Surgeons_and_Clinics RSS : Gourt

Risk management in pediatric surgery

Abstract Purpose To present the experience documented over 1 year of analysis and quality control on surgical complications and organizational accidents. Methods All children admitted during the study period at our Institution were included in the analysis, which consisted of four phases: (1) definition and standardization of perioperative diagnostic and therapeutic tracks; (2) staff education; (3) documentation and data implementation, and (4) “Morbidity and Mortality” audit. Results Over a 1-year study period, 3,116 children were admitted to our Institution: 2,222 out of 3,116 (71.3%) children underwent a surgical procedure. A total number of 184 complications were recorded in 149 patients. One hundred and seventy-one (92.9%) complications occurred following a surgical procedure. Fifty-six out of 149 complicated patients (37.6%) required a re-operation. Thirty-five out of 184 (19%) complications were classified as organizational. Infection represented the most common complication. All cases of anastomotic dehiscence and perforation, bowel obstruction, and stoma malfunction required reintervention. None of the postoperative bleedings required a second surgical procedure. Conclusion Although a proper statistical comparison with literature complication rates is not feasible, our experience confirms the importance of quality-control audit in health care systems. Prolonged observation, long-term follow up, and comparison with previous results will represent our future goal. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2407-xAuthors Girolamo Mattioli, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini, 5 16147 Genoa ItalyStefano Avanzini, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini, 5 16147 Genoa ItalyAlessio Pini-Prato, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini, 5 16147 Genoa ItalyPiero Buffa, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini, 5 16147 Genoa ItalyEdoardo Guida, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini, 5 16147 Genoa ItalyGiovanni Rapuzzi, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini, 5 16147 Genoa ItalyMichele Torre, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini, 5 16147 Genoa ItalyValentina Rossi, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini, 5 16147 Genoa ItalyGiovanni Montobbio, G. Gaslini Children’s Hospital Anesthesiology and Intensive Care Unit Genoa ItalyUbaldo Rosati, G. Gaslini Children’s Hospital Quality Control Office Genoa ItalyVincenzo Jasonni, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini, 5 16147 Genoa Italy Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358

Abdominal posterior rectopexy with an omental pedicle for intractable rectal prolapse: a modified technique

Abstract Introduction Rectal prolapse is a relatively common paediatric surgical condition. It has a number of benign aetiologies. Management is usually centred on regulating bowel habits. Surgery is considered after the failure of medical treatment. Numerous surgical techniques have been described with a spectrum of results. Materials and methods We adopted a limited abdominal approach to achieve a posterior rectopexy using an omental pedicle in intractable cases. This technique has not been performed in children previously. Results From 2005 to 2008 we have applied this technique on five patients with recurrent rectal prolapse which had failed to respond to medical treatment, injection sclerotherapy or perianal cercalage. One patient had solitary rectal ulcer syndrome, and was initially treated with a defunctioning colostomy, had a concomitant sigmoidectomy performed at the time of rectopexy. None of the patients had cystic fibrosis. There were three females and two males, with a mean age of 9.6 years (4.7–14.0). No operative complications were encountered. The mean hospital stay was 5.4 days (3–8). None of the patients experienced recurrence at a mean of 2.1 years (0.2–2.8) follow up. The cosmetic result was regarded as satisfactory by all patients. Conclusion This early experience with abdominal posterior rectopexy using an omental pedicle graft is encouraging. This technique does not involve the use of synthetic material and hence the risk of infection is low. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2404-0Authors K. Elmalik, Sheffield Children’s Hospital Paediatric Surgical Unit Western Bank Sheffield S10 2TH UKH. Dagash, Sheffield Children’s Hospital Paediatric Surgical Unit Western Bank Sheffield S10 2TH UKR. N. Shawis, Sheffield Children’s Hospital Paediatric Surgical Unit Western Bank Sheffield S10 2TH UK Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358

Duodenal atresia: associated anomalies, prenatal diagnosis and outcome

Abstract Background The diagnosis of duodenal atresia is commonly made prenatally, either as an isolated lesion or due to its association with other chromosomal abnormalities (Robertson et al. in Semin Perinatol 18:182–195, 1994; Hemming and Rankin in J Prenat Diagn 27:1205–1211, 2007). The aim of this study was to describe the prevalence of associated anomalies, prenatal diagnostic accuracy and survival of cases of congenital duodenal atresia in our institution. Methods All cases of duodenal atresia registered with our local congenital anomaly register over a 10-year period, 1995–2004 inclusive, were studied, including those resulting in termination of pregnancies, stillbirths, intrauterine deaths and neonatal deaths. To ensure high-case ascertainment, data were cross checked with prenatal ultrasound, cytogenetic laboratory, pathology department and neonatal surgical data base. Data were analysed for associated anomalies, accuracy of prenatal diagnosis and neonatal outcomes. Results A total of 65 patients were initially diagnosed as having duodenal atresia, of these 4 were subsequently excluded (1 postnatal normal bowel and 3 high jejunal atresias). In the remaining 61 cases, 35 (57%) had an association with other congenital abnormalities and 26 (43%) were isolated anomalies. Thirty-five were male and 26 female (M:F = 1.4:1). Twenty-one out of 29 (72%) patients prenatally diagnosed, compared with 14 out of 32 (44%) patients diagnosed postnatally had associated anomalies. Duodenal atresia was suspected on routine prenatal ultrasonography at 20-week gestation in 33 cases and confirmed in 29 (48%) cases with 4 false-positive diagnoses (1 normal bowel and 3 high jejunal atresias). No prenatal diagnosis was made in 32 (52%) babies. Of the 61 cases, 53 were live births with 2 early neonatal deaths (1 cardiac and 1 VACTERL), 5 terminations, 2 intrauterine deaths and 1 stillbirth (Fig. 3). Overall neonatal survival was 96% (51 cases). Mortality in the group diagnosed prenatally was 34 % (10 cases). Conclusion This study shows an overall increased association of duodenal atresia with Down’s syndrome. In the group diagnosed prenatally, mortality as well as the association with other congenital anomalies was found to be higher. We have demonstrated a greater prenatal diagnostic accuracy, but confirm postnatal outcomes similar to previous studies. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2406-yAuthors M. S. Choudhry, Children’s hospital Oxford and University of Oxford Department of paediatric surgery Headley Way Oxford OX39DU UKN. Rahman, Children’s hospital Oxford and University of Oxford Department of paediatric surgery Headley Way Oxford OX39DU UKP. Boyd, Children’s hospital Oxford and University of Oxford Department of paediatric surgery Headley Way Oxford OX39DU UKK. Lakhoo, Children’s hospital Oxford and University of Oxford Department of paediatric surgery Headley Way Oxford OX39DU UK Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358

The role of basic fibroblast growth factor to enhance fetal intestinal mucosal cell regeneration in vivo

Abstract Background/Purpose The limited application of small bowel transplantation for short bowel syndrome, mainly on the account of the morbidity and long-term implications of the procedure, has led to a search for alternative therapies. The purpose of this study was to evaluate whether basic fibroblast growth factor (bFGF) could facilitate regeneration of fetal small intestinal mucosa in vivo. Methods Intestinal epithelial organoid units harvested from fetal Lewis rats were injected into adult male Lewis rats whose colon was denuded of mucosa, as syngeneic recipients. One experimental group transplanted with the addition of 50 ng/ml bFGF, was compared with a control group that were transplanted without bFGF. The grafts were harvested and analyzed using histology and immunohistochemistry 3 weeks after operation. Results There were 4 anesthetic deaths, two in each group, and 11 deaths due to adhesive ileus. In no rat did neomucosa fully cover the denuded colonic muscle throughout the whole length of lumen. Histologically, the structure of the neomucosa, when present, was normal small intestinal mucosa. The small intestinal mucosa was partially restored in 100% (6 of 6) of bFGF, and in 28.6% (2 of 7) of those not given bFGF (P = 0.0021). Conclusions These data demonstrate that bFGF can facilitate the restoration of intestinal epithelial cells, at least to some degree. Potentially, refinements of this technique could be used to facilitate the physiologic tissue engineering of small intestine in a way that allows it to move peristaltically, and have an application in the management of patients with short bowel syndrome. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2405-zAuthors Atsushi Yoshida, Kagawa University Department of Pediatric Surgery, Faculty of Medicine Miki-cho, Kida-gun Kagawa 761-0793 JapanTakuo Noda, Kagawa University Department of Pediatric Surgery, Faculty of Medicine Miki-cho, Kida-gun Kagawa 761-0793 JapanMorimichi Tani, Kagawa University Department of Pediatric Surgery, Faculty of Medicine Miki-cho, Kida-gun Kagawa 761-0793 JapanTakanori Oyama, Kagawa University Department of Pediatric Surgery, Faculty of Medicine Miki-cho, Kida-gun Kagawa 761-0793 JapanYasuhiro Watanabe, Kagawa University Department of Pediatric Surgery, Faculty of Medicine Miki-cho, Kida-gun Kagawa 761-0793 JapanHideyasu Kiyomoto, Kagawa University Division of Nephrology and Dialysis, Faculty of Medicine Miki-cho, Kida-gun Kagawa 761-0793 JapanAkira Nishiyama, Kagawa University Department of Pharmacology, Faculty of Medicine Miki-cho, Kida-gun Kagawa 761-0793 Japan Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358

Colon replacement of vagina to restore menstrual function in 11 adolescent girls with vaginal or cervicovaginal agenesis

Abstract Aim Cervicovaginal or vaginal agenesis with functioning endometrial tissue is rare. We report the construction of a colon conduit which is anastomosed to posterior uterine wall or upper vaginal pouch to allow menstruation. Materials and methods We report seven girls with cervicovaginal agenesis and four with lower vaginal agenesis (aged 12–20 years) who presented with painful cryptomenorrheoa. All the girls wanted to conserve their uterus and menstruate normally. A colon conduit was constructed for the egress of menstrual blood. The colon conduit was anastomosed to the posterior uterine wall in the seven girls with cervicovaginal agenesis and to the distended upper vaginal pouch in the four girls with vaginal agenesis. Utero-colonic neovaginal anastomosis was performed only after excising a circular portion of the posterior myometrium to prevent stenosis. Results The colon conduit functioned effectively, providing an egress for regular painless menstruation. One patient had stenosis of the perineal neovaginal orifice for which dilations were done. One girl has married and reports satisfactory intercourse. The mean follow up is 2.2 years. Conclusions This group of patients forms a separate subgroup needing a conduit not only for sexual function but also for menstruation. However, if treated by the method described herein, they should be cautioned against pregnancy if they have cervicovaginal agenesis and against vaginal delivery if they have vaginal agenesis. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2391-1Authors Lavanya Kannaiyan, Christian Medical College and Hospital Vellore IndiaJacob Chacko, Christian Medical College and Hospital Vellore IndiaAlice George, Christian Medical College and Hospital Vellore IndiaSudipta Sen, Christian Medical College and Hospital Vellore India Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358

The impact of iatrogenic gastroschisis on pulmonary maturation in the fetal rabbit models of congenital diaphragmatic hernia

Abstract Purpose The aim of this study was to analyze the effect of iatrogenic gastroschisis on pulmonary hypoplasia in fetal rabbits with congenital diaphragmatic hernia (CDH). Materials and methods A total of 30 pregnant rabbits received fetal surgery on gestational day 23. A left diaphragmatic hernia was created in one end fetus (DH group) of each rabbit, and the other end fetus of the same rabbit received sham thoracotomy as control (CR group). Another 19 pregnant rabbits underwent partial resection of the diaphragm in both end fetuses on gestational day 23, and then artificial gastroschisis was performed on one end fetus (GS group) on gestational day 26, while the other end remained as control (CGS group). The fetuses were harvested on gestational day 30. The histological and morphometric evaluation of lungs and livers of the end fetuses in each group was conducted. Results In the DH group, the lungs were hypoplastic with a decrease in the total lung weight to body weight ratio, and remarkable thickening in alveolar septa. The lung vessels showed significantly thicker arterial walls when compared with those from control fetuses. The pathological finding in the CGS group was similar to that of the DH group. The thickness of the alveolar septa and of the pulmonary arterial walls showed no significant difference among the GS group, DH group and the CGS group. The ratio of liver weight to body weight increased notably in the GS group, DH group and CGS group compared with that in the CR group. Conclusions In the fetal rabbit models of CDH, pulmonary hypoplasia is the most significant pathological feature. Iatrogenic gastroschisis does not improve pulmonary maturation due to the active growth of the liver that herniates into the thoracic cavity. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2384-0Authors Gong Chen, FUDAN University Shanghai ChinaShan Zheng, FUDAN University Shanghai ChinaXian Min Xiao, FUDAN University Shanghai ChinaYi Luo, FUDAN University Shanghai China Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Traumatic diaphragmatic injuries in children: do they really mark the severity of injury? Our experience

Abstract Purpose Diaphragmatic injuries have been reported to be a predictor of serious associated injuries in trauma and a marker of severity. Because of its rarity in children, the diagnosis is often delayed for months and years, due to overshadowing injuries. Perhaps due to the elasticity of their tissues, traumatic diaphragmatic rupture is uncommon in children. The problem remains a challenging clinical entity and the description of such type of injuries in children remains scarce in the literature. Most of the cases are described along with associated injuries; presence of isolated diaphragmatic injuries in children is unusual. The present study highlights the presentation, diagnosis and management of all of the cases admitted with traumatic diaphragmatic injuries in a single pediatric surgical center. Methods We retrospectively studied eight children admitted to our center with a diagnosis of diaphragmatic injury following trauma during a period of 5 years (2003–2008). Relevant information regarding the mode and pattern of injuries were noted in all cases. Type of injury and surgical intervention and outcome of patients were evaluated. Results Mean age of presentation was 6.8 years (range 2–12 years). Seven patients were males, while one patient was female. Seven patients had a history of blunt trauma abdomen some time back. Only one patient had acute presentation with respiratory distress following road traffic accident, rest of the patients had no associated grievous injury at the time of presentation. One patient presented with features of acute obstruction. All patients could be diagnosed preoperatively and surgical intervention was performed in all cases. The patients recovered well and there was no mortality. Conclusion Diaphragmatic injuries in children are rare. They are usually associated with other severe injuries; however, isolated diaphragmatic injuries occur more frequently in children than adults. A high index of clinical suspicion supported by prompt radiological tests is needed to diagnose these injuries in patients who otherwise have no associated grievous injuries. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2403-1Authors Tanvir Roshan Khan, CSMMU (Upgraded KGMC) Department of Pediatric Surgery Lucknow IndiaJiledar Rawat, CSMMU (Upgraded KGMC) Department of Pediatric Surgery Lucknow IndiaMadhukar Maletha, CSMMU (Upgraded KGMC) Department of Pediatric Surgery Lucknow IndiaSarita Singh, CSMMU (Upgraded KGMC) Department of Pediatric Surgery Lucknow IndiaKumar A. Rashid, CSMMU (Upgraded KGMC) Department of Pediatric Surgery Lucknow IndiaAshish Wakhlu, CSMMU (Upgraded KGMC) Department of Pediatric Surgery Lucknow IndiaShiv Narain Kureel, CSMMU (Upgraded KGMC) Department of Pediatric Surgery Lucknow India Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Hirschsprung’s disease: the “Swiss roll” technique revisited

Abstract Purpose During pull-through for Hirschsprung’s disease (HSCR), the assessment of innervation is mainly based on the presence of ganglion cells when conventional Hematoxylin and Eosin (HE) staining is used. In hypoganglionosis, the evaluation is difficult. We adapted a standardized methodology for the examination of resected bowel after HSCR surgery, using the technique described by Moolenbeek on rodent intestine and later by Meier-Ruge in children. We have analysed the entire innervation of surgically resected bowels and compared the results with the follow up of patients. Methods Three longitudinal strips of colon were harvested from the mesenteric, anti-mesenteric and intermediate part in the whole length of resected colon of six patients with HSCR. Each strip was divided into two parts. One of the contiguous strips was assessed with HE and Hematoxylin–Phloxin–Safran, and the other one with acetylcholinesterase (AChE) histochemistry. We analyzed the distribution of ganglion cells and nerve arrangement along the strips with both techniques and compared the results obtained in the three different regions of the bowel. Results There was no significant difference in the pattern of innervation circumferentially. There was a correlation between a progressive increase of AChE activity and nerve hypertrophy and a decrease of ganglion cells from the proximal to the distal part of the resected colon in the submucosa and the myenteric plexus. Nerve hypertrophy and AChE-positive reaction in the mucosa were found at the resection border in patients who presented postoperative complications. Conclusions Simultaneous assessment of nerve cells, nerve fibers and AChE activity is important in the evaluation of the innervation of the bowel segment proximal to the aganglionic zone. The method described is feasible and can be adapted to older children and adults with larger bowels. These results point out the importance of assessing nerve fibers in intraoperative biopsies during pull-through procedures to prevent uncomplete surgical bowel resection. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2395-xAuthors Maria-Chiara Osterheld, Centre Hospitalier Universitaire Vaudois Department of Pathology 1011 Lausanne SwitzerlandKathleen Meagher-Villemure, Centre Hospitalier Universitaire Vaudois Department of Pathology 1011 Lausanne SwitzerlandAna Maria Ciola, Centre Hospitalier Universitaire Vaudois Department of Pathology 1011 Lausanne SwitzerlandPatricia Martin, Centre Hospitalier Universitaire Vaudois Department of Pediatric Surgery 1011 Lausanne SwitzerlandDaniel Vilas, Centre Hospitalier Universitaire Vaudois Department of Pathology 1011 Lausanne SwitzerlandBlaise Julien Meyrat, Centre Hospitalier Universitaire Vaudois Department of Pediatric Surgery 1011 Lausanne Switzerland Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Genetic basis of Hirschsprung’s disease

Abstract Hirschsprung’s disease (HSCR) is a developmental disorder characterized by the absence of ganglion cells in the lower digestive tract. Aganglionosis is attributed to a disorder of the enteric nervous system (ENS) whereby ganglion cells fail to innervate the lower gastrointestinal tract during embryonic development. HSCR is a complex disease that results from the interaction of several genes and manifests with low, sex-dependent penetrance and variability in the length of the aganglionic segment. The genetic complexity observed in HSCR can be conceptually understood in light of the molecular and cellular events that take place during the ENS development. DNA alterations in any of the genes involved in the ENS development may interfere with the colonization process, and represent a primary etiology for HSCR. This review will focus on the genes known to be involved in HSCR pathology, how they interact, and on how technology advances are being employed to uncover the pathological processes underlying this disease. Content Type Journal ArticleCategory Review ArticleDOI 10.1007/s00383-009-2402-2Authors Paul K. H. Tam, Queen Mary Hospital, The University of Hong Kong Division of Paediatric Surgery, Department of Surgery Pok Fu Lam Road Hong Kong People’s Republic of ChinaMercè Garcia-Barceló, The University of Hong Kong Department of Surgery, Li Ka Shing Faculty of Medicine Pok Fu Lam Road Hong Kong People’s Republic of China Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Incidence of indwelling central venous catheter-related complications using the Sri Paran technique for device fixation in children with cancer

Abstract Purpose Mechanical complications in tunneled indwelling central venous catheters (CVCs) often involve a risk of displacement. Fixation procedures are, therefore, of primary importance. We prospectively evaluated the incidence of CVC-related mechanical and infectious complications observed in devices fixated with the Sri Paran technique. Methods All CVCs inserted in children with cancer at our Institution from October 2005 to January 2007 were prospectively monitored for device-related mechanical and infectious complications. The Sri Paran fixation technique was used in all cases. The complication rate per 1,000 days was calculated as 1,000 times the number of complications divided by the total number of catheter days. Results Ninety-five CVCs were positioned in 84 children. The overall length of observation ranged between 41 and 482 days for a total of 18,618 catheter days. Mechanical complications occurred in 5% of the devices (specific rate 0.27); infections were observed in 6% of the devices (specific rate 0.32). No complications were observed during the first 30 days after CVC insertion. Conclusions The results, we obtained with the Sri Paran technique are extremely encouraging. Yet, randomized studies are required to prove these preliminary data. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2400-4Authors G. Fratino, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini 5 16100 Genoa ItalyS. Avanzini, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini 5 16100 Genoa ItalyA. C. Molinari, G. Gaslini Children’s Hospital Hematology and Oncology Department Genoa ItalyP. Buffa, G. Gaslini Children’s Hospital Pediatric Surgery Department Largo G. Gaslini 5 16100 Genoa ItalyE. Castagnola, G. Gaslini Children’s Hospital Infectious Disease Department Genoa ItalyR. Haupt, G. Gaslini Children’s Hospital Epidemiology and Biostatistics Unit-Scientific Directorate Genoa Italy Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Anterior urethral valves in children: an uncommon multipathogenic cause of obstructive uropathy

Abstract Introduction Anterior urethral valves (AUVs) are uncommon congenital anomalies causing urethral obstruction in boys. Patients and methods Medical records of 13 children were reviewed retrospectively. Each patient (pt) was evaluated with voiding cysto-urethrogram (VCUG) and renal ultrasonography. Pts older than 5 years performed an uroflowmetry. Serum creatine was determined in all children. Results All pts had difficulty in voiding and eight had recurrent urinary tract infection. Renal function was normal in all pts. VCUG showed filling of Cowper’s duct in a pt. In a case, a vesicoureteral reflux was discovered. Uroflowmetry showed a flat trace in all cases. Transurethral endoscopic resection of the valves was carried out in 11 children while open resection was necessary in two children. At serial follow-up, all pts remain symptom-free and uroflowmetry documented regular pattern. Discussion Anterior urethral valves are rare lesions that may create problems at different stages. Some AUVs may result from the obstruction distal lip of a ruptured syringocele. Improvements in endoscopic equipment allow for minimally invasive transurethral resection. Large diverticula are best managed with open diverticulectomy and reconstruction. In newborns with severe altered urinary tract drainage, particularly in low birth-weight infant, a vesicostomy may be necessary. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2393-zAuthors Salvatore Arena, University of Catania Unit of Pediatric Surgery, Department of Pediatric Surgery Catania ItalyCarmelo Romeo, University of Messina Unit of Pediatric Surgery, Department of Medical and Surgical Pediatric Sciences Policlinico, Viale Gazzi 98125 Messina ItalyFrancesca Astra Borruto, University of Messina Unit of Pediatric Surgery, Department of Medical and Surgical Pediatric Sciences Policlinico, Viale Gazzi 98125 Messina ItalySergio Racchiusa, University of Messina Unit of Radiology, Department of Radiology Messina ItalyVincenzo Di Benedetto, University of Catania Unit of Pediatric Surgery, Department of Pediatric Surgery Catania ItalyFrancesco Arena, University of Messina Unit of Pediatric Surgery, Department of Medical and Surgical Pediatric Sciences Policlinico, Viale Gazzi 98125 Messina Italy Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Omphalocele minor associated with complete absence of the large bowel

Abstract Colonic atresia, unlike small intestine atresia, is a rare congenital malformation. Congenital absence of the entire colon is exceptionally rare. Moreover, an association of omphalocele and complete absence of the colon has not yet been reported in the literature. We present an infant born with such combination of congenital anomalies. Content Type Journal ArticleCategory Case ReportDOI 10.1007/s00383-009-2397-8Authors Atakelet Ferede, Our Lady’s Children’s Hospital Crumlin IrelandFarhan Tareen, Our Lady’s Children’s Hospital Crumlin IrelandJohn Gillick, Our Lady’s Children’s Hospital Crumlin Ireland Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Management of colonic atresia with primary resection and anastomosis

Abstract Purpose Historically, the majority of patients with colonic atresia have been managed by ostomy creation at the time of initial operation; conversely, we have tended to treat the atresia with resection and anastomosis. The purpose of this study is to determine the rate of concomitant Hirschsprung’s disease and to identify potential morbidity associated with primary repair. Methods After IRB approval (#105825), charts of patients identified by ICD-9 code as having colonic atresia, who were admitted to our institution between 1993 and 2008 were, retrospectively, reviewed. Particular attention was paid to demographic data, comorbidities, operative therapy, and complications. Continuous variables were compared using an unpaired t test. A P value of <0.05 was considered significant. Results Twelve newborns with colonic atresia were identified. Two babies were managed initially with ostomy, both of whom had gastroschisis; primary repair was performed on ten, with two undergoing simultaneous rectal biopsy. No anastomotic complications occurred and there were no mortalities. One patient experienced self-limited malabsorption symptoms after repair. No cases of Hirschsprung’s disease were detected. Conclusions Uncomplicated colonic atresia can be managed by primary repair with little morbidity. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2401-3Authors Melvin Dassinger, Arkansas Children’s Hospital Little Rock USARichard Jackson, Arkansas Children’s Hospital Little Rock USASamuel Smith, Arkansas Children’s Hospital Little Rock USA Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Experience with laparoscopy-assisted retroperitoneal pyeloplasty in children

Abstract Purpose To describe a laparoscopy-assisted retroperitoneal pyeloplasty (LARP) and results of initial experience. Methods Port placement used by Farhat in retroperitoneal-assisted laparoscopic pyeloplasty was modified for better cosmetic results. Surgery was done using 2-cm incision for 5-mm camera port and two 3-mm working ports. Dissection was done anterior to the kidney. The ureteropelvic junction was brought out through the 2-cm trocar site and the pyeloplasty was performed extracorporeally. Between January 2004 and February 2008, a total of 39 kidneys in 38 children with mean age of 4.1 months underwent LARP. The operative time, hospital stay, functional outcome and follow-up renogram studies were reviewed. Results The mean operative time was 147 min. 2-cm incision was extended in one patient with malrotated kidney. There was improvement in function in 37 (95%) with no failure. The mean split renal function, preoperative and at follow-up were 35.7 and 44.2%, respectively (P = 0.000). The mean glomerular filtration rate (ml/min), preoperative and at follow-up were 27.4 and 39.1%, respectively (P = 0.000). Mean follow-up period was 24 months. Conclusion LARP is safe in treating UPJ obstruction in infants. It is recommended especially in small babies where laparoscopic pyeloplasty is difficult. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2394-yAuthors Mohan K. Abraham, Amrita Institute of Medical Sciences and Research Centre Department of Pediatric Surgery Amrita Lane, Elamakkara P.O. Kochi IndiaAbdul Rasheed A. Nasir, Amrita Institute of Medical Sciences and Research Centre Department of Pediatric Surgery Amrita Lane, Elamakkara P.O. Kochi IndiaS. Bindu, Amrita Institute of Medical Sciences and Research Centre Department of Pediatric Surgery Amrita Lane, Elamakkara P.O. Kochi IndiaP. Ramakrishnan, Amrita Institute of Medical Sciences and Research Centre Department of Pediatric Surgery Amrita Lane, Elamakkara P.O. Kochi IndiaPrashant M. Kedari, Amrita Institute of Medical Sciences and Research Centre Department of Pediatric Surgery Amrita Lane, Elamakkara P.O. Kochi IndiaGopidas R. Unnithan, Amrita Institute of Medical Sciences and Research Centre Department of Pediatric Surgery Amrita Lane, Elamakkara P.O. Kochi IndiaKalyan Ravi Prasad Damisetti, Amrita Institute of Medical Sciences and Research Centre Department of Pediatric Surgery Amrita Lane, Elamakkara P.O. Kochi India Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Usefulness of large pleural flap for the treatment of children with recurrent tracheoesophageal fistula

Abstract Purpose Recurrent tracheoesophageal fistula (RTF) complicates 5–11% of cases of children treated at birth for esophageal atresia with inferior tracheoesophageal fistula (ITF), and it represents an important problem of respiratory morbility and mortality. Surgical correction of RTF is complex with high incidence of recurrence. The aim of this work is to demonstrate the usefulness of large vascularized pleural flap in the treatment of RTF and the prevention of recurrences. Methods From 2000 to 2007, four children (3 males and 1 female) referred to our hospital for respiratory symptoms secondary to RTF. Diagnosis of RTF was made by bronchoscopy and esophagogram with contrast medium. Operative repair involved resection of the fistula, suture of trachea and esophagus followed by interposition of large vascularized pleural flap (PF). Results There were no complications during surgical procedure and after 48 h, with easy respiratory weaning after 24 h. Hospital discharge ranged from 5 to 10 days. Long-term follow-up (range 18 months–5 years) demonstrated no evidence of recurrences. Conclusion Large vascularized PF to closure RTF is a highly effective and physiologic method for preventing second recurrences. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2399-6Authors Vito Briganti, UOC di Chirurgia Pediatrica, Azienda Ospedaliera “S. Camillo-Forlanini” via Cicerone 60 00193 Rome ItalyGiovanni Mangia, Azienda Ospedaliera “S. Camillo-Forlanini” Dipartimento di Anestesia Generale Rome ItalyPasquale Ialongo, Azienda Ospedaliera “S. Camillo-Forlanini” Dipartimento di Radiologia Generale Rome ItalyAlessandro Calisti, UOC di Chirurgia Pediatrica, Azienda Ospedaliera “S. Camillo-Forlanini” via Cicerone 60 00193 Rome Italy Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Conservative approach to the treatment of injured liver and spleen in children: association with reduced mortality

Abstract Background Previous analyses of the safety of the conservative versus the operative approach to the treatment of liver and spleen blunt injuries in children often failed to account for differences in quality of care and expertise among dedicated pediatric trauma center, non-pediatric centers, centers without trauma units, and non-trauma centers. To eliminate this potential bias, the present study examined changes in the rate of surgery and their impact on outcome within the same medical centers over time. Methods The Israel Trauma Registry was searched for patients <18 years who were treated for non-penetrating liver or spleen injuries from 1998 to 2004. Patients were grouped by period, 1998–2000 and 2001–2004, and compared for type of injury, severity of injury, type of treatment, and inpatient mortality. Results The earlier period (1998–2000) was characterized by a significantly higher rate of operations compared with the later period (2001–2004) (P = 0.001) and higher in-hospital mortality (P = 0.04). Injury severity scores, type of organs injured, and accompanying injuries were similarly distributed in the two groups. Conclusions Despite the similarity in the severity and characteristics of the intraabdominal injuries in 1998–2000 and in 2001–2004, the proportion of children treated conservatively increased over time, concomitant with a significant drop in inpatient mortality. We attribute this shift over a relatively short interval to increased experience and greater acceptance of conservative management in this setting. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2398-7Authors Elad Feigin, Schneider Children’s Medical Center of Israel Department of Pediatric Surgery 49202 Petah Tiqwa IsraelLimor Aharonson-Daniel, Sheba Medical Center Israel National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research Tel Hashomer IsraelBela Savitsky, Sheba Medical Center Israel National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research Tel Hashomer IsraelRan Steinberg, Schneider Children’s Medical Center of Israel Department of Pediatric Surgery 49202 Petah Tiqwa IsraelDragan Kravarusic, Schneider Children’s Medical Center of Israel Department of Pediatric Surgery 49202 Petah Tiqwa IsraelMichael Stein, Rabin Medical Center Trauma Unit Petah Tiqwa IsraelKobi Peleg, Sheba Medical Center Israel National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research Tel Hashomer IsraelEnrique Freud, Schneider Children’s Medical Center of Israel Department of Pediatric Surgery 49202 Petah Tiqwa Israel Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Ovarian autoamputation in a neonate: a case report with literature review

Abstract A case of ovarian autoamputation in an asymptomatic neonate is presented. An abdominal cyst was detected in a 30-week-gestation fetus on an antenatal ultrasound scan (USS). Postnatal USS confirmed the presence of a cyst in the right pelvis and revealed it to be 3.2 cm in diameter. CT and MRI revealed cyst wall calcification and intracystic hemorrhage. To confirm the diagnosis and treatment, the cyst was surgically removed. During the operation, a free autoamputated right ovarian cyst was found and removed from the abdomen. Ovarian cyst autoamputation is an extremely rare complication. In this article, we review the infantile ovarian autoamputation cases reported in the literature and assess their diagnosis and therapeutic management. Content Type Journal ArticleCategory Case ReportDOI 10.1007/s00383-009-2396-9Authors Yuhki Koike, Mie University Graduate School of Medicine Department of Gastrointestinal and Pediatric Surgery Edobashi 2-174 Tsu Mie 514-8507 JapanMikihiro Inoue, Mie University Graduate School of Medicine Department of Gastrointestinal and Pediatric Surgery Edobashi 2-174 Tsu Mie 514-8507 JapanKeiichi Uchida, Mie University Graduate School of Medicine Department of Gastrointestinal and Pediatric Surgery Edobashi 2-174 Tsu Mie 514-8507 JapanAya Kawamoto, Mie University Graduate School of Medicine Department of Gastrointestinal and Pediatric Surgery Edobashi 2-174 Tsu Mie 514-8507 JapanHiromi Yasuda, Mie University Graduate School of Medicine Department of Gastrointestinal and Pediatric Surgery Edobashi 2-174 Tsu Mie 514-8507 JapanYoshinaga Okugawa, Mie University Graduate School of Medicine Department of Gastrointestinal and Pediatric Surgery Edobashi 2-174 Tsu Mie 514-8507 JapanKohei Otake, Mie University Graduate School of Medicine Department of Gastrointestinal and Pediatric Surgery Edobashi 2-174 Tsu Mie 514-8507 JapanMasato Kusunoki, Mie University Graduate School of Medicine Department of Gastrointestinal and Pediatric Surgery Edobashi 2-174 Tsu Mie 514-8507 Japan Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Pyeloplasty in children: is there a difference in patients with or without crossing lower pole vessel?

Abstract Introduction Most of the children with hydronephrosis do not require any surgical intervention. However, in individual cases, irreversible loss of renal function can develop. Predictive criteria have been proven ineffective so far in determining in which children obstruction will lead to renal damage. The aim of our retrospective study was to determine the role of a crossing lower pole vessel (CV) in children undergoing pyeloplasty. Materials and methods Between 1996 and 2003, 137 patients (age between 6 weeks and 16 years) with unilateral ureteropelvic junction obstruction and no associated urological pathologies underwent Anderson–Hynes dismembered pyeloplasty. A total of 112 patients were evaluated with complete data. One of the following criteria was considered to be indication for surgery in children with grade 4 hydronephrosis: differential renal function (DRF) <40%; clinical symptoms such as pyolenephritis and flank pain; during follow-up renographies, a reduction of DRF >10% and washout patterns II or III b according to O’Reilly. We looked at the age during surgery and the kind of presentation. DRF was measured using diuretic renography preoperatively and 1 year postoperatively. A postoperative change in DRF of group A (children without CV, n = 84) was compared to that in group B (children with CV, n = 28). Results Median age at the time of surgery was 5 months in group A compared to 23 months in group B. Only in 21.4% of the children with CV compared to 60.7% without CV hydronephrosis was diagnosed by ultrasound examination antenatally. We found a preoperative DRF of 42.4% ± 11.2 SD in group A, and of 38.9% ± 11.7 SD in group B. The percentage of postoperative improvement was 3.3% in group A and 15.4% in group B. Conclusions Children with ureteropelvic junction obstruction and CV received a delayed surgical treatment and showed a greater reduction in differential renal function preoperatively, in contrast to patients without CV. Our data show that CV is a risk factor for deterioration of renal function in children with hydronephrosis and we advocate for an early pyeloplasty in these children, especially if they have a high-grade dilatation and equivocal washout patterns in diuretic renographies. Further prospective studies are necessary in order to understand the natural history of CV and to reveal the importance of the crossing lower pole vessel as a structural anomaly lacking maturation. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2385-zAuthors Hans-Walter Hacker, Universitaetsklinik für Kinder- und Jugendmedizin Abteilung für Kinderchirurgie 72076 Tübingen GermanyPhilipp Szavay, Universitaetsklinik für Kinder- und Jugendmedizin Abteilung für Kinderchirurgie 72076 Tübingen GermanyHelmut Dittmann, Universitaetskliniksklinikum Tuebingen Department of Nuclear Medicine Hoppe-Seyler-Str.3 72076 Tübingen GermanyHans-P. Haber, Universitaetsklinik für Kinder- und Jugendmedizin Department of Pediatrics I Hoppe-Seyler-Str.3 72076 Tübingen GermanyJoerg Fuchs, Universitaetsklinik für Kinder- und Jugendmedizin Abteilung für Kinderchirurgie 72076 Tübingen Germany Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Continuous lumbar/thoracic epidural analgesia in low-weight paediatric surgical patients: practical aspects and pitfalls

Abstract Purpose Continuous epidural anaesthesia attenuates perioperative stress and avoids the need for systemic opioids. In addition, it may prevent the need for postoperative mechanical ventilation. The aim of the study was to prospectively follow the perioperative course of young infants treated with continuous thoracic/lumbar epidural anaesthesia for major surgery. Methods Data were collected prospectively from 44 epidural anaesthetics in 40 infants (18 premature or former premature) weighing 1,400–4,300 g who underwent major abdominal surgery (33 cases), thoracic surgery (5), or both (1), or ano-rectal surgery (5) at our centre. Results Epidural placement was achieved easily in all cases, with high quality analgesia for 24–96 h. Tracheal extubation was delayed after 4 anaesthetics due to muscle relaxant overdose (n = 1), surgeon’s request (n = 2), and systemic opioid administration before epidural anaesthesia was considered (n = 1). Intraoperative complications included haemodynamic instability (n = 1) and vascular catheter placement (n = 5). Postoperative complications included meningitis (n = 1), insertion site erythema (n = 7), apnoea (n = 6; 4 premature and 2 full-term infants) and tracheal re-intubation (n = 6). Conclusions Continuous epidural analgesia is effective in low-weight infants undergoing major surgery. The trachea may be extubated immediately after surgery. Attention should be paid to the unique anatomical, physiological, and pharmacological aspects. The patients should be monitored carefully for pain, respiratory failure, and meningitis (an extremely rare complication). Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00383-009-2386-yAuthors Ze’ev Shenkman, Sheba Medical Center Department of Anesthesia 52561 Tel Hashomer IsraelDavid Hoppenstein, Sapir Medical Center, Me’ir Hospital Department of Anesthesia and Critical Care Medicine Kfar Saba IsraelIlan Erez, Sapir Medical Center, Me’ir Hospital Department of Pediatric Surgery Kfar Saba IsraelTzipora Dolfin, Sapir Medical Center, Me’ir Hospital Department of Neonatology Kfar Saba IsraelEnrique Freud, Schneider Children’s Medical Center of Israel Department of Surgery Petach Tikva Israel Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009

Colonic transit studies: normal values for adults and children with comparison of radiological and scintigraphic methods

Abstract The sitz or plastic marker study for colonic transit has been around for many years. It is applicable where an X-ray machine exists, is widely used and is accepted as the gold standard for diagnosing constipation. Recently, radiopharmaceutical methods have been developed. The theme of this review is their possible roles in the assessment of paediatric bowel motility disorders in patients presenting to paediatric surgeons. This review presents data on total and segmental transit in normal adults and children and comparing the two techniques in adults. Reliability and reproducibility are presented. Normative data for colonic transit in adults and children are discussed and parameters for assessing abnormal transit are reviewed. Normal colonic transit takes 20–56 h. Plastic marker studies are more readily accessible, but the assessment may be misleading with current methods. Plastic markers show faster transit than scintigraphy. It is difficult to compare the two techniques because methods of reporting are different. Using scintigraphy, repeatability is good. Separation of normal from slow transit in the ascending colon is apparent at 24 and 48 h, but the determination of transit through the distal colon/rectum in adults may require studies of more than 7 days. In conclusion, plastic marker studies and scintigraphy show similar transit rates in young adults and children. However, scintigraphy has advantages of allowing transit through the stomach and small intestine to be measured and has proved useful in the diagnostic workup of children with intractable constipation. Content Type Journal ArticleCategory Review ArticleDOI 10.1007/s00383-009-2387-xAuthors Bridget R. Southwell, Murdoch Children’s Research Institute, Royal Children’s Hospital Surgical Research Group, Gut Motility Laboratory Parkville VIC 3052 AustraliaMelanie C. C. Clarke, Murdoch Children’s Research Institute, Royal Children’s Hospital Surgical Research Group, Gut Motility Laboratory Parkville VIC 3052 AustraliaJonathan Sutcliffe, Murdoch Children’s Research Institute, Royal Children’s Hospital Surgical Research Group, Gut Motility Laboratory Parkville VIC 3052 AustraliaJohn M. Hutson, Murdoch Children’s Research Institute, Royal Children’s Hospital Surgical Research Group, Gut Motility Laboratory Parkville VIC 3052 Australia Journal Pediatric Surgery InternationalOnline ISSN 1437-9813Print ISSN 0179-0358 Journal Volume Volume 25 Journal Issue Volume 25, Number 7 / July, 2009