PEDIATRIC SURGERY UPDATE ©
VOLUME 23, 2004
Volume 23 No 01 JULY 2004
Bites
It is estimated that more than 1.5 million bites occur yearly in the
United States. Most of them within the home setting in children younger
than five years of age. When managing bites in children three general concepts
must be observed: 1) Determine if the attacking animal has injected venom
into its victim. For this to occur the history must provide the exact identification
of the animal and type of venom. Once identified an specific antivenom
can be utilized. 2) All bites wounds are considered contaminated wounds.
This includes rabies and tetanus. Prophylaxis in either case should be
provided. Furthermore the bite can produce significant tissue loss and
destruction. Initial management should include thorough mechanical cleansing
and debridement along with systemic antibiotics. 3) An assessment should
be made of the long-term outlook for both disfigurement and loss of function
of the wound. Wounds of the face do fairly better with primary closure
no matter the inciting initial agent. Significant loss of tissue might
need conservative management followed by reconstruction when adequate granulation
tissue appears. Ischemic extremity from compartment syndrome might need
fasciotomy. Fortunately we don't see snake bites in Puerto Rico. Few cases
of spider bites has been reported. Dog bites (pit bull) are the most common
bite seen in the emergency room affecting the extremity or face of young
infants. Cat bites or scratch can produce a febrile condition associated
with lymphadenopathy. Human bites carries the risk of HIV and hepatitis
infestation.
References:
1- Wagner CW: Chapter 97 - Animal Assaults: Bites and
Stings, In Ziegler, Azizkhan and Weber "Operative Pediatric Surgery" Mc
Graw Hill Co., 2003, pags. 1153-1158
2- Calkins CM, Bensard DD, Partrick DA, Karrer FM: Life-threatening
dog attacks: a devastating combination of penetrating and blunt injuries.
J Pediatr Surg 36(8):1115-7, 2001
3- Mcheik JN, Vergnes P, Bondonny JM: Treatment of facial
dog bite injuries in children: a retrospective study. J Pediatr Surg 35(4):580-3,
2000
4- Lopoo JB, Bealer JF, Mantor PC, Tuggle DW: Treating
the snakebitten child in North America: a study of pit viper bites. J Pediatr
Surg 33(11):1593-5, 1998
5- Tuggle DW, Taylor DV, Stevens RJ: Dog bites in children.
J Pediatr Surg 28(7):912-4, 1993
Ovarian Torsion
Ovarian torsion is a true surgical emergency mostly affecting woman
during their first three decades of life. Ovarian torsion results from
partial or complete twisting of the ovarian pedicle on its axis causing
vascular compromise, congestion and hemorrhagic infarction. Clinically,
most children present with an abrupt onset of low abdominal pain, low-grade
fever, nausea and vomiting sometimes mimicking symptoms of acute appendicitis.
Mean age is 12 years. Symptoms may be recurrent. Pain is localized toward
the affected ovary. Most ovarian torsions are associated with a concomitant
ovarian cystic or solid mass. Neonates with ovarian torsion are usually
diagnosed during prenatal ultrasound studies when a cystic mass is identified.
Ultrasound is the imaging study of choice. An enlarged solid ovarian mass
with peripheral cysts noted at US suggests the diagnosis of torsion and
should be followed by diagnostic laparoscopy or exploration. A prepubertal
child will have a complex mass. CT Scan demonstrates a heterogenous, retrovesical
mass. Color Doppler US sometimes confirms the absence of ovarian blood
flow. Management is established at exploration. Removal of a mass carrying
a twisted ovary is standard therapy. Untwisting of torsed adnexa
and observation in case of absence of a mass (normal ovaries) are accepted
modes of treatment. Most common encountered morbidity is postoperative
fever. Contralateral oophoropexy in cases of torsion of a normal adnexum
is advice.
References:
1- Meyer JS, Harmon CM, Harty MP, Markowitz RI, Hubbard
AM, Bellah RD: Ovarian torsion: clinical and imaging presentation in children.
J Pediatr Surg 30(10):1433-6, 1995
2- Steyaert H, Meynol F, Valla JS: Torsion of the adnexa
in children: the value of laparoscopy. Pediatr Surg Int 13(5-6):384-7,
1998
3- Eckler K, Laufer MR, Perlman SE: Conservative management
of bilateral asynchronous adnexal torsion with necrosis in a prepubescent
girl. J Pediatr Surg 35(8):1248-51, 2000
4- Templeman C, Hertweck SP, Fallat ME: The clinical
course of unresected ovarian torsion. J Pediatr Surg 35(9):1385-7, 2000
5- Kokoska ER, Keller MS, Weber TR: Acute ovarian torsion
in children. Am J Surg 180(6):462-5, 2000
6- Ozcan C, Celik A, Ozok G, Erdener A, Balik E: Adnexal
torsion in children may have a catastrophic sequel: asynchronous bilateral
torsion. J Pediatr Surg 37(11):1617-20, 2002
Vascular Rings
A vascular ring is a rare congenital anomaly of the arterial branchial
arch system which can encircle and compress the trachea a/o esophagus.
Most vascular rings results from a lack of regression of the eighth segment
of the right dorsal aortic root. Vascular rings are classified as either
complete or partial. The most common complete vascular ring is double aortic
arch, while the most common partial vascular ring is right aortic arch
with aberrant left subclavian artery (overall most common vascular ring).
Symptoms from the vascular ring occur during the first six months of life.
These include inspiratory stridor, expiratory wheezing, recurrent cough,
recurrent respiratory infections and pneumonia. Compressive esophageal
symptoms like choking and regurgitation occurs later in life of affected
children. Diagnosis is suggested in the initial chest film. Esophagogram
is diagnostic showing the classic esophageal indentation of the ring. MRI
angiography describes the lesion. Repair of the vascular ring is indicated
in children with either esophageal or tracheal symptoms of compression.
Basic surgical procedure includes exposure through a left thoracotomy,
complete identification of the anomaly and division of the constricting
ring. The surgical risk is minimal and the long-term results are excellent.
References:
1- Chun K, Colombani PM, Dudgeon DL, Haller JA Jr.: Diagnosis
and management of congenital vascular rings: a 22-year experience. Ann
Thorac Surg 53(4):597-602, 1992
2- van Son JA, Julsrud PR, Hagler DJ, Sim EK, Pairolero
PC, Puga FJ, Schaff HV, Danielson GK: Surgical treatment of vascular rings:
the Mayo Clinic experience. Mayo Clin Proc 68(11):1056-63, 1993
3- Roberts CS, Othersen HB Jr, Sade RM, Smith CD 3rd,
Tagge EP, Crawford FA Jr.: Tracheoesophageal compression from aortic arch
anomalies: analysis of 30 operatively treated children. J Pediatr Surg
29(2):334-7, 1994
4- Kocis KC, Midgley FM, Ruckman RN: Aortic arch complex
anomalies: 20-year experience with symptoms, diagnosis, associated cardiac
defects, and surgical repair. Pediatr Cardiol 18(2):127-32, 1997
5- Woods RK, Sharp RJ, Holcomb GW 3rd, Snyder CL, Lofland
GK, Ashcraft KW, Holder TM: Vascular anomalies and tracheoesophageal compression:
a single institution's 25-year experience. Ann Thorac Surg 72(2):434-8,
2001
Volume 23 No 02 AUGUST 2004
Peptic Ulcer Disease
With the advent of more powerful acid inhibiting drugs (H2 antagonists)
and proton pump inhibitors, surgery for refractory peptic ulcer disease
(PUD) is becoming something of the past. We now manage rare complications
of PUD such as bleeding, perforation and obstruction. PUD is either primary
or secondary in origin. Secondary PUD are more common and primarily seen
in infants the result of an associated condition such as prematurity, steroids,
burns, trauma, immune deficiency and brain tumors. Primary PUD occurs more
commonly in older children and adolescents the result of an imbalance between
acid secretion and gastric mucosal protection. Helicobacter pylori infestation
plays a crucial role in the genesis of gastritis and primary duodenal ulcer
formation. Successful management of PUD disease encompasses radication
of Helicobacter infection. Initial management of PUD includes medication
to reduce acid production (omeprazole, ranitidine, cimetidine) combined
with agents that improve mucosal defense (sucralfate). Bleeding PUD manifests
itself with either melena or hematochezia. The bleeding site must be visualized
during upper endoscopy. Most cases will stop with prompt medical management
or endoscopic diathermy. Beyond 50% blood volume loss in a short
period of time (8-24 hours) is an indication for surgery. Infants
benefit from duodenotomy and bleeding ulcer ligation, while older children
will need more definite ulcer surgery (vagotomy and pyloroplasty). Perforated
PUD is the manifestation of a coexisting illness. Simple surgical closure
with an omental patch is sufficient. Obstruction produces chronic vomiting
due to pyloric scarring.
References:
1- Kumar D, Spitz L: Peptic ulceration in children. Surg Gynecol Obstet
159(1):63-6, 1984
2- Drumm B, Rhoads JM, Stringer DA, Sherman PM, Ellis LE, Durie PR:
Peptic ulcer disease in children: etiology, clinical findings, and clinical
course. Pediatrics 82(3 Pt 2):410-4, 1988
3- Tsang TM, Saing H, Yeung CK: Peptic ulcer in children. J Pediatr
Surg 25(7):744-8, 1990
4- George DE, Glassman M: Peptic ulcer disease in children. Gastrointest
Endosc Clin N Am 4(1):23-37, 1994
5- Lazzaroni M, Petrillo M, Tornaghi R, Massironi E, Sainaghi M, Principi
N, Porro GB: Upper GI bleeding in healthy full-term infants: a case-control
study. Am J Gastroenterol 97(1):89-94, 2002
Paraesophageal Hernias
Paraesophageal hernia (PEH), a rare entity in children, occurs when
the stomach protrudes laterally through the esophageal hiatus toward the
chest while the gastro-esophageal junction stays in anatomic position.
Though most cases remain asymptomatic, PEH can cause upper bowel obstruction,
gastroesophageal reflux, gastric volvulus, bleeding and perforation. Most
PEH in children are acquired resulting after fundoplication. A small group
of children are born with the PEH. Groups of patients with a higher incidence
of developing PEH after fundoplication includes infants under the age of
one, neurologic impaired children and surgical patients where a crural
repair is not done after fundoplication. PEH is linked to gagging before
an antireflux procedure in children. Diagnosis of PEH is confirmed during
a barium swallow and upper gastrointestinal series. A small PEH can be
managed non-operatively if the child is asymptomatic. With the presence
of symptoms or enlargement of the hernia operative repair must be done.
A transabdominal approach is preferred for reducing the stomach and crural
repair of the diaphragm. The use of mesh hiatal reinforcement is recommended
for patients undergoing reoperation for PEH and recurrent gastroesophageal
reflux or if the diaphragmatic crura is thought to require reinforcement
at the time of the original surgery.
References:
1- Alrabeeah A, Giacomantonio M, Gillis DA: Paraesophageal hernia after
Nissen fundoplication: a real complication in pediatric patients. J Pediatr
Surg 23(8):766-8, 1988
2- Yadav K, Myers NA: Paraesophageal hernia in the neonatal period
- another differential diagnosis of esophageal atresia. Pediatr Surg Int
12(5-6):420-1, 1997
3- Avansino JR, Lorenz ML, Hendrickson M, Jolley SG: Characterization
and management of paraesophageal hernias in children after antireflux operation.
J Pediatr Surg 34(11):1610-4, 1999
4- Lambert AW, Huddart SN: Mesh hiatal reinforcement in Nissen fundoplication.
Pediatr Surg Int 17(5-6):491-2, 2001
5- Yazici M, Karaca I, Etensel B, Temir G, Gunsar C, Guclu C, Mutaf
O: Paraesophageal hiatal hernias in children. Dis Esophagus 16(3):210-3,
2003
Keloids
Excessive scarring is deposition of collagen out of the range of normal
after surgery. Two types of excessive scarring seen in children and adults
are hypertrophic scars and keloids. Hypertrophic scars are slight elevation
of the scar restricted to the boundaries of the original wound, regress
with time and rarely cause functional impairment. Hypertrophic scars rarely
need to be removed. Keloids extend beyond the borders of the original wound,
cause functional impairment, contain mast cells that release histamine
and produce pruritus. Familial cases have been seen. Keloids do not regress
over time and recur after surgical excision. Keloids contain large thick
collagen fibers composed of numerous fibrils closely packed together. In
contrast hypertrophic scars exhibit modular structures in which fibroblastic
cells, small vessels, and fine, randomly organized collagen fibers are
present. Earlobe piercing is the main etiological factor of earlobe keloids.
Keloids removal is indicated in cases of functional impairment of a joint
or for cosmetic reasons. Excision with intraoperative local injection of
triamcinolone or alpha-2b interferon has produce some therapeutic advantage
in severe cases. Early single postoperative fraction radiotherapy claims
effectiveness in reducing keloid recurrences.
References:
1- Ehrlich HP, Desmouliere A, Diegelmann RF, Cohen IK, Compton CC,
Garner WL, Kapanci Y, Gabbiani G: Morphological and immunochemical differences
between keloid and hypertrophic scar. Am J Pathol 145(1):105-13, 1994
2- Berman B, Flores F: Recurrence rates of excised keloids treated
with postoperative triamcinolone
acetonide injections or interferon alfa-2b injections. J Am Acad Dermatol
37(5 Pt 1):755-7, 1997
3- Chowdri NA, Masarat M, Mattoo A, Darzi MA: Keloids and hypertrophic
scars: results with intraoperative and serial postoperative corticosteroid
injection therapy. Aust N Z J Surg 69(9):655-9, 1999
4- Marneros AG, Norris JE, Olsen BR, Reichenberger E: Clinical genetics
of familial keloids. Arch Dermatol 137(11):1429-34, 2001
5- Ragoowansi R, Cornes PG, Moss AL, Glees JP: Treatment of keloids
by surgical excision and immediate postoperative single-fraction radiotherapy.
Plast Reconstr Surg 111(6):1853-9, 2003
Volume 23 No 03 SEPTEMBER 2004
Periappendiceal Mass
In the event of right lower abdominal pain caused by appendicitis, almost
15% of children will present with a right lower quadrant mass effect. The
mass can be a phlegmon with a central inflamed appendix which appears after
four to five days from the onset of abdominal pain accounting for 50% of
appendiceal masses. Almost 20% of these masses will contain a frank abscess
cavity. Periappendiceal masses are the result of perforated appendicitis.
Due to the increase use of abdominal CT in the setting of abdominal pain
more cases of periappendiceal phlegmon/abscess are discovered with this
diagnostic modality. CT is reliable in distinguishing periappendiceal abscesses
from phegmons and its use can be extended into percutaneously draining
the abscess cavity. US with color Doppler demonstrates a hyperemic periappendiceal
or pelvic fluid collection and periappendiceal soft-tissue hyperemia. Management
of a periappendiceal abscess depends on the clinical condition of the child.
Nontoxic patient with mild peritoneal signs warrants non-operative management
with intravenous fluids and antibiotics until the acute process subsides.
Rising heart rate, continued spiking fever, worsening peritoneal signs,
intestinal obstruction or enlargement of the mass may require urgent surgery.
Patients undergoing initial nonoperative management have a lower rate of
complications. Six to eight weeks after resolution of the inflammatory
process interval appendectomy is recommended to avoid recurrent abdominal
pain. Laparoscopic appendectomy can be performed safely and effectively
in such interval cases.
References:
1- Barakos JA, Jeffrey RB Jr, Federle MP, Wing VW, Laing
FC, Hightower DR: CT in the management of periappendiceal abscess. AJR
Am J Roentgenol 146(6):1161-4, 1986
2- Karp MP, Caldarola VA, Cooney DR, Allen JE, Jewett
TC Jr: The avoidable excesses in the management of perforated appendicitis
in children. J Pediatr Surg 21(6):506-10, 1986
3- Vargas HI, Averbook A, Stamos MJ: Appendiceal mass:
conservative therapy followed by interval laparoscopic appendectomy. Am
Surg 60(10):753-8, 1994
4- Quillin SP, Siegel MJ: Diagnosis of appendiceal abscess
in children with acute appendicitis: value of color Doppler sonography.
AJR Am J Roentgenol 164(5):1251-4, 1995
5- Oliak D, Yamini D, Udani VM, Lewis RJ, Arnell T, Vargas
H, Stamos MJ: Initial nonoperative management for periappendiceal abscess.
Dis Colon Rectum 44(7):936-41, 2001
6- Samuel M, Hosie G, Holmes K: Prospective evaluation
of nonsurgical versus surgical management of appendiceal mass. J Pediatr
Surg 37(6):882-6, 2002
Adhesions
Postoperative adhesions are the main cause of acute and chronic mechanical
bowel obstruction in children and adults. Adhesive small bowel obstruction
(SBO) presents with bilious vomiting, abdominal distension, colicky abdominal
pain and obstipation. Simple abdominal films demonstrate distended bowel
loops with air-fluid levels. More than 80% of SBO develops within two years
of the prior operations. Appendectomy and subtotal colectomy are the most
common prior operations. The risk of developing an adhesive SBO is greater
when there is more than one prior peritoneal procedure, and when there
is established peritonitis. Initial therapy includes nasogastric decompression,
hydration and serial abdominal examination. Most cases of adhesive SBO
that will resolve, do so within 48 hours of admission. Failed conservative
therapy or worsening abdominal signs warrant surgery. Signs heralding bowel
strangulation includes spiking fever, pinpoint abdominal tenderness and
leukocytosis. Delaying lysis of adhesion and entering the GI tract during
surgery is associated with increased morbidity. Use of Gastrografin meal
in adhesive small bowel obstruction is safe and reduces the need for surgery
when conservative treatment fails
References:
1- Janik JS, Ein SH, Filler RM, Shandling B, Simpson
JS, Stephens CA: An assessment of the surgical treatment of adhesive small
bowel obstruction in infants and children. J Pediatr Surg 16(3):225-35,
1981
2- Festen C: Postoperative small bowel obstruction in
infants and children. Ann Surg 196(5):580-3, 1982
3- Akgur FM, Tanyel FC, Buyukpamukcu N, Hicsonmez A:
Adhesive small bowel obstruction in children: the place and predictors
of success for conservative treatment. J Pediatr Surg 26(1):37-41, 1991
4- van der Zee DC, Bax NM: Management of adhesive bowel
obstruction in children is changed by laparoscopy. Surg Endosc 13(9):925-7,
1999
5- Choi HK, Chu KW, Law WL: Therapeutic value of gastrografin
in adhesive small bowel obstruction after unsuccessful conservative treatment:
a prospective randomized trial. Ann Surg 236(1):1-6, 2002
Retractile Testis
Retractile testes are very common in school age boys. A retractile testis
is a testis that has completed the normal descent but is not in its normal
scrotal position due to a hyperactive cremasteric reflex. The reflex pertains
to the genitofemoral nerve at L1-L2 level. Retractile testes can be manually
placed in the scrotum, but the reflex triggered by fear, cold, stimulation
of the upper inner aspect of the thigh, or anxiety causes the testis to
ascend. This reflex is blunted by testosterone during puberty. On the contrary,
true undescended testis cannot be brought manually to the scrotum. Mean
average spermatogonial number and Sertoli cell index are significantly
reduced in undescended testes. Human chorionic gonadotropin can assist
in the diagnosis of retractile testes by stimulating descend in most cases.
Children with retractile testes does not need immediate surgery (orchidopexy),
appear to be at highest risk for acquired cryptorchidism and should be
followed yearly to detect changes in testicular volume which should prompt
orchidopexy. Most children with retractile testes have spontaneous descent
after puberty.
References:
1- Bingol-Kologlu M, Demirci M, Buyukpamukcu N, Tanyel
FC: Cremasteric reflexes of boys with descended, retractile, or undescended
testes: an electrophysiological evaluation. J Pediatr Surg 34(3):430-4,
1999
2- Han SW, Lee T, Kim JH, Choi SK, Cho NH, Han JY: Pathological
difference between retractile and cryptorchid testes. J Urol 162(3 Pt 1):878-80,
1999
3- Rusnack SL, Wu HY, Huff DS, Snyder HM 3rd, Zderic
SA, Carr MC, Canning DA: The ascending testis and the testis undescended
since birth share the same histopathology. J Urol 168(6):2590-1, 2002
4- Miller OF, Stock JA, Cilento BG, McAleer IM, Kaplan
GW: Prospective evaluation of human chorionic gonadotropin in the differentiation
of undescended testes from retractile testes. J Urol 169(6):2328-31,
2003
5- La Scala GC, Ein SH: Retractile Testis: An outcome
analysis on 150 patients. J Pediatr Surg 39(7): 1014-1017, 2004
Volume 23 No 04 OCTOBER 2004
Ventriculo-Peritoneal Shunt Cysts
Ventriculo-peritoneal shunts (VP shunts) placement is standard form
of therapy for children with communicating hydrocephalus and infants with
non-communicating hydrocephalus. The proximal end of the system is inserted
into a CSF reservoir, most commonly the lateral ventricle. The proximal
catheter is connected to a valve that serves to regulate flow through the
system. The valve is connected to the distal catheter which is inserted
into a cavity which will serve as receptacle for the CSF such as the peritoneum,
pleural cavity, central venous system or gallbladder. Complications of
VP shunts needing revision consist of shunt malfunction (occlusion of the
proximal catheter by debris of choroid plexus, glial or ependymal tissue),
shunt infection, and intraabdominal pseudocysts formation. Abdominal pseudocysts
are loculated pockets filled with unabsorbed CSF fluid. Chronic inflammation,
low grade subclinical infection, multiple surgical procedures and elevated
CSF protein causes the peritoneal mesothelial serous membrane to thickened
reducing the absorbing power. Though most cases are asymptomatic showing
no shunt malfunction, children with abdominal pseudocysts may present with
raised intracranial pressure or symptoms such as abdominal pain, distension,
vomiting, fever or anorexia. One-third are associated with an incipient
infection. Diagnosis is established with Ultrasound or CT Scan. Treatment
of the pseudocyst involves removing the peritoneal catheter with relocation
to an absorbing peritoneal surface or atrium.
References:
1- Briggs JR, Hendry GM, Minns RA: Abdominal ultrasound
in the diagnosis of cerebrospinal fluid pseudocysts complicating ventriculoperitoneal
shunts. Arch Dis Child 59(7):661-4, 1984
2- Hahn YS, Engelhard H, McLone DG: Abdominal CSF pseudocyst.
Clinical features and surgical management. Pediatr Neurosci 12(2):75-9,
1985-86
3- Besson R, Hladky JP, Dhellemmes P, Debeugny P: Peritoneal
pseudocyst--ventriculo-peritoneal shunt complications. Eur J Pediatr Surg
5(4):195-7, 1995
4- Roitberg BZ, Tomita T, McLone DG: Abdominal cerebrospinal
fluid pseudocyst: A complication of ventriculoperitoneal shunt in children.
Pediatr Neurosurg 29(5):267-73, 1998
5- Anderson CM, Sorrells DL, Kerby JD: Intra-abdominal
pseudocysts as a complication of ventriculoperitoneal shunts: a case report
and review of the literature. Curr Surg 60(3):338-40, 2003
Choledochocele
Choledochocele is an extremely rare variant of choledochal cysts classified
as type III by Alonso-Lej. The cystic dilatation occurs in the distal portion
of the common bile duct most commonly in an intrapancreatic fashion protruding
toward the duodenum. Patients with choledochocele can develop intermittent
colic abdominal pain, obstructive jaundice and recurrent bouts of pancreatitis.
Nearly half of the patients have previously undergone cholecystectomy.
Diagnosis is suggested by ultrasonography and confirmed with HIDA scan,
MRCP or ERCP. In the most common variety the ampulla opens into the choledochocele
which in turns communicates with the duodenum via another small opening.
Cyst distension explains the episodes of colicky pain. Adenocarcinoma has
been reported arising from choledochocele, though some researchers believe
choledochocele does not share the strong premalignant potential of the
more common types of choledochal cysts. The mucosa lining of choledochocele
is usually duodenal, arguing that the cyst is a duodenal duplication. Successful
endoscopic management (papillotomy) of choledochocele has been reported
when the lesion is small. Surgical management entails excision of the duodenal
luminal portion of the cyst leaving the medial portion containing the ampulla
intact. Prognosis after surgery is good.
References:
1- Greene FL, Brown JJ, Rubinstein P, Anderson MC: Choledochocele
and recurrent pancreatitis. Diagnosis and surgical management. Am J Surg
149(2):306-9, 1985
2- Ghazi A, Slone E: Endoscopic management of choledochocele.
A case report and review of the English literature. Surg Endosc 1(3):151-4,
1987
3- Sarris GE, Tsang D: Choledochocele: case report, literature
review, and a proposed classification. Surgery 105(3):408-14, 1989
4- Weisser M, Bennek J, Hormann D: Choledochocele--a
rare cause of necrotizing pancreatitis in childhood. Eur J Pediatr Surg
10(4):258-64, 2000
5- Rabie ME, Al-Humayed SM, Hosni MH, Katwah RA, Dewan
M: Choledochocele: the disputed origin. Int Surg 87(4):221-5, 2002
Perianal Abscess
Perianal abscess is a not so rare condition seen almost exclusively
in infants less than two years of age. Most cases are seen in males infants.
The infant presents with a history of increasing irritability, fever, erythema
and induration of the perianal skin. In a period of 48 to 72 hours the
area becomes fluctuant. Oral antibiotics are ineffective in controlling
the infectious process. It is theorized that a perianal abscess arises
from a developmental anomaly in the deep crypts of Morgagni which trap
bacterias initiating a cryptitis that proceed to a perianal abscess. This
abscess may open or not to become later a fistula in ano. Gut derived organisms
are isolated from most cases of perianal abscess. Most abscess are located
laterally equally divided between right and left. Perianal abscesses in
children are best treated by incision, drainage and systemic antibiotics.
A proportion of patients with perianal abscess later develop a fistula
in ano. This fact has led some researchers to propose that primary treatment
of perianal abscess in childhood involve a careful search for a coexisting
fistula and treatment of this by fistulotomy. Long term recurrence is very
rare. Recurrence should prompt a search for associated disorders such as
Crohn's, immunodeficiency and autoimmune neutropenia.
References:
1- Shafer AD, McGlone TP, Flanagan RA: Abnormal crypts
of Morgagni: the cause of perianal abscess and fistula-in-ano. J Pediatr
Surg 22(3):203-4, 1987
2- Piazza DJ, Radhakrishnan J: Perianal abscess and fistula-in-ano
in children. Dis Colon Rectum 33(12):1014-6, 1990
3- Abercrombie JF, George BD: Perianal abscess in children.
Ann R Coll Surg Engl 74(6):385-6, 1992
4- Festen C, van Harten H: Perianal abscess and fistula-in-ano
in infants. J Pediatr Surg 33(5):711-3, 1998
5- Murthi GV, Okoye BO, Spicer RD, Cusick EL, Noblett
HR: Perianal abscess in childhood. Pediatr Surg Int 18(8):689-91, 2002
6- Lejkowski M, Maheshwari A, Calhoun DA, Christensen
RD, Skoda-Smith S, Dabrow S: Persistent perianal abscess in early infancy
as a presentation of autoimmune neutropenia. J Perinatol 23(5):428-30,
2003
Volume 23 No 05 NOVEMBER 2004
Infantile Cholelithiasis
The finding of gallstones in neonates and infants is no longer rare.
With the widespread use of abdominal sonography in a growing population
of prematures TPN-fed survivals more cases of cholelithiasis in infants
are reported. Stone formation increases with the duration of TPN. Other
lithogenic factors are prolonged fasting, ileal resection, cystic fibrosis,
polycythemia, multiple blood transfusions and inflammatory bowel disease.
Approximately 80% of gallstones in children are not due to hemolytic disease.
Clinically, the symptomatic infant with gallstone can develop colicky abdominal
pain, postprandial nausea/vomiting, fatty-food intolerance and failure
to thrive. Severe complications are seen in almost one-third of the infants
with gallstones including jaundice by common bile duct obstruction, pancreatitis
and perforation with bile peritonitis. Surgery is the treatment of choice
for infants presenting with symptomatic cholelithiasis. Resolution of gallstones
is seen in most asymptomatic infants between six months and one year of
oral intake justifying a period of observation. Ursodeoxycholic acid is
not effective in the treatment of pigmented stones. Laparoscopic cholecystectomy
is recommended for the asymptomatic child younger than three years of age
when echogenic shadows have been present for at least 12 months following
resumption of oral feedings or when the gallstones are radiopaque (calcified).
References:
1- Schirmer WJ, Grisoni ER, Gauderer MW: The spectrum of cholelithiasis
in the first year of life. J Pediatr Surg 24(10):1064-7, 1989
2- Holcomb GW Jr, Holcomb GW 3rd: Cholelithiasis in infants, children,
and adolescents. Pediatr Rev 11(9):268-74, 1990
3- Rescorla FJ, Grosfeld JL: Cholecystitis and cholelithiasis in children.
Semin Pediatr Surg 1(2):98-106, 1992
4- St-Vil D, Yazbeck S, Luks FI, Hancock BJ, Filiatrault D, Youssef
S: Cholelithiasis in newborns and infants. J Pediatr Surg 27(10):1305-7,
1992
5- Debray D, Pariente D, Gauthier F, Myara A, Bernard O: Cholelithiasis
in infancy: a study of 40 cases. J Pediatr 122(3):385-91, 1993
6- Asabe K, Handa N: Infant cholelithiasis: report of a case. Surg
Today 27(1):71-5, 1997
7- Gertner M, Farmer DL: Laparoscopic cholecystectomy in a 16-day-old
infant with chronic cholelithiasis. J Pediatr Surg 39(1):E17-9, 2004
Chronic Pancreatitis
Chronic pancreatitis is an unusual condition seen in children. In contrast
to adults, chronic pancreatitis have significant lifelong morbidity. Most
common etiology of chronic pancreatitis in children consists of trauma,
cystic fibrosis, hyperparathyroidism, hyperlipidemia, aminoaciduria, hereditary,
congenital ductal anomalies and choledochal cyst. Main symptoms are recurrent
abdominal (epigastric) pain associated with nausea and vomiting.
A transient elevation of amylase and lipase is associated with the pain.
Once the diagnosis of chronic pancreatitis is suspected, the anatomy of
the pancreatic duct should be defined using ERCP or MRCP (less invasive).
In chronic pancreatitis, the pancreatic duct is frequently dilated with
one or more obstructive lesions. Ongoing attacks of pancreatitis may lead
to diabetes, steatorrhea and pancreatic stones. Early endoscopic sphincterotomy
can slow the progressive nature of the disease and has been suggested as
initial choice of treatment. With continued symptoms, lateral
pancreaticojejunostomy (Puestow procedure) in dilated and obstructed ductal
anatomy has been found to decrease significantly the pancreatitis episodes,
relieve the recurring abdominal pain and arrest the progression of exocrine
and endocrine insufficiency. Recently, the Frey procedure adding pancreatic
head coring to the pancreaticojejunostomy has provided pain relieve in
more than 85% of children with chronic pancreatitis.
References:
1- Crombleholme TM, deLorimier AA, Way LW, Adzick NS, Longaker MT,
Harrison MR: The modified Puestow procedure for chronic relapsing pancreatitis
in children. J Pediatr Surg 25(7):749-54, 1990
2- Festen C, Severijnen R, vd Staak F, Rieu P: Chronic relapsing pancreatitis
in childhood. J Pediatr Surg 26(2):182-3, 1991
3- Moir CR, Konzen KM, Perrault J: Surgical therapy and long-term follow-up
of childhood hereditary pancreatitis. J Pediatr Surg 27(3):282-6, 1992
4- Perrelli L, Nanni L, Costamagna G, Mutignani M: Endoscopic treatment
of chronic idiopathic pancreatitis in children. J Pediatr Surg 31(10):1396-400,
1996
5- Rios GA, Adams DB, Yeoh KG, Tarnasky PR, Cunningham JT, Hawes RH:
Outcome of lateral pancreaticojejunostomy in the management of chronic
pancreatitis with nondilated pancreatic ducts. J Gastrointest Surg 2(3):223-9,
1998
6- Weber TR, Keller MS: Operative management of chronic pancreatitis
in children. Arch Surg 136(5):550-4, 2001
7- Rollins MD, Meyers RL: Frey procedure for surgical management of
chronic pancreatitis in children. J Pediatr Surg 39(6): 817-820, 2004
EXIT Procedure
Large fetal neck masses can cause airway obstructions with potential
fetal mortality after delivery. The EXIT procedure refers to EX-utero Intrapartum
Treatment, a technique for safety managing airway obstruction at birth
in which placental support is maintained until the airways is evaluated,
surgically corrected and secure. The technique leaves an intact feto-placental
circulation and guarantees a normal fetal oxygenation while fetal airway
patency is secured. The EXIT procedure is indicated for infants diagnosed
by prenatal ultrasonography and born with airway obstruction caused by
laryngotracheal atresia and head and neck masses including hemangiomas,
teratomas, goiter, epignathus and lymphangiomas. These are tumors with
a high mortality rate if airway control is not obtained before clamping
the umbilical cord. During the EXIT procedure the infant can undergo bronchoscopy,
tracheostomy or resection of the neck mass. For success a team approach
consisting of a pediatric surgeon, obstetrician, anesthesiologist, operating
room staff and neonatologist is warranted. Since the procedure depends
on a cesarean section, mothers experience more postpartum wound complications
and blood loss. Maternal outcome is good overall.
References:
1- DeCou JM, Jones DC, Jacobs HD, Touloukian RJ: Successful ex utero
intrapartum treatment (EXIT) procedure for congenital high airway obstruction
syndrome (CHAOS) owing to laryngeal atresia. J Pediatr Surg 33(10):1563-5,
1998
2- Bui TH, Grunewald C, Frenckner B, Kuylenstierna R, Dahlgren G, Edner
A, Granstrom L, Sellden H: Successful EXIT (ex utero intrapartum treatment)
procedure in a fetus diagnosed prenatally with congenital high-airway obstruction
syndrome due to laryngeal atresia. Eur J Pediatr Surg 10(5):328-33, 2000
3- Stevens GH, Schoot BC, Smets MJ, Kremer B, Manni JJ, Gavilanes AW,
Wilmink JT, van Heurn LW, Hasaart TH: The ex utero intrapartum treatment
(EXIT) procedure in fetal neck masses: a case
report and review of the literature. Eur J Obstet Gynecol Reprod Biol
100(2):246-50, 2002
4- Noah MM, Norton ME, Sandberg P, Esakoff T, Farrell J, Albanese CT:
Short-term maternal outcomes that are associated with the EXIT procedure,
as compared with cesarean delivery. Am J Obstet Gynecol 186(4):773-7, 2002
5- Hirose S, Sydorak RM, Tsao K, Cauldwell CB, Newman KD, Mychaliska
GB, Albanese CT, Lee H, Farmer DL: Spectrum of intrapartum management strategies
for giant fetal cervical teratoma. J Pediatr Surg 38(3):446-50, 2003
6- Hirose S, Farmer DL, Lee H, Nobuhara KK, Harrison MR: The ex utero
intrapartum treatment procedure: Looking back at the EXIT. J Pediatr Surg
39(3):375-80, 2004
Volume 23 No 06 DECEMBER 2004
Ambulatory Laparoscopy
With the massive use of minimal invasive surgical procedures in children
the next step in research design is deriving which procedure can be conveniently
do on an ambulatory basis (meaning leaving the hospital a few hours after
surgery), and which needs overnight hospitalization. Non-randomized studies
in children have proved a safe benefit and low costs in performing diagnostic
laparoscopy for non-palpable undescended testis, intersexual problems and
contralateral inguinal hernia. Likewise, therapeutical laparoscopic procedures
done ambulatory include cholecystectomy, interval and simple appendectomy,
ovarian, omental and hepatic cysts, placement of dialysis catheter and
PEG assisted procedures. Contraindication for ambulatory laparoscopy in
children includes prematurity, cardio-respiratory and neurologic (cerebral
palsy) conditions, labile coagulopathy, long distance from medical care
facilities, procedures longer than two hours and poor social/educated conditions.
Postoperative pain control is the Achilles tendon of ambulatory surgery.
Several elements associated with reduced postoperative pain includes: use
of low carbon dioxide intra abdominal pressure, low insufflation rate,
local anesthesia infiltration at the start of the operation, warming carbon
dioxide, use of humidified gas at body temperature, evacuate all intraperitoneal
gas and a short laparoscopic procedure. After surgery narcotic analgesia
is needed. During and after the laparoscopic procedure any child
who has significant oozing, conversion to open, excessive adhesions, vomiting,
or pain should stay overnight for clinical observation.
References:
1- Llorente J: Laparoscopic cholecystectomy in the ambulatory
surgery setting. J Laparoendosc Surg 2(1):23-6, 1992
2- Sanfilippo JS, Lobe TE: Laparoscopic surgery in girls
and female adolescents. Semin Pediatr Surg 7(1):62-72, 1998
3- Lobe TE: Laparoscopic surgery in children. Curr Probl
Surg 35(10):859-948, 1998
4- Campanelli G, Cavagnoli R, Cioffi U, De Simone M,
Fabbiani M, Pietri P: Can laparoscopic cholecystectomy be a day surgery
procedure? Hepatogastroenterology 45(23):1422-9, 1998
5- Smith M 2nd, Wheeler W, Ulmer MB: Comparison of outpatient
laparoscopic cholecystectomy in a private nonteaching hospital versus a
private teaching community hospital. JSLS 1(1):51-3, 1997
6- Mouton WG, Bessell JR, Otten KT, Maddern GJ: Pain
after laparoscopy. Surg Endosc 13: 445-448, 1999
7- Arnbjornsson E, Larsson LT, Lindhagen: Complications
of laparoscopy-aided gastrostomies in pediatric practice. J Pediatr Surg
34(12):1843-6 , 1999
Neurilemmomas
Neurilemmomas, also known as Schwannomas, are peripheral nerve tumors
originating from neuronal sheath cells (Schwann cells). Most neurilemmomas
occur later in life, generally after the age of forty years. Most
neurilemmomas are benign tumors. The few malignant cases are characterized
by rapid tumor growth. Clinical picture depends on the anatomic site and
size of origin. Have been reported to occur anywhere in the body with most
cases originating in the head and neck region. Neurilemmomas in the cervical
region arise from the cranial nerves with the vagus nerve or its branches
being the most commonly affected. Other site for neurilemmomas reported
in children includes the brachial plexus, cervical nerve roots, cervical
sympathetic chain and small peripheral nerves of the hand. Bilateral vestibular
schwannomas are associated with Neurofibromatosis type II. Imaging studies
(US and CT-Scan) shows a solid encapsulated tumor. Delay in diagnosis and
treatment is very common due to the slow growing nature of the tumor. Management
consists of surgical removal whenever vital structures permit. Malignant
variants receive chemo and radiotherapy.
References:
1- Rice DH, Coulthard SW: Neurogenic tumors of the head
and neck in children. Ann Plast Surg 2(5):441-4, 1979
2- Ahmed A, Morley A, Wilson JA: Extracranial neurilemmoma:
a case report and review of the literature. J R Coll Surg Edinb 45(3):192-4,
2000
3- Oguzkurt P, Kayaselcuk F, Arda IS, Barutcu O, Tuncer
I, Oz S: Anterior abdominal wall malignant peripheral nerve sheath tumor
in an infant. J Pediatr Surg 36(12):1866-8, 2001
4- Nunes F, MacCollin M: Neurofibromatosis 2 in the pediatric
population. J Child Neurol 18(10):718-24, 2003
5- Baglaj M, Markowska-Woyciechowska A, Sawicz-Birkowska
K, Dorobisz U: Primary neurilemmoma of the thyroid gland in a 12-year-old
girl. J Pediatr Surg 39(9):1418-20, 2004
Felon
A felon is defined as a painful fusiform abscess (swelling) in the distal
fat pad of the phalanx with increased tenderness over the flexor aspect
and erythema (redness and cellulitis) distributed uniformly along the entire
flexor aspect of the pulp space. Felon is very different from a paronychia.
Paronychia is a more localized painful swelling on the extensor aspect
of the distal digit located at the proximal extent of the sulcus. Initial
management consists of antibiotics, warm soaks and elevation of the affected
extremity. If the child does not improve rapidly with medical treatment,
surgical incision and drainage are indicated to avoid involvement of the
bony distal phalanx due to rapid extension of the infections process through
synovial-lined spaces. Felons are managed with digital anesthetic block
and incision along the ulnar aspect of the digit to produce drainage of
the closed space infection. The incision is made along the ulnar aspect
of the phalanx to avoid the possibility of a painful scar on the radial
side of the phalanx which is the pinching side of the distal phalanx.
Cultures are routinely taken during surgery. Staphylococcus aureus is a
common offending organism. Penrose drain for 48 hours is recommended.
References:
1- Kilgore ES Jr, Brown LG, Newmeyer WL, Graham WP 3rd,
Davis TS: Treatment of felons. Am J Surg 130(2):194-8, 1975
2- Lewis RC Jr.: Infections of the hand. Emerg Med Clin
North Am 3(2):263-74, 1985
3- Shmerling RH: Finger pain. Prim Care 15(4):751-66,
1988
4- Connolly B, Johnstone F, Gerlinger T, Puttler E: Methicillin-resistant
Staphylococcus aureus in a finger felon. J Hand Surg 25(1):173-5, 2000
5- Clark DC: Common acute hand infections. Am Fam Physician
68(11):2167-76, 2003