticopancreatic dysplasia: diagnostic dilemma

We present the case of an eighteen day old baby boy hospitalized with an abdominal mass, renal insufficiency and jaundice. Multiple radiographic, radionuclear and surgical interventions were required to diagnose renohepaticopancreatic dysplasia, also known as Ivemark II syndrome. In spite of aggressive intensive care support, the patient developed multisystemic organ failure and died. Clinical presentation and autopsy findings are presented.

Cavernous hemangioma presenting as a right adnexal mass in a child

This is the case of an 11-year-old girl who presented with a right adnexal mass and vague abdominal symptoms since seven months prior to her hospital admission for surgery. CT-scan and sonographic images were those of a benign lesion, probably ovarian torsion or infarction. Serum tumoral markers were normal. A right salpingo-oophorectomy and appendectomy were performed. Pathology examination revealed a cavernous hemangioma of the ovary. The clinicopathologic presentation of this unusual benign ovarian tumor is discussed.

Presacral neuroblastoma in a child: a case report

Presacral location of neuroblastoma is rare. Resection entails an abdomino-sacral approach. This case report discusses clinical, imaging and successful surgical management of a presacral neuroblastoma in a one-year-old male child

Presacral neuroblastoma in a child: a case report.

Presacral location of neuroblastoma is rare. Resection entails an abdomino-sacral approach. This case report discusses clinical, imaging and successful surgical management of a presacral neuroblastoma in a one-year-old male child.

Molecular biology and genetics affecting pediatric solid tumors

Since the discovery of oncogenes more than 20 years ago, it has been proven that cancer is a genetically determined disease. Multiple genetic alteration occurs during the course of an illness for neoplasia to develop. Transformation of positive cell growth regulators (oncogenes) and inactivations of negative cell growth regulators (tumor suppressor genes) merge to express a malignant phenotype. These genetic alterations occur as chromosomal translocations, deletions, inversion, amplification or point mutation. The objective of this review is to introduce basic concepts of molecular biology and describe the molecular genetics and biologic clinical findings of the most important solid malignant tumors in children, namely Neuroblastoma, Wilms and Rhabdomyosarcoma. It is the oncology surgeons responsibility to learn basic molecular genetics and tumor biology to provide rational and appropriate care in the setting of multidisciplinary management. Identifications of new oncogenes will continue to be important milestones in diagnosis, early detection of tumor recurrence, and as potential targets for gene therapy. Fusion proteins generated by mutated translocations are true tumor specific antigens and potential targets for therapy. The predicament is that they are proteins needing therapeutic manipulation within the tumor cell nuclei. Technological advances in molecular and genetics will develop tools necessary to manipulate the cell nuclear DNA and target cancer cell

Profile of Internet users: survey of the Surgical Section of the AAP

BACKGROUND: Communication through electronic networks is becoming a most useful resource of health care providers. PURPOSE: Establish the demographic and professional profile and identify the internet service provider of members of the Surgery Section of the American Academy of Pediatrics (AAP). MATERIALS: A short survey questionnaire including variables of age, gender, years of experience, type of practice and internet service provider was mailed to all members of the Surgical Section of the AAP. Two-hundred and six responses of 588 (35%) were received and analyzed. RESULTS: Mean age of the group was 52 years of which 88% were male and 12% female (7.5:1). The group had an average of eighteen years of practice; 185 members (90%) have access to Internet and 188 (92%) use it mainly for e-mailing from either home (25%), hospital/office setting (30%) or both (42%). Twenty-three percent of member were willing to receive section news and correspondence by electronic means, by print-mail 34% and both 44%. Overall type of practice was private 21%, University 54% or combined 23%. No access to internet means an older member (57 yrs, p = 0.02) sharing solo (private) practice (p = 0.006). Two-third of internet service providers were university-based (-edu) or hospital organizations (-org) with a younger age group (48 yrs, p = 0.000001). CONCLUSIONS: E-mailing is becoming the preferred method of communication among many members of the Section of Surgery of the AAP. Net accessibility through University or Children Hospital servers account for the high number of young members in this practice setting

Profile of Internet users: survey of the Surgical Section of the AAP.

BACKGROUND: Communication through electronic networks is becoming a most useful resource of health care providers. PURPOSE: Establish the demographic and professional profile and identify the internet service provider of members of the Surgery Section of the American Academy of Pediatrics (AAP). MATERIALS: A short survey questionnaire including variables of age, gender, years of experience, type of practice and internet service provider was mailed to all members of the Surgical Section of the AAP. Two-hundred and six responses of 588 (35%) were received and analyzed. RESULTS: Mean age of the group was 52 years of which 88% were male and 12% female (7.5:1). The group had an average of eighteen years of practice; 185 members (90%) have access to Internet and 188 (92%) use it mainly for e-mailing from either home (25%), hospital/office setting (30%) or both (42%). Twenty-three percent of member were willing to receive section news and correspondence by electronic means, by print-mail 34% and both 44%. Overall type of practice was private 21%, University 54% or combined 23%. No access to internet means an older member (57 yrs, p = 0.02) sharing solo (private) practice (p = 0.006). Two-third of internet service providers were university-based (-edu) or hospital organizations (-org) with a younger age group (48 yrs, p = 0.000001). CONCLUSIONS: E-mailing is becoming the preferred method of communication among many members of the Section of Surgery of the AAP. Net accessibility through University or Children Hospital servers account for the high number of young members in this practice setting.

Molecular biology and genetics affecting pediatric solid tumors.

Since the discovery of oncogenes more than 20 years ago, it has been proven that cancer is a genetically determined disease. Multiple genetic alteration occurs during the course of an illness for neoplasia to develop. Transformation of positive cell growth regulators (oncogenes) and inactivations of negative cell growth regulators (tumor suppressor genes) merge to express a malignant phenotype. These genetic alterations occur as chromosomal translocations, deletions, inversion, amplification or point mutation. The objective of this review is to introduce basic concepts of molecular biology and describe the molecular genetics and biologic clinical findings of the most important solid malignant tumors in children, namely Neuroblastoma, Wilms and Rhabdomyosarcoma. It is the oncology surgeons responsibility to learn basic molecular genetics and tumor biology to provide rational and appropriate care in the setting of multidisciplinary management. Identifications of new oncogenes will continue to be important milestones in diagnosis, early detection of tumor recurrence, and as potential targets for gene therapy. Fusion proteins generated by mutated translocations are true tumor specific antigens and potential targets for therapy. The predicament is that they are proteins needing therapeutic manipulation within the tumor cell nuclei. Technological advances in molecular and genetics will develop tools necessary to manipulate the cell nuclear DNA and target cancer cell.

Pediatric thyroid nodules: insights in management.

BACKGROUND: Multiple diagnostic studies are utilized to unveil malignancy in pediatric thyroid nodules and determine whether surgical therapy is needed. PURPOSE: The aim of this report was to determine whether management of pediatric thyroid nodules has changed with the current use of diagnostic modalities such as ultrasonography (US), radionuclear scans (RNS) and fine needle aspiration biopsy (FNAB). MATERIAL/METHODS: Twenty-four children with thyroid nodules managed during a ten-year period comprised the study group. Demographic characteristics, clinical manifestations, US and RNS imaging findings, FNAB results, surgical therapy, complications and pathological reports were retrospectively reviewed. US, RNS and FNAB results were categorized as either benign, malignant, suspicious or insufficient. RESULTS: Females outnumbered males by a five to one ratio. Mean age was 14.9 years. Nineteen nodules were benign (79%) and five malignant (21%). All children were euthyroid. Benign nodules were soft, movable, solitary and nontender. Malignant nodules were characterized by localized tenderness, a multiglandular appearance, and fixation to adjacent tissues. US and RNS gave no clue toward management since cystic and hot nodules figured among malignant cases respectively. US achieved 86% accuracy, 80% sensitivity and 88% specificity; RNS showed 26% accuracy, 80% sensitivity and 11% specificity; FNAB achieved 80% accuracy, 60% sensitivity and 90% specificity. Suppressive thyroid hormone therapy was useless in the few cases tried. Physical examination findings, persistence of the nodule, progressive growth and cosmetic appearance where the most common indications for surgery. CONCLUSIONS: Present diagnostic modalities played a minor role in the decision to withhold surgery. US was useful for aiming aspiration of cystic nodules. RNS decided the functionality of the nodule, but its accuracy was far from ideal. FNAB is a safe procedure whose greatest help was to resolve in case of suspicious or malignant cytology that a more radical procedure is needed. Clinical judgement as determined by serial physical findings and suspicion continues to be the most determinant factors in the management of thyroid nodules in children.

Pediatric thyroid nodules: management in the era of fine needle aspiration.

BACKGROUND/PURPOSE: Thyroid nodules are rare in children. The need to uncover malignancy is the most challenging dilemma in management. The aim of this report was to determine whether management of pediatric thyroid nodules has changed in the era of fine-needle aspiration (FNA) cytology. METHODS: Twenty-four children with thyroid nodules comprised the study group. Demographic characteristics, clinical manifestations, imaging results, FNA cytology results, surgical therapy, complications, and pathological reports were reviewed retrospectively. FNA cytology results were categorized as either benign, malignant, suspicious, or insufficient. RESULTS: Girls outnumbered boys (five to one) with a mean age of 14.9 years. Nineteen nodules were benign and five malignant. Malignancy was characterized by localized tenderness, multiglandular appearance, and fixation to adjacent tissues. Ultrasound scans and nuclear scans gave no clue toward management because cystic, hot, and warm nodules figured among malignant cases. FNA in 18 children achieved 80% accuracy, 60% sensitivity, 90% specificity, 75% positive, and 81% negative predictive value. Physical examination findings, persistence of the nodule, and progressive growth decided for surgery in most children. CONCLUSIONS: FNA is a safe adjunctive test that plays a minor role in the decision to withhold surgery. Its greatest strength is to resolve, in case of suspicious or malignant cytology, that a more radical procedure will be needed. Clinical judgement as determined by serial physical findings continues to be the most important factor in the management of thyroid nodules in children.

El rol de Internet en la cirugía pediátrica / The role of Internet in pediatric surgery

Internet, la mayor red de computadoras conectadas se ha constituído en la última adquisición para que los agentes de salud accedan a información. Analizaremos como el desarrollo de esta tecnología es una fuente de educación en Cirugía Pediátrica y describimos conceptos básicos en el uso de esta red. Los elementos básicos de la red de Internet son: el Correo Electrónico (e-mail), Grupos de Discusión (List), Transferencia de Archivos o Documentos y exploración en el "World Wide Web" (WWW). El correo electrónico acerca a los profesionales con intereses comunes. Los cirujanos lo emplean como herramienta de comunicación. Las responsabilidades legales están ligadas a su uso. Los grupos de discusión permiten el debate de casos clínicos, operaciones, investigación, publicación de oportunidades laborales y anuncio de reuniones científicas. La Transferencia de Archivos brinda la oportunidad de obtener artículos de bibliotecas públicas. La WWW es la más fructífera herramienta por su accesible herramienta por su accesible y fácil exploración. La mayoría de los médicos no requieren tener conocimientos extensos sobre computación para explorar el pandemonio de información ofrecida. "Click and Play" con las actuales aplicaciones estimula a los neófitos a conectarse. Se requiere de un equipo (hardware) y programas (software) adecuados junto a un proveedor de servicio de Internet. En el futuro se desarrollarán publicaciones electrónicas, se implementarán progresos en Telemedicina, conferencias internacionales y concentración de la información en un "ciber-espacio" centralizado en Cirugía Pediátrica con ágiles instrumentos de búsqueda

El rol de Internet en la cirugía pediátrica / The role of Internet in pediatric surgery

Internet, la mayor red de computadoras conectadas se ha constituído en la última adquisición para que los agentes de salud accedan a información. Analizaremos como el desarrollo de esta tecnología es una fuente de educación en Cirugía Pediátrica y describimos conceptos básicos en el uso de esta red. Los elementos básicos de la red de Internet son: el Correo Electrónico (e-mail), Grupos de Discusión (List), Transferencia de Archivos o Documentos y exploración en el "World Wide Web" (WWW). El correo electrónico acerca a los profesionales con intereses comunes. Los cirujanos lo emplean como herramienta de comunicación. Las responsabilidades legales están ligadas a su uso. Los grupos de discusión permiten el debate de casos clínicos, operaciones, investigación, publicación de oportunidades laborales y anuncio de reuniones científicas. La Transferencia de Archivos brinda la oportunidad de obtener artículos de bibliotecas públicas. La WWW es la más fructífera herramienta por su accesible herramienta por su accesible y fácil exploración. La mayoría de los médicos no requieren tener conocimientos extensos sobre computación para explorar el pandemonio de información ofrecida. "Click and Play" con las actuales aplicaciones estimula a los neófitos a conectarse. Se requiere de un equipo (hardware) y programas (software) adecuados junto a un proveedor de servicio de Internet. En el futuro se desarrollarán publicaciones electrónicas, se implementarán progresos en Telemedicina, conferencias internacionales y concentración de la información en un "ciber-espacio" centralizado en Cirugía Pediátrica con ágiles instrumentos de búsqueda

Pediatric thyroid nodules: insights in management

BACKGROUND: Multiple diagnostic studies are utilized to unveil malignancy in pediatric thyroid nodules and determine whether surgical therapy is needed. PURPOSE: The aim of this report was to determine whether management of pediatric thyroid nodules has changed with the current use of diagnostic modalities such as ultrasonography (US), radionuclear scans (RNS) and fine needle aspiration biopsy (FNAB). MATERIAL/METHODS: Twenty-four children with thyroid nodules managed during a ten-year period comprised the study group. Demographic characteristics, clinical manifestations, US and RNS imaging findings, FNAB results, surgical therapy, complications and pathological reports were retrospectively reviewed. US, RNS and FNAB results were categorized as either benign, malignant, suspicious or insufficient. RESULTS: Females outnumbered males by a five to one ratio. Mean age was 14.9 years. Nineteen nodules were benign (79%) and five malignant (21%). All children were euthyroid. Benign nodules were soft, movable, solitary and nontender. Malignant nodules were characterized by localized tenderness, a multiglandular appearance, and fixation to adjacent tissues. US and RNS gave no clue toward management since cystic and hot nodules figured among malignant cases respectively. US achieved 86% accuracy, 80% sensitivity and 88% specificity; RNS showed 26% accuracy, 80% sensitivity and 11% specificity; FNAB achieved 80% accuracy, 60% sensitivity and 90% specificity. Suppressive thyroid hormone therapy was useless in the few cases tried. Physical examination findings, persistence of the nodule, progressive growth and cosmetic appearance where the most common indications for surgery. CONCLUSIONS: Present diagnostic modalities played a minor role in the decision to withhold surgery. US was useful for aiming aspiration of cystic nodules. RNS decided the functionality of the nodule, but its accuracy was far from ideal. FNAB is a safe procedure whose greatest help was to resolve in case of suspicious or malignant cytology that a more radical procedure is needed. Clinical judgement as determined by serial physical findings and suspicion continues to be the most determinant factors in the management of thyroid nodules in children

Congenital diaphragmatic hernia: mortality determinants in a Hispanic population.

OBJECTIVES: Determine which factors were associated with mortality in our patients, specifically whether ventilatory parameters and arterial blood gas could be used to predict outcome. The role of delaying surgery and the presence of contra lateral pneumothorax were also assessed. BACKGROUND: Mortality among babies born with congenital diaphragmatic hernia remains high. The associated pulmonary hypoplasia and hypertension account for most of the overall mortality. There is no uniform consensus as to which parameters predict outcome. METHOD: Study population consisted of thirty-two patients with CDH managed during a ten-year period. Retrospective data obtained included: perinatal data, postnatal complications, ventilatory parameter data, arterial blood gas, type and age of surgery. Ventilatory index, oxygenation index and arterial to alveolar oxygen difference (A-aDO2) within the first 24 hours of life and after surgical correction were compared among the 23 patients who underwent surgical correction. Timing of surgery and frequency of pneumothorax were compared between survivors and non-survivors. Epi-Info Software Package was used for statistic analysis. RESULTS: Overall survival was 40%. Survival of surgically corrected infants was 61%. Non-survivors had significantly higher A-aDO2 than survivors (p < 0.05). No significant differences in pCO2, ventilatory index, or oxygenation index were identified between survivors and non survivors. Surgical repair performed after the first twenty-four hours of life, was associated with a higher survival rate (p < 0.05). Fourteen patients (39%) developed contralateral pneumothorax, eleven (79%) of these died. CONCLUSIONS: (1) contralateral pneumothorax was associated with higher mortality, 2) A-aDO2 was a better prognostic indicator than pCO2, ventilatory index, or oxygenation index, 3) delaying surgical repair was associated with better survival rate.

Trends in management of gallbladder disorders in children.

Gallbladder disorders have been recognized with increasing frequency in pediatric patients. This study aimed to identify recent trends in management and compare the effectiveness of laparoscopic (LC) over open cholecystectomy (OC) by a retrospective chart analysis of all cholecystectomies from 1990 through 1995. Information obtained included demographics, symptoms, predisposing conditions, associated illnesses, family history, imaging studies, type of cholecystectomy, complications, operative time, pain medication, diet recommencement, pathologic findings, and length of hospital stay. The type of cholecystectomy (OC vs. LC) was compared with the clinical variables using standard statistics. Eighty-three patients between 21 months and 18 years of age were identified; their mean age was 14.8 years. Females (76%) with classic biliary symptoms predominated;12% of the patients developed gallstone pancreatitis and 7% jaundice. Abnormal liver chemistry values, obesity, and elevated triglyceride levels comprised the most significant predisposing factors. Indications for surgery were cholelithiasis in 71 patients (86%), gallbladder dyskinesia in 10 (12%), and sludge/polyp in 2. Fifty-nine cholecystectomies (71%) were done laparoscopically and 24 (29%) open. Choledocholithiasis in 6 children (7%) was managed by open extraction with t-tube placement or endoscopic papillotomy followed by LC. No major ductal complication was identified. The predominant pathologic finding was chronic cholecystitis, including the subgroup with biliary dyskinesia. Statistical comparison showed that LC is superior to OC in regard to length of stay, diet resumption, use of pain medication, operating time, and cosmetic results. It is concluded that a contemporary diet, obesity, and abnormal liver chemistry are the main predisposing conditions of gallbladder disease in children in this decade. Females in their teenage years with typical symptoms continue to be the most commonly affected group. Persistent biliary symptoms associated with low gallbladder ejection fractions during hepatobiliary cholecystokinin-stimulated scans can be caused by dyskinesia. The method of choice to remove the diseased gallbladder in children is LC, which is safe, efficient, and superior to the conventional method. Common duct stones can be managed by simultaneous endoscopic papillotomy. The costs of LC are reduced by employing reusable equipment and selective cholangiographic indications.

Role of Internet in medicine

Internet, the largest network of connected computers, is becoming the ultimate frontier to access information for health providers. This review focus on how developments of this communication technology have become a useful educational resource in medicine, and describes modest ideas in computer network use. Internet basic resources are electronic mailing (E-mail), discussion groups, file transfer, and browsing the World Wide Web (WWW). E-mail brings physicians with common interest together. Surgeons employ it as a communicating tool. Legal and social responsibility is bounded with its use. Discussion groups permits debate including clinical cases, operations, techniques research, career opportunities, and meetings. File transfer provides the opportunity of retrieving archives from public libraries. The WWW is the most resourceful tool due to its friendly interface and ease of navigation. The average physician needs to know almost nothing on how computers work or where they came from to navigate through this pandemonium of information. Click and play with today graphical applications encourage the computer illiterate to connect. Establishing the connections envelops the need of hardware, software and a service provider. Future development consists of online journals with new ideas in peer-review and authentication, telemedicine progression, international chatting, and centralization of cyber space information into database or keyword search engines