PEDIATRIC SURGERY UPDATE ©
VOLUME 43, 2014
PSU Volume 43 No 01 JULY 2014
Port CVC: Infections
Central venous catheters (CVC) related
infections are the most common complication of harboring a central
venous catheter with or without a port. This is followed by thrombosis
of the catheter/port and mechanical problems. CVC using a port is
extremely valuable for the long-term used of chemotherapy in children
with malignancies. The most common causative organism of infected port
CVC is coagulase negative staphylococcus. Factors that increase the
risks of port CVC infections include younger age at the time of a
malignant diagnosis, patient with leukemia and intensive chemotherapy
with periods of severe neutropenia. It is globally recommended that the
patient have an optimal neutropenic level at the time of port placement
to decrease the infection risk. The number of port CVC removed due to
infection is significantly greater the younger the patient. Other
factors identified as increasing the rate of catheter removal due to
blood stream infection include periods of hypotension, persistent
bacteremia, stem cell transplantation, exit site infection,
inappropriate empiric therapy and Candida infections. The use of
prophylactic antibiotics is not recommended as an effective management
to prevent catheter-associated blood stream infections in children. The
use of chlorhexidine-impregnated dressings has shown to be a clinical
management that decreases the incidence of bacterial colonization. In
the setting of an infection the port CVC should be removed if the child
has persistent or relapsing bacteremia in spite of adequate systemic
antibiotic therapy, if the blood stream infection is caused by gram
negative bacilli or Candida species, and if the patient clinical
picture warrants removal.
References:
1- Elihu A, Gollin G: Complications of implanted
central venous catheters in neutropenic children. Am Surg 73(10):
1079-1082, 2007
2- Adler A, Yanily I, Steinberg R, et al: Infectious complications of
implantable ports and Hickman catheters in paediatric
haematology-oncology patients. J of Hospital Infection 62(3): 356-358,
2006
3- Loh AH, Chui CH: Port-A-Cath insertions in acute leukemia: does
thrombocytopenia affects morbidity? J Pediatr Surg 42(7): 1180-1184,
2007
4- Adler A, Yanily I, Solter E, et al: Catheter-associated bloodstream
infections in pediatric hematology-oncology patients: factors
associated with catheter removal and recurrence. J Pediatr Hematol
Oncol 28(1):23-28, 2006
5- Dogar SA, Khan MA: Implantable port devices in paediatric oncology
patients: a clinical experience from a tertiary care hospital. J Pak
Med Assoc. 63(10): 1248-1251, 2013
6- Garland J, Alex C, Mueller C, et al: A randomized trial comparing
povidone-iodine to a chlorhexidine gluconate-impregnated dressing for
prevention of central venous catheter infections in neonates.
Pediatrics. 107(6): 1431-1436, 2001
Autoimmune Hepatitis
Autoimmune hepatitis (AIH) is a
progressive inflammatory disorder of the liver characterized by high
level of transaminases, immunoglobulin G, presence of autoantibodies,
histological evidence of interface hepatitis with portal plasma cell
infiltration, and unknown etiology. Most affected children are females
in their adolescent age. Two types of AIH are recognized. Type 1 is the
most common and is characterized by positive antinuclear and/or
anti-smooth muscle antibody presenting around puberty. Type 2 presents
at a younger age and has positive anti-liver kidney microsomal
antibodies and/or anti liver cytosol 1 antibodies. Type 2 presents with
higher levels of bilirubin and transaminases, along with a more
fulminant course of hepatic failure. Clinically children with AIH
present with nonspecific symptoms of malaise, nausea/vomiting,
anorexia, abdominal pain, followed by jaundice, dark urine and pale
stools. Most children have clinical signs of chronic liver disease.
Sclerosing cholangitis is often associated with AIH as an overlap
syndrome suggesting both are part of the same pathogenic process. AIH
responds to immunosuppression (steroids and azathioprine) and treatment
should be initiated promptly to avoid progression of disease. Goals of
treatment are to reduce or eliminate liver inflammation, to induce
remission, improve symptoms, and prolong survival. With early treatment
remission occurs in 80% of cases. Cirrhosis is found in 40-80% at
diagnosis. Development of end-stage liver disease requiring liver
transplant is 10% with most children remaining clinically stable with a
good quality of life on long-term treatment. The role of surgery in AIH
is provide histologic evidence of progression of disease by open or
laparoscopic liver biopsy.
References:
1- Mieli-Vergani G, Heller S, Jara P, Vergani D, et al: Autoimmune hepatitis. J Pediatr Gastroenterol Nutr. 49(2):158-64, 2009
2- Chai PF, Lee WS, Brown RM, McPartland JL, Foster K, McKiernan PJ,
Kelly DA: Childhood autoimmune liver disease: indications and outcome
of liver transplantation. J Pediatr Gastroenterol Nutr. 50(3):295-302,
2010
3- Mieli-Vergani G, Vergani D: Autoimmune liver diseases in children -
what is different from adulthood? Best Pract Res Clin Gastroenterol.
25(6):783-95, 2011
4- Della Corte C, Sartorelli MR, Sindoni CD, Girolami E, Giovannelli L,
Comparcola D, Nobili V: Autoimmune hepatitis in children: an overview
of the disease focusing on current therapies. Eur J Gastroenterol
Hepatol. 24(7):739-46, 2012
5- Vajro P, Paolella G: Autoimmune hepatitis: current knowledge. Clin Res Hepatol Gastroenterol. 36(3):284-6, 2012
6- Vitfell-Pedersen J, Jargensen MH, Maller K, Heilmann C: Autoimmune
hepatitis in children in Eastern Denmark. J Pediatr Gastroenterol Nutr.
55(4):376-9, 2012
Traumatic Bile Leaks
Traumatic bile leaks are a potential
complication and sequelae of blunt hepatic injury whether managed
operatively or non-operatively occurring exclusively in higher-grade
injuries (> Grade III). A bile leak in the setting of trauma occurs
after traumatic biliary tract laceration, parenchymal disruption,
ductal ischemia, delayed rupture of subcapsular bile collections or
persistent leak following hepatorraphy or hepatic resection during
laparotomy. The bile leak leads to an intrahepatic biloma or
intraperitoneal leakage of bile. The affected child develops symptoms
such as nausea, increasing pain, abdominal distension, prolongation of
the intestinal ileus and ascites after an initial period of clinical
improvement from his hepatic trauma. The first study to confirm the
diagnosis should be a HIDA scan due to its high sensitivity. Drainage
of the biloma whether image-guided, laparoscopic or during laparotomy
should be the first therapeutic intervention once the diagnosis of the
biliary leak is made. Properly placed catheters can convert a leak into
a controlled bile fistula. If the child continues to leak, an ERCP
should be performed along with endoscopic sphincterotomy, nasobiliary
drainage and/or stent placement across the papilla. The stent lowers
the intrabiliary pressure by keeping the ampulla open. Biliary leaks
can take more than six months to resolve. Strict follow-up is required
for removal of the indwelling biliary stent as they can dislodge, block
and cause pancreatitis.
Reference:
1-Hollands MJ, Little JM: Post-traumatic bile fistulae. J Trauma. 31(1):117-20, 1991
2- Castagnetti M, Houben C, Patel S, Devlin J, Harrison P, Karani J,
Heaton N, Davenport M: Minimally invasive management of bile leaks
after blunt liver trauma in children. J Pediatr Surg. 41(9):1539-44,
2006
3- Durakbasa CU, Balik E, Yamaner S, et al: Diagnostic and therapeutic
endoscopic retrograde cholangiopancreatography (ERCP) in children and
adolescents: experience in a single institution. Eur J Pediatr Surg.
18(4):241-4, 2008
4- Sharma BC, Mishra SR, Kumar R, Sarin SK: Endoscopic management of
bile leaks after blunt abdominal trauma. J Gastroenterol Hepatol.
24(5):757-61, 2009
5- Kulaylat AN, Stokes AL, Engbrecht BW, McIntyre JS, Rzucidlo SE,
Cilley RE: Traumatic bile leaks from blunt liver injury in children: a
multidisciplinary and minimally invasive approach to management.
J Pediatr Surg. 49(3):424-7, 2014
PSU Volume 43 NO 02 AUGUST 2014
Ileocecal Duplication Cyst
Congenital duplications of the
gastrointestinal tract are rare and usually detected in the first two
years of life or prenatally. The clinical presentation depends on
location, size, and presence of ectopic gastric or pancreatic
mucosa. Intestinal duplications lead to volvulus, intussusception,
bowel obstruction, bleeding or perforation. They can occur anywhere in
the GI tract with the ileum, ileocecal and duodenum segment as the most
common sites. Most alimentary tract duplications are cystic
(80%–90%), with the remainder being tubular. The presence of
gastric or pancreatic mucosa can lead to peptic ulceration,
perforation, and hemorrhage. Most of the intestinal duplications share
a common muscular wall and blood supply with the native bowel,
especially those located in the abdomen, where they lie in the
mesenteric border. The management of duplication cysts consists of
resection of the segment harboring the duplication with anastomosis
unless the duplications encompass a long segment of bowel. Ileocecal
duplications are more frequently cystic lesions of varying size, share
a common blood supply and wall with the ileum for a few centimeters
from the valve and compress the cecum. These malformations manifest a
clinical picture usually characterized by early presentation, occlusive
feature and potentially deadly outcome. In many reports duplications in
the ileocecal area have been managed with resection of the ileocecal
valve. Removal of the ileocecal valve can lead to bacterial overgrowth,
reduced intestinal transit time and impaired absorption with symptoms
like diarrhea, malnutrition, and electrolyte imbalance. This has
prompted management of ileocecal duplication cysts performing excision
of the cyst together with the common wall of the ileum and restoring
ileal wall continuity with transverse anterior enterorrhaphy preserving
the functional ability of the ileocecal valve.
References:
1- Tong SC, Pitman M, Anupindi SA: Best cases from the AFIP. Ileocecal enteric duplication cyst:
radiologic-pathologic correlation. Radiographics. 22(5):1217-22, 2002
2- Haratz-Rubinstein N, Sherer DM: Prenatal sonographic findings of
congenital duplication of the cecum. Obstet Gynecol. 101(5 Pt
2):1085-7, 2003
3- Foley PT, Sithasanan N, McEwing R, Lipsett J, Ford WD, Furness M:
Enteric duplications presenting as antenatally detected abdominal
cysts: is delayed resection appropriate? J Pediatr Surg. 38(12):1810-3,
2003
4- Corroppolo M, Zampieri N, Erculiani E, Cecchetto M, Camoglio FS:
Intussusception due to a cecal duplication cyst: a rare cause of acute
abdomen. Case report. Pediatr Med Chir. 29(5):273-4, 2007
5- Kashiwagi Y, Suzuki S, Watanabe K, Nishimata S, Kawashima H,
Takekuma K, Hoshika A:Sudden unexpected death associated with ileocecal
duplication cyst and clinical review. Clin Med Insights Pediatr.
4:25-8, 2010
6- Catalano P, Di Pace MR, Caruso AM, De Grazia E, Cimador M: Ileocecal
duplications cysts: Is loss of the valve always necessary? J Pediatr
Surg 49: 1049-1051, 2014
Fecal Microbiome Transplant
Fecal microbiome transplant (FMT) also
known as stool transplantation is the infusion of human stool, obtained
from a healthy donor with no risk factors for transmissible diseases
into the gastrointestinal tract of a disease patient. FMT purpose is to
normalize the gut flora of the recipient. The human GI microbiota is
considered a tissue, not an organ, and is used in FMT to implant in a
recipient's GI tract. Routes of instillation for FMT includes retention
enemas (most common route), colonoscopy and nasojejunal tubes. Enema
administration is effective, cheap, and safe and carries fewer
procedural or institutional admission costs. FMT has been used
effectively to manage patients with refractory/recurrent
pseudomembranous enterocolitis and Clostridium difficile infection with
a success rate of 81% following a single infusion and 94%
following a second infusion. No significant adverse events were noted
other than mild infusion-related diarrhea and discomfort. FMT has also
been used successfully in cases of inflammatory bowel disease
(ulcerative colitis and Crohn disease) reducing symptoms, reversing
disease and stopping medication, though its use is actually reserved
for clinical trials. FMT in the management of inflammatory bowel
diseases causes that 76% of subjects experience improvement in symptoms
and 63% achieve clinical remission. Other conditions that could benefit
from FMT include anorexia nervosa, constipation, diabetes mellitus,
eosinophilic disorders of the GI tract, food allergies, irritable bowel
syndrome, obesity, neurodegenerative and neurodevelopment disorders,
and systemic autoimmunity disorders. Treatment may consist of a
single dose of FMT or multiple doses depending on the condition and
response of the patient during treatment. Common treatment-related
symptoms include bloating/flatulence, abdominal pain/cramping,
diarrhea, blood in stool, and fatigue. The absence of consensus in
regards to volume, route, donor screening, safety measures, and the
potential lack of medical supervision in children is still being
discussed and studied.
References:
1- Kellermayer R: Prospects and challenges for intestinal microbiome
therapy in pediatric gastrointestinal disorders. World J Gastrointest
Pathophysiol. 4(4):91-93, 2013
2- Borody TJ, Paramsothy S, Agrawal G: Fecal microbiota
transplantation: indications, methods, evidence, and future directions.
Curr Gastroenterol Rep. 15(8):337, 2013
3- Kunde S, Pham A, Bonczyk S, Crumb T, Duba M, Conrad H Jr, Cloney D,
Kugathasan S: Safety, tolerability, and clinical response after fecal
transplantation in children and young adults with ulcerative colitis. J
Pediatr Gastroenterol Nutr. 56(6):597-601, 2013
4- Allegretti JR, Hamilton MJ: Restoring the gut microbiome for the
treatment of inflammatory bowel diseases. World J Gastroenterol.
20(13):3468-74, 2014
5- Samuel BP, Crumb TL, Duba MM: What Nurses Need to Know About Fecal
Microbiota Transplantation: Education, Assessment, and Care for
Children and Young Adults. J Pediatr Nurs. Feb 7, 2014
6- Borody TJ, Campbell J: Fecal microbiota transplantation: techniques,
applications, and issues. Gastroenterol Clin North Am. 41(4):781-803,
2012
Subcostal Hernias
Subcostal hernia is a very rare entity
presenting as an isolated defect or a complex multisystem defect, the
exact etiology of which is still unknown. They more probably occur
secondary to traumatic abdominal wall weakness or previous surgery,
than congenital. They most commonly appear in the left subcostal region
as a small protruding defect of 2 cm. Protrusion through the hernial
content includes stomach and/or small/large bowel. There is risk of
incarceration due to the small ring of defect. Associated conditions
identified in the few case reports include left absent kidney, deformed
thoracic cage, cardiac malformations, agenesis of the müllerian
ducts & left ovary, and aplasia cutis congenita. The pathogenesis
includes failure of the ectoderm to develop adequately in the area of
the hernia that may lead to underlying embryologic defects as a result
of disrupted inductive interactions between the abdominal wall layers,
which occur during normal development The diagnosis can be confirmed
with US, MRI or simple physical examination. The hernial defect has a
sac. Management is straightforward and consists of surgical closure of
the hernia defect using the surrounding rim of open external abdominal
fascia. Recurrence is rare and the prognosis is good.
References:
1- Nicksa GA, Christensen EP, Buchmiller TL: A case report of a
congenital left subcostal hernia in a neonate. J Pediatr Surg.
44:1653–1655, 2009
2- Monteagudo J, Ruscher KA, Margolis E, Balazero F, Finck CM:
Congenital subcostal hernia with unusual contents. J Pediatr Surg.
45:435–437, 2010
3- Sengar M, Manchanda V, Mohta A, Jain V, Das S:Intercostal variant of
lumbar hernia in lumbocostovertebral syndrome: our experience with 6
cases. J Pediatr Surg. 2011 Oct;46(10):1974-7. 4- Lyngdoh TS, Mahalik
S, Naredi B, Samujh R, Khanna S: Lumbocostovertebral syndrome with
associated VACTERL anomaly. J Pediatr Surg. 45(9):e15-7, 2010
5- Raghu SR(1), Alladi A, Vepakomma D, Siddappa OS, Tilak P:
Embryogenesis and types of subcostal hernia--a rare entity. J Pediatr
Surg. 48(3):533-537, 2013
PSU Volume 43 NO 03 SEPTEMBER 2014
Near-Infrared Spectroscopy
Near-infrared spectroscopy (NIRS) is a
noninvasive monitoring method to measure cerebral and somatic
oxygenation during a surgical procedure. NIRS is based on the
differential absorption of varying wavelengths of light by hemoglobin
as it associates with oxygen. It provides a regional measurement of
oxygen content in a localized tissue bed. The main purpose of NIRS is
to evaluate regional tissue perfusion and oxygenation continuously. It
has been used as standard of care during cardiac surgery to monitor the
possible associated neurologic dysfunction from the hemodynamic changes
occurring during the procedure. Cerebral hemoglobin oxygen saturation
measured with NIRS (rSO2c) is utilized to monitor and titrate brain
oxygen delivery preoperatively, during cardiopulmonary bypass, and
postoperatively in the pediatric intensive care unit.
Somatic/renal NIRS (rSO2s) has also been proposed, as an estimate of
somatic oxygen delivery and as a measure of optimized systemic
perfusion, coupled with cerebral NIRS. A near-infrared spectrometer
equipped with two independent emittent–sensor pairs is used for
simultaneously measurement of rSO2c and rSO2s by cerebral and
splanchnic sensors applied to the forehead and renal region,
respectively. For example, during thoracoscopy pleural absorption of
CO2 causes acidosis which in turn causes of vasoconstriction and
reduced cerebral oxygenation signaled as such by the cerebral NIRS
sensor placed in the head. Low intraoperative cerebral NIRS values are
associated with worse neurological outcomes. Also, perioperative
periods of diminished cerebral oxygen delivery, as indicated by rSO2c,
are associated with one-year brain MRI abnormalities among infants
undergoing reparative heart surgery. NIRS has recently been used in
cases of non-cardiac neonatal surgery helping understand neonatal
physiological changes occurring in these patients.
References:
1- Berens RJ, Stuth EA, Robertson FA, Jaquiss RD, Hoffman GM,
Troshynski TJ, Staudt SR, Cava JR, Tweddell JS, Bert Litwin S: Near
infrared spectroscopy monitoring during pediatric aortic coarctation
repair. Paediatr Anaesth. 16(7):777-81, 2006
2- Hirsch JC, Charpie JR, Ohye RG, et al. Near-infrared spectroscopy:
what we know and what we need to know—a systematic review of the
congenital heart disease literature. J Thorac Cardiovasc Surg
137:154–9, 2009
3- Durandy Y, Rubatti M, Couturier R: Near Infrared Spectroscopy during
pediatric cardiac surgery: errors and pitfalls. Perfusion. 26(5):441-6,
2011
4- Holtby H, Skowno JJ, Kor DJ, Flick RP, Uezono S: New technologies in
pediatric anesthesia. Paediatr Anaesth. 22(10):952-61, 2012
5- Abu-Sultaneh S, Hehir DA, Murkowski K, Ghanayem NS, Liedel J,
Hoffmann RG, Cao Y, Mitchell ME, Jeromin A, Tweddell JS, Hoffman GM:
Changes in cerebral oxygen saturation correlate with S100B in infants
undergoing cardiac surgery with cardiopulmonary bypass. Pediatr
Crit Care Med. 15(3):219-28, 2014
6- Conforti A, Giliberti P, Mondi V, et al: Near infrared spectroscopy:
Experience on esophageal atresia infants. J Pediatr Surg. 49:
1064-1068, 2014
Choledochal Cyst Type II
Choledochal cysts are dilatation of
the extrahepatic and/or intrahepatic biliary tree causing myriad of
complications in children. Choledochal cyst type II is the rarest of
all types of choledochal cysts commonly described as diverticular
malformation of the common bile duct with an otherwise normal intra-
and extrahepatic biliary tree. Such diverticular cysts may be either
small or very large occurring in less than 2% of all reported cases of
choledochal cysts. The pathogenesis of this type of choledochal cyst
remains speculative between an acquired and congenital process, with
the common channel theory of insertion of the bile duct into the
pancreatic duct allowing pancreatic enzymes to reflux into the common
bile duct causing inflammation, weakness and eventual fibrosis, as the
most plausible explanation. Others believe that the diverticulum is a
remnant of an earlier stage of bile development or an end-stage healing
of prenatal rupture of the common duct. Symptoms associated with this
type of cyst includes abdominal pain, cholangitis, jaundice, fever and
pancreatitis. First diagnostic study should be an abdominal
ultrasound. This can be followed by an MRCP to precisely delineate the
rare biliary anatomy. The management of choledochal cysts is surgical
excision whenever possible. Removal of the diverticulum is an accepted
mode of treatment, leaving patent the native extrahepatic biliary tree.
This procedure can be performed either open or laparoscopically with
good results. If the cyst has a wide opening to the biliary tree or
dilatation of the common bile duct is present (mixed variety) excision
and bilio-enteric reconstruction is needed. Whatever technique the
surgeon chooses, before removing the diverticular cyst, an
intraoperative cholangiogram should be done to delineate precisely the
surgical anatomy including demonstrating a normal appearing common bile
duct with free flow of contrast into the duodenum and proximally into
the intrahepatic ductal branches. Long-term follow up is needed to
asses surgical outcome, notably complications such as stricture
formation or the development of malignancy.
References:
1- Liu DC, Rodriguez JA, Meric F, Geiger JL: Laparoscopic excision of a
rare type II choledochal cyst: Case report and review of the
literature. J Pediatr Surg. 35(7): 1117-1119, 2000
2- Chan ES, Auyang ED, Hungness ES: JSLS. 13: 436-440, 2009
3- Yamashita H, Otani T, Shioiri T, Takayama T, Kakiuchi C, Todani T,
Makuuchi M: Smallest Todani's type II choledochal cyst. Dig Liver Dis.
35(7):498-502, 2003
4- Kaneyama K, Yamataka A, Kobayashi H, Lane GJ, Miyano T: Mixed type I
and II choledochal cyst: a new clinical subtype? Pediatr Surg Int.
21(11):911-3, 2005
5- Agarwal N, Kumar S, Hai A, Parfitt R: Mixed type I and II
choledochal cyst in an adult. Hepatobiliary Pancreat Dis Int.
8(4):434-6, 2009
6- Hwang SO, Lee TH, Bae SH, Han DJ, Lee HM, Park SH, Kim CH, Kim SJ:
Diverticular Choledochal Cyst with a Large Impacted Stone Masquerading
as Mirizzi's Syndrome. Case Rep Gastroenterol. 7(1):164-8, 2013
Sacral Nerve Stimulation
Sacral nerve stimulation (SNS), also
known as sacral neuromodulation, is a novel well-establish therapy
utilized for fecal incontinence in adults. In children, sacral nerve
stimulation has proven to be effective in dysfunctional elimination
syndrome, dysfunctional voiding, urinary retention, urgency, fecal
soiling and recently constipation. SNS has also been found to be a
valuable tool for intraoperative guidance in anorectal malformations
allowing direct neuromuscular response to be identified helping
surgeons operate closer to the individual anatomy. Electrical
stimulation of sacral nerve roots has been shown to have a positive
effect on peristalsis in the large bowel in patients with spinal cord
injury. The procedure consists of placing programmable stimulators
subcutaneously which delivers low amplitude stimulation via a lead to
the sacral nerves usually assessed through the S3 foramina. Placement
of the electrode using local anesthesia is preferred to ensure perfecto
positioning based on sensory reaction to stimulation. The most common
complaint after the procedure is pain from mechanical pressure or
stimulation, and lead migration. SNS has been found recently to improve
defecation in adolescent suffering from slow transit constipation
refractory to intensive medical therapy. This needs to be confirmed in
larger prospective studies with longer follow-up. Experience using SNS
in smaller children is lacking.
References:
1-van Wunnick BP, Peeters B, Govaert B, et al: Sacral Neuromodulation
Therapy: A promising treatment for adolescent with refractory
functional constipation. Dis Colon Rectum. 55: 278–285, 2012
2- Everaert K, Van den Hombergh U: Sacral nerve stimulation for pelvic
floor and bladder dysfunction in adults and children. Neuromodulation.
8(3):186-7, 2005
3- Thompson JH, Sutherland SE, Siegel SW: Sacral neuromodulation: Therapy evolution. Indian J Urol. 26(3):379-84, 2010
4- Lansen-Koch SM, Govaert B, Oerlemans D, Melenhorst J, Vles H,
Cornips E, Weil EH, van Heurn E, Baeten CG, van Gemert WG: Sacral
nerve modulation for defaecation and micturition disorders in patients
with spina bifida. Colorectal Dis. 14(4):508-14, 2012
5- Dudding TC: Sacral nerve stimulation for constipation in children: a
caution for a treatment in development. Dis Colon Rectum.
55(3):237-8, 2012
6- Hasselbeck C, Reingruber B: Sacral nerve stimulation is a valuable
diagnostic tool in the management of anorectal and pelvic
malformations. J Pediatr Surg. 47(7):1466-71, 2012
PSU Volume 43 NO 04 OCTOBER 2014
Recurrent Adhesive Bowel Obstruction
Adhesive bowel obstruction (ABO) is a
significant cause of morbidity following abdominal surgery in children.
Readmission to hospital because of adhesions is estimated to affect up
to 19% of children within four years of major abdominal surgery with
almost 8% needing surgical intervention within the first two years
after surgery. The rate of recurrence increases with each surgical
procedure performed in the abdomen. The most common procedures observed
in patients managed for ABO are appendectomy, colostomy
creation/closure, Ladd's procedure, Nissen fundoplication and repair of
Congenital diaphragmatic hernia in descending order of
occurrence. Diagnosis of adhesive bowel obstruction is made
clinically (bilious vomiting, abdominal distension and obstipation) and
radiographically with simple abdominal films or CT-Scan. Clinical
predictors of intestinal ischemia include fever, tachycardia,
leukocytosis, localized pinpoint tenderness and evidence of complete
small bowel obstruction. Initial conservative management of
adhesive bowel obstruction consist of hydration, NPO and nasogastric
decompression. When conservative management fails surgery will be
needed to release the entrapped bowel. Recurrent episodes of ABO may
occur in up to 42% of all patients. For such recurrent situations the
surgeon should consider using long-tube (Jones or Thow) intraluminal
stenting of the bowel. Stenting can be done through a jejunostomy or
retrograde through the base of the appendix. The tube should remain at
least for two weeks when new adhesions have formed. Plication (Noble)
carries a high incidence of postop complications and has been
abandoned. Seprafilm reduces the incidence of ABO in the pediatric
patients undergoing laparotomy. Fibrin-sealed plication of the bowel
has found to decrease the risk of recurring obstruction.
References:
1- Eeson GA, Wales P, Murphy JJ: Adhesive small bowel obstruction in
children: should we still operate? J Pediatr Surg. 45(5):969-74, 2010
2- Inoue M, Uchida K, Otake K, Nagano Y, Ide S, Hashimoto K, Matsushita
K, Koike Y, Mohri Y, Kusunoki M: Efficacy of Seprafilm for preventing
adhesive bowel obstruction and cost-benefit analysis in pediatric
patients undergoing laparotomy. J Pediatr Surg. 48(7):1528-34, 2013
3- Sprouse LR 2nd, Arnold CI, Thow GB, Burns RP: Twelve-year experience
with the Thow long intestinal tube: a means of preventing
postoperative bowel obstruction. Am Surg. 67(4):357-60, 2001
4- Holland-Cunz S(1), Boelter AV, Waag KL: Protective fibrin-sealed
plication of the small bowel in recurrent laparotomy. Pediatr
Surg Int. 19(7):540-3, 2003
5- Valkodai RR, Gurusami R, Duraisami V: Postoperative adhesive
intestinal obstruction: The role of intestinal stenting. J Indian Assoc
Pediatr Surg. 17(1):20-2, 2012
6- Fazel MZ, Jamieson RW, Watsn CJE: Long-term follow-up of the use of
the Jones' intestinal tube in adhesive small bowel obstruction. Ann R
Coll Surg Engl 91: 50-54, 2009
Accessory Hemidiaphragm
An accessory hemidiaphragm (AHD)
is a very rare thoracic anomaly in children in which the hemithorax is
divided by a transverse fibromuscular septum separating the
affected hemithorax into two cavities. It most commonly occurs in
the right side and the septum attaches anteriorly and medially to the
central tendon of the thoracic diaphragm and pericardium. The septum
has serosal lining, is fibrous, but it can contain striated muscle.
Lung is trapped under the septum causing hypoplasia or agenesis with
anomalous vascular connections. The anomaly is believed to occur due to
the result of the lung bud growing into the posthepatic mesenchymal
plate which normally forms the greatest part of the diaphragm. The
child can develop respiratory, cardiovascular or be asymptomatic.
Symptoms in the majority of cases are related either to inability of
the trapped lung to expand or because of the previously described
anomalous vessels. Though the diagnosis of AHD can be suspected in
plain chest films, it will need a CT-Scan or MRI for final
confirmation. It is important to describe well the associated
cardiovascular anomalies. On bronchoscopy the bronchi to trapped lobes
are narrow and they are crowded together toward the back of the
affected hemithorax. Management of the symptomatic child with
compromised lung function due to AHD consists of excision along with
the entrapped lung tissue. This can be performed by open thoracotomy,
thoracoscopy or through a subcostal laparotomy depending on the anatomy
and extent of the lesion. Simultaneous or metachronous repair of an
associated cardiovascular defect might be needed in some patients.
Excision of the accessory diaphragm does not necessarily solve the
problem of coexisting lung hypoplasia.
References:
1*- Radhakrishnan J, Bean J, Piazza DJ, Chin AC: Accessory hemi diaphragm. J Pediatr Surg. 49(8):1326-1331, 2014
2- Wille L, Holthusen W, Willich E: Accessory diaphragm. Report of 6
cases and a review of the literature. Pediatr Radiol. 4(1):14-20, 1975
3- Becmeur F, Horta P, Donato L, Christmann D, Sauvage P: Accessory
diaphragm--review of 31 cases in the literature. Eur J Pediatr Surg.
5(1):43-7, 1995
4- Kimura M, Asao M, Kawano Y, Inakazu T, Hamamoto K, Oda T: Scimitar
syndrome with an accessory diaphragm and an absent right superior vena
cava. Jpn J Surg. 16(4):284-7, 1986
5- Hart JC, Cohen IT, Ballantine TV, Varrano LF: Accessory diaphragm in an infant. J Pediatr Surg. 16(6):947-9, 1981
6- Izeldin OM(1), Ahmed ME: Presentations of agenesis of the hemidiaphragm in an adult. Saudi Med J. 29(3):441-3, 2008
*Best review
Peritoneal Dialysis with VP Shunts
Peritoneal dialysis (PD) is the
preferred method for end-stage renal disease children needing chronic
dialysis support. Ventriculoperitoneal shunts (VPS) are routinely used
to managed hydrocephalus especially in children with spina bifida. A
small number of children with VPS will need chronic dialysis support
using PD. These means two foreign bodies are within the abdominal
cavity simultaneously creating fear of ascending (meningitis from
peritonitis) or descending (meningitis to peritonitis) infections and
VPS dysfunction. Studies have demonstrated a rate of one
peritonitis per 19 months use in children with simultaneous VPS and PD
catheters with an absence of meningitis in cases with peritonitis.
Regarding the possibility of a higher rate of VPS malfunction with the
automated cycler dialysis in the supine position overnight and filling
of less than 1,000 ml/m2 for any day dwell, it seems very
unlikely that the intraperitoneal pressure would ever persistently
exceed the CSF pressure and inhibit VPS function. Besides the design of
the VPS currently in use which allows CSF to flow in one way only,
avoids reflux to the ventricles. There is a small inherent risk of
chronic encapsulating peritonitis developing with loss of absorptive
capacity. Concurrent use of a VPS and PD is a safe and acceptable
option in the rare child requiring dialysis and a cerebral fluid shunt
with no evidence to support an increased risk of peritonitis, ascending
ventricular infections, or shunt dysfunction. Either the VPS and/or the
PD catheter can be placed laparoscopically.
References:
1- Jachimiak B, Jarmoliaski T: [A child with myelomeningocele as a dialytic patient]. Przegl Lek. 3:176-9, 2006
2- Grunberg J, Verocay MC, Rebori A, Pouso J: Comparison of chronic
peritoneal dialysis outcomes in children with and without spina bifida.
Pediatr Nephrol. 22(4):573-7, 2007
3- Johnson BW, Pimpalwar A: Laparoscopic-assisted placement of
ventriculo-peritoneal shunt tips in children with multiple previous
open abdominal ventriculo-peritoneal shunt surgeries. Eur J Pediatr
Surg. 19(2):79-82, 2009
4- Ram Prabahar M, Sivakumar M, Chandrasekaran V, Indhumathi E,
Soundararajan P: Peritoneal dialysis in a patient with neurogenic
bladder and chronic kidney disease with ventriculoperitoneal shunt.
Blood Purif. 26(3):274-8, 2008
5- Grunberg J, Rebori A, Verocay MC: Peritoneal dialysis in children
with spina bifida and ventriculoperitoneal shunt: one center's
experience and review of the literature. Perit Dial Int. 23(5):481-6,
2003
6- Dolan NM, Borzych-Duzalka D, Suarez A, Principi I, Hernandez O,
Al-Akash S, Alconchar L, Breen C, Fischbach M, Flynn J, Pape L,
Piantanida JJ, Printza N, Wong W, Zaritsky J, Schaefer F, Warady BA,
White CT: Ventriculoperitoneal shunts in children on peritoneal
dialysis: a survey of the International Pediatric Peritoneal Dialysis
Network. Pediatr Nephrol. 28(2):315-9, 2013
PSU Volume 43 No 05 NOVEMBER 2014
Fingertip Injury
Fingertip injuries are the most common
injury to the hand needing evaluation in an emergency department in
young children. Though often viewed as relatively minor injury improper
management can lead to considerably loss of skilled hand function.
Distal fingertip injuries in children are more common in boys, and
right and left-hand injuries occur at near equal frequencies despite
the majority of the population being right-handed. Crush injury
predominates. Most of these injuries can be managed
conservatively. Others will need surgical management. The goals
of treatment are to maintain the length of the digit, as well as to
provide well-padded, stable yet sensate pain-free skin with long-term
functionality. Simple hand x-ray film should be obtained in all cases
to determine bone involvement. Possible treatment includes primary
closure, healing by secondary intention, skin grafting, local tissue
rearrangement, microvascular free tissue transfer or perforator flaps.
The PNB classification takes into consideration whether damage included
the pulp, nail and/or bone. This will help determine if conservative
management is needed for distal pulp isolated injuries or if the nail
is involved full-thickness skin grafting is warrant since they contract
less, are more durable, and regain sensibility better than split
thickness grafts. An excellent donor site for these skin grafts is the
hypothenar eminence. In children the absolute size of the defect
relative to the size of the finger must be taken into consideration. If
it is felt that the defect is too large for secondary intention
healing, a full-thickness skin graft is a viable management option.
Injuries with fingertip pulp loss and exposed bone necessitate more
complex treatment options including local tissue flaps such as simple
V-Y, cross finger, homodigital or distal-based thenar flaps. With more
severe proximal injury or amputation with viable adequate tissue,
reimplantation is an option. Hand surgeons are expert in the management
of such injuries.
References:
1- Fitoussi F, Ghorbani A, Jehanno P, Frajman JM, Penneaot GF: Thenar
flap for severe finger tip injuries in children. J Hand Surg Br.
29(2):108-12, 2004
2- Salazard B, Launay F, Desouches C, Samson P, Jouve JL, Magalon G:
[Fingertip injuries in children: 81 cases with at least one year
follow-up]. Rev Chir Orthop Reparatrice Appar Mot. 90(7):621-7, 2004
3- Muneuchi G, Tamai M, Igawa K, Kurokawa M, Igawa HH: The PNB
classification for treatment of fingertip injuries: the boundary
between conservative treatment and surgical treatment. Ann Plast
Surg. 54(6):604-9, 2005
4- Gellman H: Fingertip-nail bed injuries in children: current concepts
and controversies of treatment. J Craniofac Surg. 20(4):1033-5, 2009
5- Al-Anazi AF: Fingertip injuries in paediatric patients - experiences at an emergency centre in
Saudi Arabia. J Pak Med Assoc. 63(6):675-9, 2013
6- Capstick R, Giele H: Interventions for treating fingertip entrapment
injuries in children. Cochrane Database Syst Rev. 30;4:CD009808, 2014
*7- Barr JS, Chu MW, Thanik V, Sharma S: Pediatric thenar flaps: a
modified design, case series and review of the literature. J Pediatr
Surg. 49(9):1433-8, 2014
Unexpected Pathology after Appendectomy
Acute appendicitis is the most common
surgical emergency in children, making appendectomy the most frequent
worldwide operation performed in the abdomen. Though obstruction of the
lumen of the appendix by lymphoid hyperplasia or fecalith is the
dominant factor causing appendicitis, other unexpected pathology may be
the cause of obstruction of the lumen in less than 2% of all cases.
Histopathological evaluation of the removed appendix is essential to
determine the etiology of such causes. The most common unusual factors
associated with appendicitis include carcinoids tumors, granulomatous
disease, enterobiasis, eosinophilia, teniasis, ascariasis, lymphomas
other infectious etiologies, melanosis coli, serosal inflammation, and
xanthomatous changes. Carcinoids are the most common tumors found in
the appendix. They are asymptomatic, difficult to diagnose, and are
incidentally found on histopathological examination. Fortunately the
carcinoid typically does not develop carcinoid syndrome, recurrence,
and metastasis. Appendectomy alone is the only treatment necessary in
most cases. Enterobius vermicularis (pinworm) is the most common
helminth infection worldwide and a rare cause of appendicitis. After
being hatched in the stomach, larvas migrate to the cecum to become
adult. It is here that they can occlude the lumen of the appendix
causing obstructive and inflammatory symptoms. Adult female pinworms
travel at night to the perianal area depositing eggs and causing anal
pruritus. After pathological diagnosis the child should receive
antihelminthic therapy. Granulomatous disease of the appendix is a very
rare cause of appendicitis reported in cases of Crohn's disease,
sarcoidosis, foreign body reaction, and infectious processes. Acute
eosinophilic appendicitis is the result of an allergic response
associated with eosinophilic enteritis, polypoid lesions,
intussusception or gastrointestinal bleeding. Other unusual findings in
appendicitis such as melanosis coli, infectious processes, xanthomatous
changes, lipomatous hypertrophy, and serosal inflammation are rare
entities seldom causing complications.
References:
1- Akbulut S, Tas M, Sogutcu N, Arikanoglu Z, Basbug M, Ulku A, Semur
H, Yagmur Y: Unusual histopathological findings in appendectomy
specimens: a retrospective analysis and literature review. World J
Gastroenterol. 17(15):1961-70, 2011
2- Emre A, Akbulut S, Bozdag Z, Yilmaz M, Kanlioz M, Emre R, Sahin N:
Routine histopathologic examination of appendectomy specimens:
retrospective analysis of 1255 patients. Int Surg. 98(4):354-62,
2013
3- Yilmaz M, Akbulut S, Kutluturk K, Sahin N, Arabaci E, Ara C, Yilmaz
S: Unusual histopathological findings in appendectomy specimens from
patients with suspected acute appendicitis. World J Gastroenterol.
19(25):4015-22, 2013
4- Swank HA, Eshuis EJ, Ubbink DT, Bemelman WA: Is routine
histopathological examination of appendectomy specimens useful? A
systematic review of the literature. Colorectal Dis.13(11):1214-21, 2011
5- Arca MJ, Gates RL, Groner JI, Hammond S, Caniano DA: Clinical
manifestations of appendiceal pinworms in children: an institutional
experience and a review of the literature. Pediatr Surg Int.
20(5):372-5, 2004
*6- Alemayehu H, Snyder CL, St Peter SD, Ostlie DJ: Incidence and
outcomes of unexpected pathology findings after appendectomy. J Pediatr
Surg. 49(9):1390-3, 2014
Bowel Length
Assessment of small bowel length
determination in children and adults is essential specially in cases of
large intestinal resections to determine and manage nutritional problem
arising from reduced absorptive capacity. Small bowel length, defined
as distance between Treitz and ileocecal valve, correlates with
gestational age, sex, weight, height and racial origin of the subjects.
For example in men the small intestine is 8% longer and the colon
14% longer than women. Intestinal length after loss of intestine is
best expressed as a percentage of predicted for gestational age rather
than the absolute length in centimeters. Between all the compounding
variables affecting small bowel length, height has been found to
correlate better by determining more exactly such length of the small
and large intestine of humans. Height was chosen for practical reasons
since the difference between observation and actual measurement is less
compared to weight. A simple formula using height in centimeters has
been developed for such purpose: Small bowel length (cm) = 6.741 -
80.409/height (cm). Similarly, Colon length (cm) = 0.111 * height (cm).
Small bowel length (SBL) does not increase with growth like other
anthropometric variables. The SBL/height ratio significantly decreases
with growth; however, bowel diameter increases.
References:
1- Gondolesi G, Ramisch D, Padin J, Almau H, Sandi M, Schelotto PB,
Fernandez A, Rumbo C, Solar H: What is the normal small bowel length in
humans? first donor-based cohort analysis. Am J Transplant. Suppl
4:S49-54, 2012
2- Siebert JR: Small-intestine length in infants and children. Am J Dis Child. 134(6):593-5, 1980
3- Hosseinpour M, Behdad A: Evaluation of small bowel measurement in alive patients. Surg Radiol Anat. 30(8):653-5, 2008
4- Hounnou G, Destrieux C, Desmé J, Bertrand P, Velut S:
Anatomical study of the length of the human intestine. Surg Radiol
Anat. 24(5):290-4, 2002
5- Touloukian RJ, Smith GJ: Normal intestinal length in preterm infants. J Pediatr Surg. 18(6):720-3, 1983
*6- Struijs MC, Diamond IR, de Silva N, Wales PW: Establishing norms
for intestinal length in children. J Pediatr Surg. 44(5):933-8, 2009
PSU Volume 43 NO 06 DECEMBER 2014
Bladder Diverticulum
A bladder diverticulum (BD) is a rare
pseudodiverticulum formed by mucosal herniation through an area of
weakness in the muscular wall of the bladder typically in a
paraureteral location. They are classified as congenital, acquired,
iatrogenic or part of a syndrome. They result from congenital
disarrangement of the detrusor muscle fibers at the ureterovesical
junction or associated with increased intravesical pressure due to
bladder-outlet obstruction. Bladder diverticulum can cause chronic
urinary infection, urinary retention, pelvic mass or acute urethral
obstruction by impinging upon the posterior urethra when they enlarged.
BD in childhood almost exclusively occurs in the male. The most common
clinical presentation of BD is acute pyelonephritis due to urine stasis
within the diverticulum. A high prevalence of neurogenic bladder is
present in patients with urinary BD. Long-term presence of a bladder
diverticulum can lead to malignancy. VCUG is the most accurate imaging
tool in the diagnosis of large bladder diverticula offering information
regarding concomitant vesicoureteral reflux and bladder-neck and
urethral morphology. Additional imaging methods of diagnosis include
intravenous urography, urodynamics studies, nuclear renal scans,
CT-Scan and MRI. Diverticulectomy is the recommended treatment of
choice for bladder diverticulum either symptomatic or not. Transvesical
diverticulectomy is the recommended technique as it allows complete
correction of any accompanying pathology by ureteral reimplantation or
bladder-neck incision with minimal complications and no morbidity
regarding long-term bladder function. Recurrence of the diverticula
after appropriate surgery is usually associated with Ehlers-Danlos,
Menkes or William syndrome or other collagen vascular disorders. Most
patients recover and progress well after surgical management.
References:
1- Bogdanos J, Paleodimos I, Korakianitis G, Stephanidis A,
Androulakakis PA: The large bladder diverticulum in children. J Pediatr
Urol. 1(4):267-72, 2005
2- Alexander RE, Kum JB, Idrees M: Bladder diverticulum:
clinicopathologic spectrum in pediatric patients. Pediatr Dev Pathol.
15(4):281-5, 2012
3- Appeadu-Mensah W, Hesse AA, Yaw MB: Giant bladder diverticulum: a
rare cause of bladder outlet obstruction in children. Afr J Paediatr
Surg. 9(1):83-7, 2012
4- Khemakhem R, Ghorbel S, Jlidi S, Nouira F, Louati H, Douira W,
Chennoufi F, Bellagha I, Chaouachi B: Management of congenital bladder
diverticulum in children: A report of seven cases. Afr J Paediatr Surg.
10(2):160-3, 2013
5- Bhat A, Bothra R, Bhat MP, Chaudhary GR, Saran RK, Saxena G:
Congenital bladder diverticulum presenting as bladder outlet
obstruction in infants and children. J Pediatr Urol. 8(4):348-53, 2012
6- Oge O(1), Gemalmaz H, Ozeren B: Acute urinary retention in a child
caused by a congenital bladder diverticulum. J Pediatr Surg.
37(6):926-7, 2002
Upper Lip Frenulum
Oral frenulum is a bandlike formation
of congenital origin located in the midline composed of fibrous,
muscular or fibromuscular tissue covered with a mucous membrane. Under
normal conditions most oral frenulum do not have pathological
consequences, otherwise they can present clinical problems of
orthodontic, prosthetic, phonetic or periodontal nature. The upper lip
frenulum is an oral mucosal membrane extending from the internal
surface of the upper lip to its insertion on the midline of the
attached interincisal gingival tissue of the upper maxilla. In children
this type of frenulum can cause breastfeeding problems, interincisal
diastema, denture related problems, periodontal disease secondary to
retained or impacted food, oral hygiene difficulties and impairment of
lip mobility and short lip which in turn require orthodontic treatment.
The diagnosis is clinical. Management of upper lip frenulum causing
this different problems is surgical. Frenulectomy should be performed
in children under general anesthesia. Techniques of frenulectomy
include simple or rhomboidal excision, V-Y plasty procedure and/or
Z-plasty. Simple removal consists of sectioning or transverse
sectioning the frenulum with simple suturing. They can leave a scar in
the same direction of the frenulum bringing problems with upper lip
lengthening and are contraindicated in cases with short lips exhibits
an impaired lip seal. In this cases the best technique is Z-plasty. The
procedure can be performed using laser being more precise and clean,
shorter operative time, eliminating bleeding and not needing suturing
since the wound is left opened to heal by secondary
intention.
References:
1- Kondamudi NP, Ayush Gupta, Kaur R: Magnet balls stuck to the frenulum of the lip. J Emerg Med. 2014 Mar;46(3):345-7
2- Kotlow LA: Diagnosing and understanding the maxillary lip-tie
(superior labial, the maxillary labial frenum) as it relates to
breastfeeding. J Hum Lact. 2013 Nov;29(4):458-64
3- Pie-Sanchez J, Espana-Tost AJ, Arnabat-Dominguez J, Gay-Escoda C:
Comparative study of upper lip frenectomy with the CO2 laser versus the
Er, Cr:YSGG laser. Med Oral Patol Oral Cir Bucal. 2012 Mar
1;17(2):e228-32
4- Bagga S(1), Bhat KM, Bhat GS, Thomas BS: Esthetic management of the
upper labial frenum: a novel frenectomy technique. Quintessence Int.
2006 Nov-Dec;37(10):819-23
5- Wiessinger D, Miller M: Breastfeeding difficulties as a result of
tight lingual and labial frena: a case report. J Hum Lact. 1995
Dec;11(4):313-6
6- Brabant P, Van der Veen JA:[Surgical treatment of the hypertrophic
frenum of the upper lip]. Acta Stomatol Belg. 1988 Sep;85(3):179-83
Ceftriaxone Biliary Pseudolithiasis
Ceftriaxone is a semisynthetic third
generation cephalosporin with a wide spectrum of powerful antimicrobial
activity administered in one daily dose. If administered in high doses
ceftriaxone can induce reversible gallbladder sludge, which can mimic
true cholelithiasis clinically and sonographically. The term
pseudolithiasis is coined to denote the reversible, benign character of
this complication upon discontinuation of ceftriaxone therapy.
Ceftriaxone associated pseudolithiasis is related to the high
concentration and precipitation of this drug in the gallbladder as an
insoluble calcium-ceftriaxone complex salt. Approximately 40% of
ceftriaxone is excreted unmetabolized into the bile exceeding its
solubility potential. The other 60% is excreted in the urine.
Pseudolithiasis develops in 25 to 50% of children receiving
ceftriaxone. The time for pseudolithiasis to develop and resolve
completely is unrelated to age, sex or type of infection. Fasting is
unrelated to development of pseudolithiasis. A few cases might also
develop nephrolithiasis as well. Pseudolithiasis is usually
asymptomatic and diagnosed using ultrasound. Cholecystectomy, even if
symptomatic, in cases of ceftriaxone induced pseudolithiasis is
unnecessary. Observation and ultrasound follow-ups will help recognize
the dissolution of the biliary lithiasis. When gallstone and/or sludge
are detected in the gallbladder in children by ultrasonographic
examination, the administration of ceftriaxone must be sought beyond
other causative factors.
References:
1- Alemayehu H, Desai AA, Thomas P, Sharp SW, St Peter SD:
Ceftriaxone-induced pseudolithiasis in children treated for perforated
appendicitis. Pediatr Surg Int. 30(3):323-6, 2014
2- von Martels JZ, Van de Meeberg EK, Holman M, Ligtenberg JJ, Ter
Maaten JC: Pseudolithiasis after recent use of ceftriaxone: an
unexpected diagnosis in a child with abdominal pain. Am J Emerg Med.
31(8):1294.e5-6, 2013
3- Meng D, Cao Y, Fu J, Chen R, Lu L, Tu Y: Sonographic assessment of
ceftriaxone-associated biliary pseudolithiasis in Chinese children. J
Int Med Res. 38(6):2004-10, 2010
4- Biner B, Oner N, Celtik C, BostancioÄŸlu M,
Tunçbilek N, Güzel A,
KarasalihoÄŸlu S: Ceftriaxone-associated biliary
pseudolithiasis in children. J Clin Ultrasound. 34(5):217-22, 2006
5- Ozturk A, Kaya M, Zeyrek D, Ozturk E, Kat N, Ziylan SZ:
Ultrasonographic findings in ceftriaxone: associated biliary sludge and
pseudolithiasis in children. Acta Radiol. 46(1):112-6, 2005
6- Ceran C, Oztoprak I, Cankorkmaz L, GumuÅŸ C, Yildiz T,
Koyluoglu G: Ceftriaxone-associated biliary pseudolithiasis in
paediatric surgical patients. Int J Antimicrob Agents.
25(3):256-9, 2005