Treatment of congenital pulmonary lymphangiectasia using ethiodized oil lymphangiography.

Historically, congenital pulmonary lymphangiectasia (CPL) has had poor treatment outcomes despite aggressive therapy. There are recent reports of ethiodized oil (Lipiodol) lymphangiography successfully treating lymphatic leakage in adults. In this report, we describe two infants with CPL complicated by chylothoraces successfully treated by instillation of ethiodized oil into the lymphatic system. Congenital atresia of the thoracic duct was demonstrated on the lymphangiogram in both patients before treatment. Both patients have shown good short-term outcomes without supplemental oxygen or fat restricted diets at 9 months of age. Ethiodized oil lymphangiography represents a new treatment modality for some patients with CPL.

Operative management of chronic pancreatitis in children.

HYPOTHESIS: Chronic pancreatitis in childhood is a rare but potentially debilitating disorder, and failure of conservative therapy with chronic pain medication use is common. We hypothesize that aggressive surgical therapy may hold promise for long-term remission. DESIGN: Retrospective analysis of data collected prospectively for 12 years. SETTING: Tertiary care children's hospital. PATIENTS: Eighteen children (aged 3-13 years, 11 girls) underwent surgical treatment of chronic pancreatitis after 1 to 6 years of various medical therapies (parenteral nutrition, somatostatin, or pain medication). These patients required a mean +/- SD 6 +/- 0 hospitalizations before operation. Pancreatitis was familial in 9 patients, idiopathic in 5, and secondary to trauma and medication use in 2 each. Preoperative endoscopic retrograde cholangiopancreatography showed pancreatic duct dilatation in 7, strictures in 5, ductal stones in 4, and normal findings in 2. The operative therapy consisted of longitudinal pancreaticojejunostomy in 2 children (both children failed pancreaticojejunostomy but improved after undergoing pancreatectomy) and distal pancreatectomy with Roux-en-Y pancreaticojejunostomy in 16 children. OUTCOME MEASURES: Survival, need for rehospitalization or reoperation, and chronic pain medication requirements. RESULTS: All patients survived. Follow-up ranged from 1 to 15 years. Thirteen (72%) of 18 patients have required no further hospitalizations or medications. Two patients required a second operation to convert their longitudinal pancreaticojejunostomy to distal pancreatectomy, and 3 patients have required 2 to 5 additional hospitalizations for recurrent pancreatitis. Endoscopic retrograde cholangiopancreatography on 5 patients 2 to 4 years postoperatively showed patent distal pancreaticojejunostomy. CONCLUSIONS: This series suggests that distal pancreatectomy and pancreaticojejunostomy are effective treatments for this difficult group of patients, while longitudinal pancreaticojejunostomy was ineffective. Long-term relief of pain and reduced need for rehospitalization are the usual results after this procedure.

Glasgow Coma Scale predicts coagulopathy in pediatric trauma patients.

The aim of this study was to determine if neurologic findings at the time of initial resuscitation can predict coagulation abnormalities resulting from head injury. Fifty-three children with head injury were reviewed for Glasgow Coma Scale (GCS), prothrombin time (PT), international normalized ratio (INR), partial thromboplastin time (PTT), use of fresh frozen plasma (FFP) and outcome. Twenty-six of the 53 children (49%) presented with a GCS of 15 and 27 (51%) had a GCS less than 14. The incidence of computed tomography (CT)-documented intracranial injury was 12% in those children with a GCS of 15 versus 78% when GCS < or = 14 (P < .05). Abnormal coagulation (PT > 14.5, INR > 1.2, PTT > 38) in children with a GCS = 15 was 7% v 67% when GCS was < or = 14 (P < .05). A mean of 1 unit of FFP per patient was required in children with a GCS of < or = 14. No child with GCS of 15 and CT evidence for intracranial injury had a coagulopathy, and no child with GCS of 15 required FFP. In head injured children, significant coagulation abnormalities requiring treatment are excluded by the presence of a normal GCS at presentation. Children with GCS less than 14 are at risk for intracranial injury and coagulopathy, this risk increases inversely with the GCS. Children who present with a GCS less than 8 should have FFP prepared at the time of admission. These data may guide the use of laboratory tests and blood bank resources during trauma resuscitation.

Characteristics of pediatric cervical spine injuries.

PURPOSE: The objective of this study was to assess the mechanisms and patterns of injury and outcome in children with cervical (C) spine trauma. METHODS: We reviewed the National Pediatric Trauma Registry between April 1994 and March 1999 and identified (by ICD-9 criteria) all cases of blunt trauma victims with cervical fractures, dislocations, and spinal cord injuries without radiographic abnormality (SCIWORA). Data are shown as mean +/- SEM. RESULTS: During the 5-year period, the incidence of blunt C-spine injury was 1.6% (n = 408 of 24,740 total entries). Mean age was 10.5+/-0.3 (1 to 20) years, and 59% were boys. Leading mechanisms were motor vehicle accidents (n = 179; 44%), sports (n = 66; 16%), and pedestrian injuries (n = 57, 14%). Younger (< or =10 years) children more often sustained high (C1 to C4) vs low (C5 to C7) injuries (85% v 57%; P<.01) and also had a higher incidence of dislocations (31% v 20%; P<.01) and cord injuries (26% v 14%; P<.01), whereas older children had more C-spine fractures (66% v 43%; P<0.01). Mortality rates (overall, 17%) were higher in younger children (n = 180) when compared with older children (n = 228; 30% v 7%; P<.01). Overall, the majority of deaths (93%) were associated with brain injuries. No children with cervical dislocations had neurologic sequelae. The preponderance of children with fractures (83%) also were without neurologic injury, whereas those associated with SCIWORA usually were (80%) partial. Overall, complete cord lesions were infrequent (4%). CONCLUSIONS: These data, representing the largest series to date, confirm that blunt C-spine injuries in children are rare. Patterns of injury vary significantly according to child age. Major neurologic sequelae in survivors is uncommon, does not correlate well with cord level, and rarely is complete.

Outcome of the antegrade colonic enema procedure in children with chronic constipation.

BACKGROUND: Chronic constipation and fecal incontinence in children related to pelvic trauma, congenital anomalies, or malignancy will eventually lead to significant social and psychologic stress. Maximal medical treatment (daily enemas and laxatives) can also be difficult to maintain in many children. METHODS: At our children's hospital, 11 children with chronic constipation or fecal incontinence or both underwent the antegrade colonic enema (ACE) procedure. The operation involved constructing a conduit into the cecum using either the appendix (n = 8) or a "pseudo-appendix" created from a cecal flap (n = 3). We report our surgical results. RESULTS: Mean child age was 9.6 (5 to 18) years. With a mean follow-up of 14 (6 to 24) months, 10 of the children (91%) had significant improvement and 7 children (64%) are completely clean with no soiling and controlled bowel movements after irrigation. CONCLUSIONS: Regular colonic lavage after the ACE procedure allows children with chronic constipation and fecal incontinence to regain normal bowel habits and a markedly improved lifestyle. This procedure should be considered before colostomy in children and adults for the treatment of fecal incontinence from a variety of causes.

Predicting hollow visceral injury in the pediatric blunt trauma patient with solid visceral injury.

BACKGROUND: Nonoperative management of a solid organ injury (SVI) is accepted in the stable pediatric trauma patient. A concern with nonoperative management is missing a hollow visceral injury (HVI). Factors that may help predict HVI have not been well documented. METHODS: The National Pediatric Trauma Registry was reviewed for the period October 1988 through September 1998 for all blunt injured, hemodynamically stable pediatric patients (age < or =12 years) with an SVI (kidney, liver, pancreas, spleen) of Abbreviated Injury Scale (AIS) score > or =2. HVIs included AIS > or =2 gastrointestinal tract injuries. RESULTS: For the decade of review, 2,977 pediatric patients sustained an SVI, including 96 with an HVI (3.2%). The mean age was 6.6 years, with a mean Injury Severity Score of 12.4. An occupant in a motor vehicle accident was the most common injury mechanism (30.4%), but assault was the most likely to result in an HVI (11.5%). The liver was the most common SVI (n = 1,400), the spleen the least likely to have an associated HVI (2.5%). Pancreatic injuries had a higher rate of HVI (P < .001). The majority of patients had a single SVI (n = 2,507) with 71 associated HVIs (2.8%). The risk of associated HVI increased as the number of solid organs injured increased: 4.7% with 2 organs, 13.5% if 3 organs were injured (P< .001). In patients with a single SVI, the rate of HVI did not differ as AIS increased (range, 2.7% to 6.5%, Pvalue not significant). CONCLUSIONS: The overall rate of HVI was low (3.2%). Higher rates of HVI were found in assaulted patients and patients with multiple SVIs or pancreatic injuries. The risk of associated HVI was dependent more on number of SVIs than severity of the individual organ injury. This data suggest that nonoperative management is justified in the patient with a single SVI but should be used cautiously in the patient with multiple SVI or a pancreatic injury.

Acute ovarian torsion in children.

BACKGROUND: Acute ovarian torsion (OT) is an uncommon cause of abdominal pain in children and is frequently confused with other conditions. METHODS: We reviewed the records (1983 to 1999) of all children treated for acute OT at our children's hospital. RESULTS: Mean child age (n = 51) was 12.5 +/- 0.3 years. Children presented with either right-sided (n = 29) or left-sided (n = 22) pain. Diagnosis of OT was confirmed preoperatively by ultrasound (73%) or computed tomography (CT) scan (10%) while nine children (17%) with right-sided pain underwent surgery for presumed appendicitis. Despite a relatively short time from diagnosis to surgery, all 51 children required salpingooophorectomy. Contralateral biopsy was performed in 29% and 57% had an appendectomy. Younger children more commonly had either a mature cystic teratoma or torsion with no underlying abnormality as an etiology compared with OT in older children that was more likely to result from either a follicular or corpus luteal cyst. Pathologic examination of the contralateral ovary and appendix was normal in all children who underwent biopsy and appendectomy. CONCLUSION: Ultrasonography with color doppler is helpful for differentiating acute OT from appendicitis. Although the twisted ovary can rarely be salvaged, the etiology is usually benign. Preoperative serum markers and contralateral ovary biopsy may be unnecessary.

Imaging of surgical diseases of the newborn chest. Intrapleural mass lesions.

Prenatal detection of intrapleural mass lesions is commonplace. Diagnostic treatment plans often are formulated before birth. The radiologist's involvement in dealing with congenital lobar emphysema, congenital cystic adenomatoid malformation, extralobar pulmonary sequestration, and congenital diaphragmatic hernia has changed. The need for immediate postnatal diagnosis has been de-emphasized, but the demand for precision and efficiency in preoperative cross-sectional imaging, monitoring progress and complications of treatment, and assistance with nutritional support has increased.

Pediatric splenic injury: pathway to play?

BACKGROUND: Nonoperative management of blunt splenic injury (BSI) remains a "gold standard" in pediatric trauma care. Controversy exists regarding the minimal hospital stay necessary for the care of these patients and the appropriate duration of reduced activity required after discharge. METHODS: A clinical pathway was developed in an attempt to standardize the hospital and outpatient management of children with BSI cared for at the Children's Hospital of Philadelphia. From July 1, 1996 to September 30, 1997, all children with BSI were treated using this pathway (pathway group). To better evaluate outcome, data were compared with an historical control of consecutive children treated at our institution during the previous 2 years (control group). RESULTS: Twenty-eight children in the control group and 21 children in the pathway group comprise the study population. Average age, injury mechanism, grade of splenic injury, injury severity score, length of intensive care unit stay, and number of transfusions were not significantly different between the two groups (P<.05). As expected, there was a significant decrease in the length of stay on the general care units (5.3+/-1.2 v 2.9+/-0.9 days, control v pathway, P<.05), which, in turn, resulted in a significant decrease in the total length of hospitalization (6.7+/-1.4 v 3.9+/-1.2 days, P<.05) and estimated hospital charges. During follow-up, no complications or missed injuries were identified at a standard 3-week and the 3-month office visit. CONCLUSION: Hemodynamically stable children with isolated blunt splenic injuries may be treated safely with a 4-day hospital stay followed by 3 weeks of quiet activities at home and 3 months of light activity before return to full, unrestricted activity.

Percutaneous needle aspiration of small interloop abscesses in children.

Treatment of small postoperative interloop abscesses (ILA) can be challenging. In children, these collections have usually been drained surgically at a second operation. This article describes three children with small postoperative ILAs who were treated by percutaneous needle aspiration and parenteral antibiotics, with good outcomes. The advantages of this technique and its utilization in the management of children with ILAs are discussed.

Diagnostic imaging in pediatric trauma.

In the head and neck, the futility of skull radiography is again reemphasized as a poorer predictor of intracranial injury than is a neurologic examination, though controversy continues as to which neurologic criteria should be the ones leading to a cranial computed tomography scan. Understanding the anatomic variations in the radiography of the cervical spine in small infants and children can help avoid overdiagnosis in this group and can obviate the need for additional unwarranted computed tomography studies and undue clinical concern. Magnetic resonance imaging can show anatomically exquisite portrayals of growing skull fractures for neurosurgical planning, but its routine use for imaging the cervical cord in shaken, abused infants without clinical abnormality appears unwarranted. Within the chest, the radiograph remains a highly accurate and low cost cornerstone in traumatized patients. The use of ultrasound imaging to detect pleural fluid is being investigated and has been found to be accurate but cannot compare to all of the information gleaned from the radiograph. The pericardium is clearly an exception. Abdominal trauma in children is triaged vastly differently from that of adults. Imaging of adults looks for signs to diagnose significant bleeding and need for operation, while pediatric trauma imaging has its greatest effect in reducing the intensity of care. Administration of oral contrast has not been very effective in aiding diagnosis of hollow visceral perforations and is being used less in blunt abdominal trauma computed tomography. Children with microscopic hematuria and no evidence of multiple system trauma seem to be helped little by imaging. The utility of finding and extracting subcutaneous foreign material, usually in extremities, by ultrasound imaging remains controversial. Experience, equipment, and effort all seem to play a role.

Arterial waveforms in the femoral heads of healthy neonates.

OBJECTIVE: The objective of this study was to characterize the Doppler waveform in the cartilaginous capital femoral epiphysis of healthy neonates with the aid of power Doppler and duplex Doppler imaging. SUBJECTS AND METHODS: In this prospective study, both hips were examined in 63 neonates. We used conventional sonographic imaging and power Doppler imaging. Spectral Doppler tracings were obtained when possible. Spectral analysis and resistive index measurements were performed. RESULTS: The examination was completed in 97 hips, revealing pulsatile arterial blood flow with a low-velocity, low-resistance, reproducible waveform. Mean resistive index was 0.48 +/- 0.11. Additional time spent on the Doppler study was documented in all patients and averaged 6 min. CONCLUSION: The arterial blood flow pattern in the femoral chondroepiphysis of healthy neonates has been described. The additional time spent doing the Doppler examination is acceptable. In future studies, this pattern of blood flow can be compared with that of abnormal hips and those undergoing treatment for developmental dysplasia.

Umbilical venous catheterization and the risk of portal vein thrombosis.

Portal vein thrombosis has been associated with umbilical venous catheterization. We studied the incidence of portal vein thrombosis associated with umbilical venous catheterization with the catheter tip not in the portal venous system. Appropriate placement of an umbilical venous catheter in sick neonates is associated with a low risk of portal vein thrombosis (actual incidence, 1.3%).

Hemophilia presenting in an infant as a radial artery pseudoaneurysm following arterial puncture.

The case presented is of an infant who developed a radial artery pseudoaneurysm following arterial puncture and was subsequently diagnosed with hemophilia. A discussion of radial artery pseudoaneurysms follows.

The ultrasonographic differentiation of obstructive versus nonobstructive hydronephrosis in children: a multivariate scoring system.

PURPOSE: We identified sonographic prognosticators to aid in distinguishing obstructive from nonobstructive hydronephrosis in children. MATERIALS AND METHODS: Twelve sonographic variables were initially analyzed to determine significant associations between the variables and the presence of urinary tract obstruction as defined by diuretic radionuclide renography. The significant findings were subsequently subjected to logistic regression models to identify potential predictors for obstructive hydronephrosis. RESULTS: The 7 variables associated with a significantly higher risk of urinary tract obstruction were increased echogenicity, parenchymal rims 5 mm. or less, contralateral hypertrophy, resistive index ratio 1.10 or greater, resistive index difference with diuresis of 70% or greater, ureter diameter 10 mm. or greater and aperistaltic ureter. These variables were used for the development of a multivariate scoring system. CONCLUSIONS: The obstructive scoring system shows promise as a screening method for the sonographic differentiation of obstructive from nonobstructive hydronephrosis in children.

Idiopathic bilateral anterior mediastinal abscesses.

Mediastinal suppuration and abscess formation are uncommon in the era of antibiotics. The case of a child with seemingly idiopathic bilateral and separate anterior mediastinal abscesses is presented. The chest radiography, sonography and computed tomography findings are described.

The diagnosis of malrotation during air enema procedure.

This paper describes the correct diagnosis of cecal malposition, suggesting midgut malrotation, during air enema examination in seven patients. It is possible to diagnose cecal malposition by air enema, even in the presence of a reducible intussusception.