Balloon embolization of a bleeding gastroduodenal artery in a 1-year-old child.

Severe stress can produce ulceration and uncontrollable hemorrhage in the pediatric age group. Modern angiographic techniques, using embolization of a Silastic balloon to occlude a visualized bleeding vessel, can successfully control hemorrhage and avoid surgical intervention and its resultant disordered gastric physiology. Recently this technique was used to control hemorrhage from the gastroduodenal artery in a 1-year-old child with severe respiratory sepsis. This is the youngest reported child in whom the technique has been used to control bleeding from this vessel.

Urokinase in the management of complicated parapneumonic effusions in children.

OBJECTIVE: Use of intrapleural fibrinolytic agents in the management of complicated parapneumonic effusions has been widely reported in adults. Such agents promote drainage of fluid through the thoracostomy tube and may obviate surgery. Both streptokinase and urokinase have been used for this purpose, but there are few reports of their use in the children. The objective of this study was to evaluate the role of intrapleural urokinase in the management of complicated parapneumonic effusions in children. METHODS: We reviewed the hospital course of nine children, ages 6 months to 6 years, with complicated parapneumonic effusions who received intrapleural urokinase after failing to respond to I.V. antibiotics and closed-tube thoracostomy drainage. Four subjects had additional thoroscopic adhesiolysis before intrapleural instillation of urokinase; 20,000 IU of diluted urokinase was instilled three times a day via the thoracostomy tube for 3 days. RESULTS: Eight subjects responded to 3 days of urokinase instillation, with increased thoracostomy tube drainage and clinical resolution of symptoms. The remaining subject responded to a second course of instillation. Two subjects needed oral analgesic for transient chest pain. All subjects tolerated the procedure well. No bleeding, fever, anaphylaxis, or allergic reactions were noted. The coagulation parameters remained unchanged. CONCLUSION: Intrapleural instillation of urokinase appears to be a useful and safe adjunct in the management of complicated parapneumonic effusions in children. Its use may be considered in potential decortication patients in an effort to prevent surgery and possibly shorten hospitalization.

Isochromosome 7q and Wilms tumor.

Isochromosome 7q is a nonrandom cytogenetic abnormality in Wilms tumor. Two notable cases are described: (1) a case of bilateral Wilms tumor in which only the left-sided tumor contained isochromosome 7q and (2) a case of left-sided Wilms tumor in which the tumor contained isochromosome 7q, in addition to four other chromosomal abnormalities associated with Wilms tumor.

Appendicitis in children: a systematic approach for a low incidence of complications.

Four hundred fourteen appendectomies in children have been described. Acute nonperforated appendicitis was seen in 57.1 percent of the patients and perforated appendicitis in 18.6 percent. A histologically normal appendix was seen in 14.3 percent of the patients. In 31 of these patients, other pathologic abnormalities were found to account for the symptoms, thus the number of negative explorations was reduced to 7 percent. The average length of hospitalization was 5.3 days for patients with acute nonperforated appendicitis and 7.3 days for patients with perforated appendicitis. A protocol was followed which consisted of fluid resuscitation, preoperative and postoperative administration of antibiotics, and surgical exploration with appendectomy in all patients. No interval appendectomies were performed. The peritoneal cavity was not irrigated and the use of drains was avoided as much as possible. All wounds were closed primarily without wound drains. Topical cefamandole powder was used in all cases. Aerobic and anaerobic culture specimens were obtained in all cases from the peritoneal cavity and appendiceal stump. Twenty-eight different organisms were recovered, B. fragilis being the most common followed by E. coli. Excellent results were obtained without mortality and a less than 1 percent complication rate. There was a shorter period of hospitalization for patients with perforated appendicitis and a shorter period of antibiotic treatment.

Idiopathic post-operative pulmonary hypertension in the newborn.

A case of severe pulmonary hypertension following the primary repair of an omphalocele in a term infant is reported. There were no pre-disposing factors known to contribute to the postoperative pulmonary hypertension (PPH). Therapy was successful first by using hyperventilation, and then subsequently with tolazoline. Upper gastrointestinal bleeding limited the use of tolazoline after the first fourty-eight hours. Complete recovery ensued. The occurrence of PPH and the current therapy of this unpredictable condition is discussed.

Pull-through with isolated jejunal loop for ulcerative colitis.

Total colectomy with endorectal mucosectomy and ileal pull-through to preserve fecal continence is well known for ulcerative colitis. A female patient developed severe ulcerative colitis at 5 years of age and had an emergency subtotal colectomy and ileostomy at 7 years of age. The rectum was preserved. At 9 years of age rectal mucosectomy and a pull-through using isolated jejunal loop were performed. Postoperatively she was treated with ano-rectal physiotherapy and balloon dilatations of the new rectum. Six months later the ileostomy was closed. Two and a half years after her operation she has 2-4 soft bowel movements daily, perfect diurnal control with occasional night soiling. A pull-through using an isolated loop of jejunum leaves intact a good functioning ileostomy. The blood supply to the jejunum is better than the terminal ileum. Bacterial contamination with jejunum is less than with ileum. There is no need for a reservoir; if the pull-through fails valuable terminal ileum is not lost.

Giant hemangioma: treatment with intermittent pneumatic compression.

Giant cavernous hemangiomas in newborns and infants can present with life-threatening complications. Although some modes of therapy are effective, there is a significant associated morbidity and mortality. The author reports two cases of complicated giant cavernous hemangiomas treated successfully with intermittent pneumatic compression. This mode of therapy is effective in the treatment of accessible giant hemangiomas. It is safe, simple, and inexpensive and, when possible, should be used as a primary mode of treatment in complicated cases.

Extensive intestinal aganglionosis including the ileum: a new surgical technique.

Extensive aganglionosis including the ileum occurs in less than 5% of children with Hirschsprung's disease; in these cases nutrition, fluid, and electrolyte balance are a problem. The author reports an infant with extensive aganglionosis including the ileum in whom an endorectal pull-through of the Soave type as modified by Boley was performed with a longitudinal side-to-side anastomosis between the aganglionic and normal intestine, preserving terminal ileum and ileocecal valve. At two and one-half years of age the infant is well. He is toilet trained and has 1 to 4 soft bowel movements per day as he is in the 50th percentile for weight. When extensive aganglionosis involves the small intestine, saving the important function of the terminal ileum and the ileocecal valve is possible and highly desirable.

Gastrostomy with antireflux properties.

The need for feeding gastrostomy seems to be increasing in children with neurological impairment and swallowing incoordination. Because gastrostomy can cause or increase gastroesophageal reflux, an antireflux procedure has been advocated at the time of gastrostomy placement in neurologically impaired children. A gastrostomy in the lesser gastric curvature with antirefluxing properties was performed in nine neurologically impaired children. All had severe swallowing incoordination with aspiration and malnutrition. Postoperatively none of the nine patients have demonstrated clinical evidence of vomiting or gastroesophageal reflux. This type of gastrostomy prevents the developement of gastroesophageal reflux by increasing the length of the intraabdominal esophagus and by increasing the acuity of the gastroesophageal angle of His. When compared with an antireflux procedure, it has less complications, shorter postoperative recovery, and is more economical.

Large gastroschisis: primary repair with Gore-Tex patch.

The author reports four newborns with large gastroschisis, in whom primary fascial closure could not be accomplished. They were successfully treated by primary repair with Gore-Tex patch. Gore-Tex patch closure is a safe and good alternative in large abdominal wall defects when primary fascial repair is not feasible.

Klippel-Trenaunay syndrome and other cases of lower limb hypertrophy: pediatric surgical implications.

We report 16 cases of lower limb hypertrophy seen in the past 5 years; of these, four had a typical picture of Klippel-Trenaunay syndrome. We discuss diagnostic modalities, complications, treatment, and outcome. Special emphasis is placed on the treatment with intermittent pneumatic compression and the importance of an organized approach to the condition.

A model to study the direct effect of diet on early intestinal growth and maturation using Thiry-Vella loops.

Thiry-Vella loops (TVL) are neurovascular intact intestinal segments isolated from the normal flow of chyme. TVL have been used to assess the effects of local and systemic factors in the intestine of adult animal models. To assess the direct effect of diet in growth and maturation of the intestine in the growing animal, the authors developed a similar model in the weanling rat. The surgical technique is described. Results include weight gain, morphometry of the intestine, dissacharidases, total proteins, and nucleic acid in both TVLs and intestine in continuity. This model is inexpensive, easy to handle, and ideal for studying the effect of dietary factors on intestinal growth and maturation, separating the direct effect of diet on the intestine from systemic effects.

Idiopathic perforation of the biliary tract in infancy.

Idiopathic perforation of the bile duct is rare in children. Sixty-seven cases were reported in the English literature to 1980. It is, nevertheless, the second commonest surgical cause of jaundice in the neonate. The etiology is unknown though distal obstruction and weakness in the bile duct wall have been postulated. Limited surgical treatment with external drainage is the preferred therapy. In isolated cases internal drainage procedures or repeated aspiration have been successful. The diagnosis should be suspected in the presence of jaundice and ascites with or without abdominal pain and signs of peritoneal irritation. We describe a 3-month-old girl presenting with anemia, vomiting, jaundice, and ascites. This was initially diagnosed as hepatitis but bilious fluid was found on paracentesis. Computerized tomography with cholangiography and 99 MTC Diisopropyl IDA cholescintigraphy confirmed the diagnosis. The latter seems to be more accurate than I-131 Rose Bengal. The perforation was at the junction of the hepatic and cystic ducts. It was treated successfully by external drainage and a cholecystostomy. Direct attempts to close the perforation, or more complicated surgical procedures, are unnecessary while nonoperative treatment carries a high mortality. At follow-up after 1 year the IV cholangiogram and liver-function tests are normal. Cholecystostomy provided good drainage of the biliary ducts as well as easy access for follow-up cholangiography.

Torsion of the wandering spleen: splenectomy or splenopexy.

Torsion of the wandering spleen is a rare condition usually unsuspected preoperatively. In previously reported cases in the past, attempts at splenopexy have failed and splenectomy has been regarded as the treatment of choice. We are presenting two children with splenic torsion. In one complete infarction of the spleen had occurred and so splenectomy could not be avoided. In the second, the spleen was viable and splenopexy was successfully performed. The clinical presentation, etiology, diagnostic procedures and management are discussed, and a surgical technique for splenopexy is described.

Fictitious pancreatitis in choledochal cyst.

The classical presentation of choledocal cyst has been regarded as a triad of abdominal pain, jaundice and a palpable abdominal mass; unusual presentations include rupture of the choledocal cyst with bile peritonitis, pancreatitis and bleeding esophageal varices. We are reporting 3 children presenting clinically as recurrent acute pancreatitis with elevated serum amylase and found to have type I choledocal cyst. Despite elevated serum amylase there was no evidence of pancreatic inflammation at laparotomy. High amylase concentration was found in fluid contained within the cyst. This was probably responsible for the elevated serum amylase and also the inflammatory reaction seen in the wall of the choledocal cyst. These cases support the hypothesis that pancreatic reflux into the bile ducts is the etiological factor in the development of choledocal cyst. Our 3 cases were treated by cyst excision and have remained asymptomatic. The presence of hyperamylasemia should not delay appropriate surgical management. The treatment of choice is cyst excision, since it will eliminate factors contributing to the development of cholangitis and hyperamylasemia.

The effect of intestinal anastomosis on gut growth and maturation.

We evaluated the effect of intestinal anastomosis without resection on gut morphometry (muscle thickness, villus height, and crypt depth), growth indices (DNA, protein, and protein:DNA ratio), and disaccharidase activity (maltase, sucrase, and lactase) in the growing animal. A group of 10 weanling Sprague-Dawley rats at 21 days of age was subjected to intestinal transection and anastomosis in the upper jejunum, 10 cm distal to the ligament of Treitz. A second group of 10 similar rats was used as a control group. All rats were fed a regular diet and kept under the same conditions. They were sacrificed 2 weeks later. Body weight, intestinal weight, and intestinal length measurements were obtained. The intestine was divided into two sections: preanastomotic (section A) and postanastomotic (section B) in the surgery group and equivalent sections A and B in the control group. Specimens were subjected to morphometric evaluation and mucosal scrapings for biochemical analysis. Despite significant weight gain in the control group, there were no differences in intestinal length, intestinal weight, and mucosal weight between the two groups. Muscle thickness, villus height, and crypt depth were significantly increased in the preanastomotic segment. Protein and DNA were also higher in the preanastomotic segment, but the protein:DNA ratio was less affected. There was significantly decreased enzymatic activity in the preanastomotic segment. Intestinal anastomosis has a significant effect on gut growth and maturation in the growing animal and may have important implications in the postoperative management of newborns and infants following intestinal surgery.

Condyloma acuminata in children.

Condyloma Acuminata (venereal warts) are sexually transmitted involving the human papilloma virus. It has become commoner in adults in the last decade. While infection is most often by sexual intercourse, it can be transmitted at birth and with close contact with infected individuals. It is common in marked sexual promiscuity. Condyloma acuminata in children should alert the physician to the possibility of sexual abuse or early sexual activity. We report 14 cases of condyloma acuminata in children; from 6 months to 17 years. Sex incidence was equal. All had social and family problems in common, except for one who developed perianal condyloma after repeated rectal dilatations because of a pull through procedure for Hirschsprung's Disease. Two cases of sexual abuse were documented. Treatment methods included podophyllin, liquid nitrogen, 5 fluorouracil cream, fulguration and laser therapy. An adequate social history was available only in six cases. Investigations should include VDRL and cultures for Gonococcus, careful medical and social history for neglect or abuse.

Infantile mammary duct ectasia: a cause of bloody nipple discharge.

Bloody nipple discharge in infancy has been rarely reported in the medical literature. Its cause is unknown. We report a three-year-old male infant and a five-month-old female infant with bloody nipple discharge. Because of persistent bloody discharge, a subcutaneous mastectomy was performed in the boy; the problem resolved in the girl after a period of observation. The specimen showed histologic changes identical to those seen in adult mammary duct ectasia. All the endocrinologic work-up was normal. We suspect that bloody nipple discharge in infancy is underreported. This is a benign condition with histologic changes similar to adult mammary duct ectasia and if persistent, should be properly investigated; biopsy or excision are not indicated.

Omphalocele closure: surgical technique with preservation of the amniotic sac.

The ideal surgical closure for large omphaloceles remains controversial. Most techniques described advocate removal of the amniotic sac prior to repair of the abdominal wall defect. Herein, the authors describe a surgical technique preserving the amniotic sac, which has distinct advantages in achieving safe and rapid closure of the omphalocele by primary or secondary means in selected patients.

Treatment of choledochal cyst by excision.

Since 1969 excision of choledochal cyst and establishment of bile drainage by Roux-en-Y hepaticojejunostomy has been performed in 7 children whose ages ranged from 10 mo to 11 yr. In 3 children, the cyst had been treated 5 yr, 4 wk, and 3 wk previously by cystduodenostomy, cystjejunostomy, and cholecystduodenostomy, respectively; further surgery was indicated for biliary obstruction and severe cholangitis. The other four children were not acutely ill. All cysts were located distal to the confluence of the right and left hepatic ducts. The volume of the smallest cyst was 25 ml and the largest 500 ml. In all children a small remnant of distal cyst was not excised to avoid injury to the duodenum and pancreas. In four children a remnant of proximal cyst was left attached to the hepatic duct to allow a large biliary intestinal anastomosis and minimize the possibility of stricture. No serious intraoperative problems were encountered. Prolonged drainage (2-3 wk) from Penrose drain sites in two children were the only postoperative complications. Liver function tests have remained normal in all and no episodes of cholangitis or jaundice have been noted during follow-up (median: 4.5 yr). This experience supports recent reports that indicate that cyst excision is associated with low mortality and morbidity. Cyst excision is preferred over traditional internal drainage procedures because it (A) eliminates a reservoir for bile stasis, (B) removes a mechanism which allows continuous reflux of pancreatic juice into the cyst, and (C) probably prevents the occurrence of bile duct carcinoma which has been noted in 3.0% of patients with choledochal cyst.