Histologic Analysis of 'Distraction Vaginogenesis' in a Rat Model.

Vaginal agenesis (VA) is frequently associated with mullerian agenesis. VA treatments include mechanical dilation and surgical vaginoplasty. We created a vaginal expansion sleeve (VES) as a novel device to progressively lengthen the vaginal canal. This study evaluated the histologic effects of the VES on rat vaginal tissue. The VES is a spring-like device made of proprietary woven cylindrical material and flat resin caps. The VESs were constructed as 25-30 mm, pre-contracted springs, which were secured into the vaginas of six Sprague Dawley rats and allowed to re-expand post-surgically. After one week, the VESs were removed, and the vaginas were harvested and measured in length. Test (n = 6) and control (n = 4) formalin-fixed paraffin-embedded tissues were stained with hematoxylin and eosin (H&E), Masson's trichrome, and anti-Desmin antibodies. The VESs achieved significant vaginal lengthening. The mean vaginal canal length increased from 20.0 ± 2.4 mm to 23.8 ± 1.2 mm after removal of the VESs (n = 6, p < 0.001), a 19% increase. There was a positive correlation between the expander/tension generated in the vagina and the amount of acute and chronic inflammation. H&E staining revealed increased submucosal eosinophilia in five of the six test tissues. One VES sample that was lengthened to 30 mm long showed evidence of lymphocytic and neutrophilic inflammation. Desmin immunostaining and Masson's trichrome stain revealed a thinner muscularis with more infiltrative fibrous tissue between muscle fibers in the test tissue compared to the control tissue. Although effective, the VES may provoke at least a transient increase in eosinophils consistent with a localized immune reaction during muscularis remodeling.

'Distraction Vaginogenesis': Preliminary Results Using a Novel Method for Vaginal Canal Expansion in Rats.

Vaginal atresia is seen in genetic disorders such as Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, which can cause significant sexual dysfunction. Current treatments include surgical reconstruction or mechanical dilation of the vaginal canal. Mechanical dilation requires patients to be highly motivated and compliant while surgical reconstruction has high rates of complications. This study evaluated a novel vaginal expansion sleeve (VES) method as an alternative treatment for vaginal atresia. The proprietary cylindrical VES is a spring-like device consisting of polyethylene terephthalate helicoid trusses capped at each end with a fixed diameter resin cap for fixation within tissues. Following the development of the VES and mechanical characterization of the force-length relationships within the device, we deployed the VES in Sprague Dawley rat vaginas anchored with nonabsorbable sutures. We measured the VES length-tension relationships and post-implant vaginal canal expansion ex vivo. Vaginal histology was examined before and after implantation of the VES devices. Testing of 30 mm sleeves without caps resulted in an expansion force of 11.7 ± 3.4 N and 2.0 ± 0.1 N at 50% and 40%, respectively. The implanted 20 mm VES resulted in 5.36 mm ± 1.18 expansion of the vaginal canal, a 32.5 ± 23.6% increase (p = 0.004, Student t test). Histological evaluation of the VES implanted tissue showed a significant thinning of the vaginal wall when the VES was implanted. The novel VES device resulted in a significant expansion of the vaginal canal ex vivo. The VES device represents a unique alternative to traditional mechanical dilation therapy in the treatment of vaginal atresia and represents a useful platform for the mechanical distension of hollow compartments, which avoids reconstructive surgeries and progressive dilator approaches.

Is there a role for routine preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in children?

HYPOTHESIS: Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used preoperatively in adult patients with suspected choledocholithiasis. Cholelithiasis occurs much less often in children, and the indications for ERCP are not established. We hypothesized that the natural history of choledocholithiasis in children is spontaneous passage of stones through the papilla and that these children can be managed without routine preoperative ERCP. DESIGN: Retrospective analysis of patients treated over a 10-year period. SETTING: Tertiary care children's hospital. PATIENTS: All patients with cholecystectomy for biliary disease. INTERVENTIONS: Cholecystectomy; intraoperative cholangiography for suspected choledocholithiasis: hyperbilirubinemia, gallstone pancreatitis, and ultrasonographic evidence of common bile duct dilation or common bile duct stones; and postoperative ERCP for symptomatic choledocholithiasis: pain and jaundice. MAIN OUTCOME MEASURES: Incidence and complications of choledocholithiasis and frequency of ERCP. RESULTS: One hundred patients (63 females) were studied. Indications included acute cholecystitis (10%), chronic cholecystitis (59%), gallstone pancreatitis (26%), and choledocholithiasis (5%). An intraoperative cholangiography was performed in 45 patients, and common bile duct stones were identified in 13. Expectant management of asymptomatic common bile duct stones was associated with sonographic resolution within 1 week. One patient with intraoperative cholangiography-proven choledocholithiasis required ERCP for symptoms 24 hours after operation. One additional patient, who did not undergo intraoperative cholangiography, developed symptomatic choledocholithiasis and required ERCP. There were no choledocholithiasis- or ERCP-related complications. CONCLUSIONS: This study suggests that choledocholithiasis occurs frequently in children and that spontaneous passage of common bile duct stones is common. This could explain the relatively high incidence of gallstone pancreatitis. Conservative management of choledocholithiasis is successful in the majority of patients. Routine preoperative or postoperative ERCP is usually not indicated.

Fibrosing mediastinitis secondary to zygomycosis in a twenty-two-month-old child.

We report the case of a 22-month-old immunocompetent male child with fibrosing mediastinitis secondary to zygomycosis, an unusual presentation of a rare fungal infection. This patient was successfully treated with amphotericin B and itraconazole for 20 weeks. Stenting of the superior vena cava was helpful in relieving the patient's superior vena cava syndrome.

Pneumoretroperitoneum in two patients with Clostridium perfringens necrotizing pancreatitis.

Pancreatic gas gangrene is an uncommon and often fatal complication of acute pancreatitis, due to the sporulating anaerobe Clostridium perfringens. C. perfringens is a normal constituent of colonic flora, but infects the pancreas by either transmural spread from the colon or via the biliary tree. Only three reported cases in the world literature describe acute pancreatitis with pneumoretroperitoneum and clostridial infection. Two separate cases, at the same institution, of acute pancreatitis complicated by C. perfringens were analyzed. The records of patients were reviewed for admission history, laboratory and radiology results, intensive care support, surgical intervention, and outcome. Retroperitoneal air was visualized early in the clinical course of both patients by computed tomography. Early surgical debridement, drainage, parental antibiotics, and reexploration resulted in an uncomplicated recovery. Early computed tomography in patients with suspected necrotizing pancreatitis contributes to early intervention and may advantageously enhance survival.

Port insertion and removal techniques to minimize premature rupture of the membranes in endoscopic fetal surgery.

BACKGROUND: Premature rupture of membranes (PROM) remains a significant complication of fetal surgery. Rates of 40% to 100% have been reported after both open and endoscopic fetal surgery. We describe a technique of endoscopic port insertion and removal that minimizes trauma to the membranes. METHODS: Twenty-seven consecutive patients undergoing endoscopic laser ablation for twin-to-twin transfusion syndrome were reviewed. In each case, a minilaparotomy was performed, and the amniotic cavity was entered under direct vision of the uterus using a Seldinger technique. The entry site was carefully dilated to accommodate a 4.0-mm-diameter cannula. A gelatin sponge plug was placed at port removal. Postoperative management and outcome were evaluated. RESULTS: Median gestational age at operation was 21.3 weeks. Median operating time was 60 minutes. One patient delivered intraoperatively because of fetal distress. Seventeen (65.4%) patients required postoperative tocolysis (median duration, 12 hours). Median postoperative gestation was 6.5 weeks (range, 1-20 weeks). Only 1 (4.2%) of 24 patients with successful gelatin sponge placement developed PROM. CONCLUSIONS: Meticulous technique and atraumatic insertion and removal of ports help minimize the risk of postoperative amniotic leak after endoscopic fetal surgery. Our PROM rate of 4.2% contrasts sharply with previously reported rates after similar operations.

Isolated computed tomography diagnosis of pulmonary contusion does not correlate with increased morbidity.

BACKGROUND: Increased utilization of computed tomography (CT) has led to a rise in the diagnosis of pulmonary contusion. Its clinical significance, in the absence of findings on chest radiograph (CXR), has not been defined. This study examines the clinical course of patients with CT-only diagnosis of pulmonary contusion and compares it with that of patients with CXR-proven pulmonary contusion. METHODS: The trauma database identified all children undergoing chest CT for blunt thoracic trauma during a 3-year period. Records were reviewed for age, mechanism of injury, Injury Severity Score (ISS), length of hospital stay (LOS), need for intensive care unit admission, and need for endotracheal intubation. A pediatric radiologist reviewed all films in a blinded fashion. Statistical analysis was performed using analysis of variance and Fisher's Exact test for 2 x 3 tables. RESULTS: Eighty-two patients were identified. There were no CXR-positive, CT-negative cases. A CT diagnosis of pulmonary contusion was made in 46 patients. Of these, 31 had a contusion on CXR as well (CXR+ group) and 15 had a normal CXR (CT+ only group). Mean ISS score did not differ significantly between the two groups (27 +/- 12.3 and 22 +/- 10.3, respectively). Thirty-six patients had a normal CT (control). Mean LOS was significantly longer in the CXR+ group (13 +/- 12.0 days) than in the CT+ only and control groups (5 +/- 3.6 and 9 +/- 9.5 days, respectively; P < .01). The percentages of children requiring intensive care unit admission and intubation were also significantly higher in the CXR+ group. CONCLUSION: The finding of pulmonary contusion by CT alone does not increase patient morbidity and appears to be of limited clinical significance.

Pediatric trauma patients with isolated airway compromise or Glasgow Coma Scale less than 8: does immediate attending surgeon's presence upon arrival make a difference?

BACKGROUND/PURPOSE: Optimal trauma care requires an attending pediatric surgeon to head a trauma team for the most severely injured patients. Recently, the American College of Surgeons-Committee on Trauma has added "Glasgow Coma Scale (GCS) <8" and "airway compromise" to the existing anatomical and physiological criteria for immediate attending presence. This report analyzes the outcome of children who met these isolated criteria and were treated before the change in guidelines was made. METHODS: The trauma registry of this level I trauma center was queried for all pediatric patients with GCS <8 or airway compromise. Age, sex, initial GCS, Revised Trauma Score, Injury Severity Score, outcome, and probability of survival (TRISS methodology) were recorded. The subgroup of patients for whom an attending surgeon was not immediately present was further analyzed. RESULTS: Over a 5-year period, 2895 trauma patients (aged 0-16 years) were admitted. One hundred fifteen patients had a GCS <8 and/or airway compromise. In 61 cases, an attending surgeon was not present upon patient arrival. Of these patients, 24 died (group D), 15 were discharged to a rehabilitation facility (group R), and 22 were discharged home (group H). Ten patients with a probability of survival of lower than 0.5 survived. Only 4 of the 24 patients who died had a probability of survival of >0.5 (mean, 0.697). All 4 had an Injury Severity Score >25 and a GCS < or =4. All deaths were reviewed through a quality improvement program and were deemed nonpreventable by objective reviewers. Patient outcome was not affected by the presence or absence of an attending surgeon upon patient arrival. CONCLUSIONS: Outcome of severely injured children with GCS <8 or airway compromise met and, in some cases, exceeded expectations of survival according to the TRISS methodology. The lack of immediate attending surgeon's presence does not appear to have negatively influenced the outcome in these children. Based on this series, there is no evidence to justify mandatory immediate presence of an attending surgeon for these 2 criteria alone.

Pulmonary embolism: which pediatric trauma patients are at risk?

BACKGROUND/PURPOSE: Deep vein thrombosis and pulmonary embolism (DVT/PE) are rare in pediatric trauma patients, and guidelines for prophylaxis are scarce. The authors sought to identify subgroups of patients who may be at higher risk of developing DVT/PE. METHODS: Case-control study of pediatric trauma patients with DVT/PE. Odds ratios (ORs) and confidence intervals (CIs) were calculated for known risk factors of PE using matched trauma controls (chi2 analysis). RESULTS: A total of 3637 pediatric trauma patients was admitted over the last 7 years. Three patients developed DVT/PE (overall incidence, 0.08%). There were 2 girls and 1 boy, aged 15, 15, and 9 years, respectively. All 3 had an Injury Severity Score (ISS) > or =25 and an initial Glasgow Coma Score (GCS) < or =8. None of the known and potential risk factors significantly increased the OR for developing DVT/PE: age 9 years or older (OR, 3.6; CI, 0.4-26), presence of head injury (OR, 2.9; CI, 0.3-22), female sex (OR, 1.2; CI, 0.15-9.1), GCS < or =8 (OR, 9.2; CI, 0.9-230), except ISS > or =25 (OR, 82; CI, 7.6-2058). The OR for a combination of age and GCS was 106, and the OR for the 3 risk factors (age, ISS, GCS) common to all 3 patients was 114 (CI, 10-5000; P < .001). CONCLUSIONS: The overall incidence of DVT/PE in pediatric trauma patients is <0.1% and routine prophylaxis is not recommended. Children aged 9 years or older with an initial GCS < or =8 and patients with an estimated ISS > or =25 may constitute a high-risk group in which prophylaxis could be considered.

Spontaneous postnatal resolution of a cystic lung mass: A case report.

Postnatal cystic adenomatoid malformations (CAMs) are managed by surgical excision. Asymptomatic CAMs have decreased in size with initial observation. This is the first reported case of complete resolution of a postnatal CAM. Premature infants with asymptomatic CAMs may benefit from careful observation as their initial treatment.

Eukaryotic initiation factor 4E staining as a clinical marker in pediatric neuroblastoma.

OBJECTIVES: Neuroblastoma (NBL) has several well-established prognostic factors. Eukaryotic initiation factor 4E (4E) has shown promise as a prognostic marker in other cancers. We hypothesize that a correlation exists between 4E staining and NBL clinical outcome. METHODS: Eleven adrenal NBL patient charts were reviewed for data, including age, stage, MYCN amplification, Shimada classification, and mortality. These patients' surgical specimens were stained with 4E antibody and scored for staining density. 4E expression, quantified by staining density, was compared to clinical data. CONCLUSION: 4E staining significantly correlates with age at diagnosis. The remaining prognostic factors lack statistically significant correlation. Increasing sample size may further establish statistically significant correlations. 4E could become an additional prognostic factor of NBL.

Extracorporeal membrane oxygenation in piglets using a polymerized bovine hemoglobin-based oxygen-carrying solution (HBOC-201).

PURPOSE: The purpose of this study was to determine if the polymerized bovine hemoglobin-based oxygen-carrying solution HBOC-201 is an acceptable substitute for blood in a healthy porcine, extracorporeal membrane oxygenation (ECMO) model. METHODS: Ten piglets (15 to 25 kg) were placed on venoarterial ECMO. Four animals received blood-primed ECMO, and 6 animals received HBOC-201-primed ECMO. Hemodynamic variables, urine output, blood gas analyses, complete blood counts, and lactate levels were followed for 6 hours. Data were analyzed using a nonparametric sign test and repeated measures analysis of variance (ANOVA). RESULTS: All animals survived the 6-hour ECMO procedure. Heart rate, mean arterial pressure, urine output, and serum lactate levels were not significantly different between groups. Postpriming volume was 176 +/- 156 mL in the blood group. None of the animals in the HBOC-201 group required additional volume to maintain target flow during ECMO (P <.05). Arterial pH, pO2, and oxygen content between groups were not significantly different. Hematocrit for the HBOC-201 group was significantly (P <.05) lower than the blood group. CONCLUSIONS: HBOC-201-primed ECMO in a healthy porcine model showed similar hemodynamics and equivalent oxygen carrying capacity to blood-primed ECMO. Postpriming volume requirement was decreased significantly in the HBOC group. ECMO using HBOC-201 instead of blood appears promising and warrants further investigation.