Intraoperative magnetic resonance imaging-guided drainage of nonpalpable abscesses.

SUMMARY: Intraoperative magnetic resonance imaging provides the surgeon with powerful, high-resolution, real-time imaging. Procedures may be performed with minimal invasion, with the benefit of reduced tissue damage, improved wound healing, and a better cosmetic result. The authors present a case of a leukemic pediatric patient with a few large, deeply situated, nonpalpable abscesses that were drained successfully with intraoperative magnetic resonance imaging guidance. In this case, this new intraoperative imaging method enabled minimal invasiveness, with fast recovery.

CT diagnosis of delayed presentation of congenital diaphragmatic hernia simulating massive pleuropneumonia.

A case of an 11-month-old infant with a delayed presentation of congenital diaphragmatic hernia is reported. Incarceration of the herniated colon caused a misleading appearance on the chest X-ray which was interpreted as massive pleuropneumonia. Computed tomography, performed because of continuing deterioration in the clinical condition, showed fluid-filled bowel loops in the chest and dilated bowel loops with air-fluid levels in the abdomen, suggesting the correct diagnosis.

[Preliminary report of experience with laparoscopic splenectomy in adults and children].

Laparoscopic splenectomy is effective and technically feasible for treating various hematological diseases such as idiopathic thrombocytopenic purpura (ITP), congenital spherocytosis, hemolytic anemia, and Hodgkin's lymphoma. An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is frequently difficult. The laparoscopic posterolateral approach involves dissection of the posterolateral attachments to the diaphragm, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. We used it in 9 adults and 4 children: 11 patients had ITP, 1 spherocytosis and 1 Hodgkin's lymphoma. This procedure was completed in 13 patients, but in 2 it had to be converted to open surgery. Mean operating time was 3 hours and mean postoperative stay 3 days. Blood transfusion was not required and there were no postoperative complications. Laparoscopic splenectomy is safe in both adults and children, and the posterolateral approach provides excellent visualization and allows control of the branches of the splenic vein and artery in the splenic hilum.

Congenital aorto-caval fistula in the newborn: a case report.

The authors report a rare case of congenital fistula between the distal aspect of the descending aorta and the inferior vena cava. The clinical features of this aortocaval fistula is being described as well as the preoperative diagnostic workup, the intraoperative findings, and the complicated postoperative course and treatment.

Is abdominal cavity culture of any value in appendicitis?

BACKGROUND: Intraperitoneal culturing during appendectomy is a routine procedure. Significant decrease in the mortality and dramatic improvement in the morbidity were achieved by using antibiotics perioperatively. The value of intraoperative abdominal cavity culture was assessed in our study. METHODS: A total of 499 patients formed two groups, those with acute nonperforated appendicitis (group A) and those with perforated appendicitis (group B). Intraoperative abdominal cavity culture were taken randomly in both groups. The perioperative morbidity, the validity, and the impact of positive culture on the antibiotic treatment were examined in both groups. RESULTS: Clinical diagnosed perforation was confirmed histologically in 176 patients (98.3% accuracy). Intraperitoneal cultures were obtained in 30.1% of the patients in group A and in 67.1% of group B. The majority of the patients in group A were treated preoperatively and postoperatively by a single antibiotic agent whereas 58.0% of the patients in group B were started on triple-agent antibiotics for significantly longer periods (22.4 +/- 9.4 versus 5.7 +/- 7.4 doses, respectively; P < 0.0001). No significant difference was found in both groups in the postoperative complication rate (wound infection, intra-abdominal abscess and small bowel obstruction) whether intra-abdominal culture was obtained or not (5.9% versus 4.7% in group A and 21.2% versus 21.9% in group B; P > 0.05). CONCLUSION: Traditional intraoperative abdominal cavity culture can be abandoned. In perforated appendicitis, colonic flora can be predicted, and antibiotic therapy should begun without any abdominal cavity culture results. This practical approach will save money and reduce laboratory work without affecting the patient's morbidity.

A bizarre bezoar: case report and review of the literature.

A bizarre case of a foreign-body bezoar is presented. A 16-year-old girl swallowed large amounts of toilet paper as a means of dieting. She presented with a palpable abdominal mass, multiple bezoars in the bowel, and paper excretion in the feces before admitting intentional ingestion of toilet-paper balls. Administration of Gastrografin via a nasogastric tube and enemas resulted in gradual excretion of the paper balls.

Results of liver transplantation in children with unresectable liver tumors.

Liver cancer is an uncommon indication for liver transplantation in children. Between 1986 and 1995, five children with hepatocellular cancer (HCC), three with hepatoblastoma (HEP), and one with sarcoma were referred to the transplant service. All nine tumors were considered unresectable. Four of the five children with HCC had underlying predisposing conditions (2 hepatitis B, 1 biliary atresia, 1 tyrosinemia). Preoperative evaluation of all patients included careful radiological screening and pretransplantation laparotomy for staging. Two patients with HCC were excluded from further consideration because of intraabdominal spread. Three patients had transplantation (mean age, 6.0 +/- 7.1 years), and all have survived for 1 to 5 years with no evidence of recurrence. Three patients with HEP were assessed (mean age 2.0 +/- 1 years); two had stage 4 disease and one had stage 3. All three received preoperative chemotherapy. The two with stage 4 had thoracotomies as part of their assessment. Two of three patients had a significant decrease in the size of the primary tumor during the waiting period. These two patients and one with stage 4 disease have survived more than 2 years since transplantation, with no recurrence. The third patient had recurrence within 2 months of transplantation. In summary, liver transplantation should be considered for all children who have unresectable hepatic malignancies, given the 83% survival rate and no evidence of tumor recurrence. Stage 4 disease in HEP does not necessarily exclude patients from transplantation. Early referral is encouraged so that tumor spread beyond the liver is minimized.

Unconventional treatment of neuroenteric cyst in a newborn.

Neuroenteric cysts are uncommon congenital malformations that can require early surgical treatment. The authors report on an unusual treatment of a very large neuroenteric cyst that involved most of the small bowel and extended into the chest. A 1-day-old boy was admitted because of abdominal distension. The prenatal ultrasound results at 8 and 36 weeks had been normal. Examination showed right upper quadrant fullness and mild respiratory distress. A malformed sternum and asymmetric upper thoracic vertebra were seen on the initial x-rays. The possibility of a midthoracic right paravertebral mass was raised. Abdominal ultrasound findings were consistent with a large bowel duplication cyst. Laboratory results were all normal except the bilirubin level, which was (59 mmol/L). During laparotomy, the second part of the duodenum was found to enter a dilated cyst, and the terminal ileum arose from the cyst. The total length of the intact small bowel was 20 cm including a competent ileocecal valve. The site of the biliary duct entering the cyst was not clear. The surgical procedure involved partial resection of the anterior wall of the cyst, creation of an enteric tube from the posterior cyst wall to communicate between the duodenum and the ileum, and addition of another 25 cm of length to the small bowel. An enterocutaneous fistula was created with the proximal portion of the cyst because the site of the papilla of Vater was suspected to enter this part of the cyst. A postoperative HIDA scan showed good uptake with no excretion into the gut or the proximal pouch.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of biliary cirrhosis following hepatic arterial thrombosis after liver transplantation in children by using ursodeoxycholic acid.

Hepatic artery thrombosis (HAT) after liver transplantation is a severe complication that often requires retransplantation. The authors have adopted a different approach, aimed at treating the perioperative HAT complications aggressively and early, with ursodeoxycholic acid (UDCA), to try to preserve the original graft. Eighty-six liver transplants were performed in 73 children (age range, 4.5 months to 17.5 years; median, 2.6 years). HAT occurred eight times, in seven patients (9.3%). Patients with HAT were significantly younger and smaller (mean age, 0.8 +/- 0.4 v 4.8 +/- 5.3 years; P < .02; mean weight, 7.4 +/- 0.8 v 18.7 +/- 16.2 kg; P < .05). The incidence of HAT varied significantly according to the method of arterial reconstruction used: 4 of 16 (25%) when a donor iliac artery interposition graft to the aorta was used, 4 of 61 (6.6%) when the native hepatic artery was used, and 0 of 9 when the donor celiac axis was anastomosed directly to the aorta (P < .05). The incidence of HAT was not significantly different when reduced-size grafts were used. Early retransplantation was performed in three of the eight patients; two survived. All other patients were treated for 4 to 6 weeks with broad-spectrum antibiotics and amphotericin. Five patients were treated with UDCA, three immediately after the acute event and two after 4 and 6 months (respectively) post-HAT. The patients who had UDCA immediately post-HAT had histologically normal liver biopsy specimens. Results of liver function tests have been normal. One of these patients required transhepatic stenting of a common bile duct stricture for several months.(ABSTRACT TRUNCATED AT 250 WORDS)

Survival after reduced-size liver transplantation is dependent on pretransplant status.

Orthotopic liver transplantation (OLT) in children is characterized by unique problems including a shortage of compatible-size donors resulting in long waiting periods, significant deterioration while waiting, and death before transplantation. To improve the chances of obtaining an organ for the sickest patients, reduced-size liver transplantation (RSLT) was offered to all hospital-bound children starting in July 1988. Since then, 68 OLTs were performed in 58 children. Thirty-six RSLTs were done in 30 children (42% of total 86 OLT, 53% since 1988). The mean weight of the RSLT patients was 13.5 +/- 10.4 kg versus 23.8 +/- 21.9 kg in the full-size (FSLT) group (P < .05). Twenty-five of 39 transplants (71.4%) done in children < 10 kg were RSLTs in comparison to only 10 of 47 (21.3%) in patients > 10 kg (P < .0005). Since 1988, 25 of 34 (73.5%) of all transplants in children < 10 kg have been RSLTs. Average donor to recipient weight ratio in the RSLT group was 4.21:1 versus 1.17:1 in the FSLT group (P < .0001). RSLT was done as a primary procedure in 26 patients and as a retransplant in 10. Mean blood product replacement was significantly higher in the RSLT group both intraoperatively (515.7 +/- 490.9 v 177.2 +/- 278.3 mL/kg, P < .005) and during the first 24 hours postoperation (50.5 +/- 81.8 mL/kg v 16.4 +/- 28.5 mL/kg, P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Malignant benign neonatal sacrococcygeal teratoma.

Thirty-six patients with benign neonatal sacrococcygeal teratoma (SCT) were treated in our medical center from 1972 to 1990. Mean gestational age was 38.6 +/- 3.3 weeks with a mean birth weight of 3,484.0 +/- 938.5 g. Twenty-nine patients (89%) were females. The majority of the tumors (75%) contained cystic components and 96% were Altman classification I and II. The initial surgical removal of the SCT (including the coccyx) was carried out during the first 7 days of life. Six patients (22%) developed recurrence of the tumor. Three were benign and reappeared locally after 12 +/- 3 months and were reexcised. The mean serum alpha-fetoprotein level in this group was 13 +/- 1 g/L. The malignant recurrence (all originally reported as being mature benign SCT) appeared at 20.3 +/- 1.5 months and had markedly elevated serum alpha-fetoprotein levels (7,320 +/- 4,630 micrograms/L). All the patients in this group had multimodal therapy including complete excision of the recurrent tumor. We conclude that SCT, although histologically benign, has an alarming potential to recur either as a benign or malignant tumor during the first 2 years of life. Close follow-up for at least 3 years (frequent examination, serum alpha-fetoprotein, and diagnostic imaging) is recommended for all patients who had undergone excision of SCT in the newborn period.

Flow-cytometric characterization of cardiac allograft-infiltrating cells following MHC class I antigen pretreatment in the mouse.

Changes in the graft-infiltrating cell population (GIC) induced by Class I MHC pretreatment were characterized using flow cytometric analysis. C3H mice received 10(7) EL4 cells intravenously 14 days prior to transplant with C57BL/10 (H-2b) hearts. Transplanted hearts were removed from six recipients in both groups at 4, 6, 9, 12, 15, and 21 days after transplantation. GICs were harvested and incubated with FITC-conjugated Lyt-1 and Lyt-2 and phycoerythrin-conjugated L3T4 monoclonal antibodies. The proportion of GICs which were Lyt-1, L3T4, or Lyt-2 positive was similar in both control and pretreated groups at all times posttransplant, and all three cell populations exhibited similar changes over the course of the study in both groups. At Post-transplant Day (PTD) 9, there were significantly more double-staining cells (L3T4+, Lyt2+) in the pretreated group than in the control group (8.58 +/- 2.49% vs 4.36 +/- 1.32%, P < 0.05). By PTD 15, the double-staining cells had increased in pretreated mice to 17.46 +/- 4.36% of the total GICs (P < 0.05). The percentage of GICs in EL4-pretreated mice which were Lyt-1- was significantly higher at all time points than the percentage of L3T4- or Lyt-2- cells, whereas in the control, these cell populations were equivalent, implying that in pretreated mice, cells are present which are L3T4+ or Lyt2+ but Lyt-1-.(ABSTRACT TRUNCATED AT 250 WORDS)

Alteration of pulmonary function by filtration of intravenous nutrient mixture.

In view of contradicting results concerning alteration in lung function during hyperalimentation and the administration of intravenous lipid emulsion, a study was planned to determine possible changes in pulmonary blood perfusion during administration of total nutrient admixture (TNA) and the effect of filtration. Sixteen patients (8 men, 8 women; mean age 65.6 yr) with no previous lung disease received TNA at the rate of 4-5 g lipid/h as preoperative treatment for 5-9 days (mean 6.7 days). The 5-microns filter was randomly used in eight patients. The lung blood perfusion parameters measured repeatedly during this period included blood gases, percentage of the predicted value of vital capacity (VC), and pulmonary diffusing capacity for carbon monoxide (DLCO), as well as the value of the dead space volume and the tidal volume ratio (VD/VT) and the calculated shunt (QS/QT). TNA infusion appears to cause only a slight decrease in PaO2 and DLCO and a similar increase in VC and QS/QT, whereas VD/VT decreased significantly. The latter effect was abolished by filtration of TNA. There were no significant differences between the two groups. We therefore conclude that short-term preoperative administration of TNA at the rate of 4-5 g lipid/h in patients without preexisting lung disease does not jeopardize lung functions. Filtration of the TNA is, however, recommended to avoid the potential hazardous effects of long-term treatment of TNA on lung function.

Surgical complications in children after liver transplantation.

The frequency of surgical complications after liver transplantation remains high. Sixty transplants were done in 48 patients during 4 years. Eleven patients were retransplanted (re-transplant rate, 20%) for primary nonfunction (6), arterial thrombosis (3), warm ischemia (1), and rejection (2). Right pleural effusions were drained in 13 patients and left ones in 2. Forty-eight re-explorations excluding retransplantation were performed in 20 patients. Twelve laparotomies were for control of postoperative intraabdominal bleeding. The majority of these patients (8/10, 80%) were transplanted with reduced-size grafts. Early postoperative vascular complications were detected in 12 grafts (5 portal vein occlusions, 7 arterial thromboses). All 5 patients with portal vein (PV) occlusions were reexplored, and PV flow was reestablished in all 5. Biliary leaks were diagnosed in 6 patients and were associated with arterial thromboses in 2 cases. Reoperation was required in 4 of 6 patients. Bowel perforation occurred in 4 patients; 2 small bowel, 1 duodenum, and 1 colon. There was 1 postoperative bowel obstruction requiring laparotomy. Two splenectomies were required in 4 patients with splenic infarction. Resection of part of a transplanted liver was done in 1 patient to exclude septic infarcts. Pancreatitis was diagnosed in 4 patients and one required laparotomy for control of pancreatic hemorrhage. Intraabdominal abscesses required open drainage in 2 patients and percutaneous drainage in 4. Seven thoracotomies were done in 6 patients: 5 open lung biopsies, 1 for control of hemorrhage, and 1 for diaphragmatic plication. The current high survival rates following liver transplantation require aggressive surgical management of a myriad of complications and numerous procedures are necessary both as treatment modalities and as diagnostic aids.

Coagulation plasma factor levels are early indicators of graft nonfunction following liver transplantation in children.

Following liver transplantation, the decision to retransplant in cases in which graft function is marginal must be taken early. Plasma coagulation factor monitoring was evaluated as an early predictor of graft failure requiring retransplantation in the first posttransplant week. Plasma levels of fibrinogen, factors V, VII, VIII, IX, antithrombin III, protein C, and plasminogen were measured in all patients at 0, 12, 24, 48, 72, 96, and 120 hours posttransplant in 46 patients who received 56 grafts and results were compared between livers that failed early (group 1) and those that functioned adequately (group 2). Six grafts were included in group 1: one patient died before retransplantation, four were retransplanted once, and one patient was retransplanted twice. Three grafts had primary nonfunction (PNF), 2 had obstructed portal veins, and 1 had a long period of warm ischemia during the initial transplant. In group 1, plasma levels of factor V were significantly lower than in group 2 at 24, 48, and 72 hours posttransplant (21.2% +/- 14.2%, 12.4% +/- 4.5%, and 13.0% +/- 5.0% v 39.1% +/- 23.9%, 48.8% +/- 31.9%, and 60.9% +/- 25.9%; P less than .05, P less than .01, and P less than .005, respectively). Similarly, plasma levels of factor VII were significantly lower in group 1 over the same period of time (7.3% +/- 2.7%, 4.2% +/- 1.8%, and 4.7% +/- 2.5% v 27.4% +/- 17.1%, 34.1% +/- 21.6%, and 34.8% +/- 18.6%, respectively; P less than .005).(ABSTRACT TRUNCATED AT 250 WORDS)

Primary closure of contaminated wounds in perforated appendicitis.

We studied the clinical course of 506 children consecutively admitted with appendicitis at The Hospital for Sick Children from 1985 to 1989. One hundred eighty-one children (35%), ranging in age from 1 to 17 years, presented with perforation verified by histological examination. Ninety-six of them (53%) had generalized peritonitis, 47 (26%) had localized peritonitis, and 38 (21%) had abscess formation. Usually, triple antibiotics were begun preoperatively if perforation was suspected; otherwise, cefoxitin was started. Triple antibiotics were used postoperatively for 5 to 7 days in almost all children in the perforated group. Neither abdominal nor subcutaneous drainage was routinely used even in cases of intraabdominal abscess. The skin was closed primarily with steri-strips (63%), staples (20%), subcutaneous Dexon (11%), or silk (4%). Postoperative wound infection arose in 20 children (11%). Wound infections were noted from 1 to 14 days postoperatively (mean, 5.9 days). Whereas 9 of these were treated with local therapy only, 11 delayed the child's discharge or necessitated readmission. No patient suffered major complications from wound infection in that there were no cases of necrotizing fasciitis, reoperation for debridement, sepsis, or death. The intraabdominal abscess rate in this group of 181 children was 6% (n = 11). The low rate of infective complications fully justifies the policy of primary closure in contaminated wounds. This policy eliminates the necessity for painful and time-consuming dressing changes, shortens hospitalization, and obviates the trauma of delayed suturing of wounds in children.

Inflammatory pseudotumor in childhood. A diagnostic and therapeutic dilemma.

We describe a case of inflammatory pseudotumor of the lower abdomen in a young child. The urinary bladder and abdominal wall were involved, and the pseudotumor simulated a malignant sarcomatous tumor. Surgical excision was undertaken, and the outcome was favorable. This rare tumor simulates a true neoplasm both clinically and morphologically and presents a diagnostic and therapeutic dilemma. Our case and a review of the literature indicate that an effort should be made to perform a radical excision. This is considered the treatment of choice except if it requires a mutilating procedure.