The use of peritoneal venous shunting for intractable neonatal ascites: a short case series

Introduction

Intractable ascites in neonates has a varied etiology; and often, the cause is idiopathic. The management usually consists of observation, diuretics, paracentesis, albumin replacements, and self correction. However, in some cases, the above treatment remains unsuccessful.

Results

We present 2 cases of intractable ascites causing metabolic abnormalities, severe protein and immunoglobulin loss, and respiratory compromise. Although the use of peritoneovenous shunts for intractable ascites has been reported previously, our cases differ in both technique and patient size. Our first patient is an ex-28-week premature, 1.4-kg infant with intractable ascites for which a peritoneal drain was initially placed. After 3 weeks and putting out nearly 300 mL of ascitic fluid daily, we placed a peritoneal venous shunt attached to a Medtronic pump. A 6.6F Broviac was placed through the Internal Jugular. The Medtronic pump was placed subcutaneously on the right chest. The pump was compressed 5 to 10 times every 8 hours, keeping fluid actively being infused from the belly to the vascular system. The second patient was 5 months old, 2.8 kg, with a course complicated by necrotizing enterocolitis, prolonged total parenteral nutrition, and progressive liver failure and underwent the same procedure. Both patients had dramatic responses to the shunting postoperatively, with clinical, radiographic, and laboratory evidence of resolution of the ascites. The first patient had the shunt removed at 6 months of age and continues to do well, whereas our second patient had no recurrence of the ascites, but died about 1 year later from cardiopulmonary complications.

Conclusion

These 2 cases demonstrate that peritoneovenous shunting, with the assistance of a Medtronic pump, is an effective treatment of intractable neonatal ascites and should be considered early in the course before complications develop.     

Pressure-limited vesico-amniotic shunt tube for fetal obstructive uropathy

Introduction

In utero shunting (vesico-amniotic shunt) of obstructive uropathy in fetal lambs produces a shrunken, noncompliant bladder. We hypothesized that using a ventriculo-peritoneal shunt for the vesico-amniotic shunt may preserve the filling/emptying cycle and thus normal bladder development.

Materials and Methods

We created obstructive uropathy in 60-day gestation fetal lambs, ligating the urethra and urachus. Vesico-amniotic shunting was performed 21 days later using the valve end of a ventriculo-peritoneal shunt (valve shunt) or silastic tubing (nonvalve shunt). They were delivered at term (145 days), and the bladder volume was measured and compared to normal term fetuses. The lambs were sacrificed, and the kidneys and bladder removed for histology.

Results

Twenty-seven lambs were shunted. Of 14 valve shunts, 8 were effective. Of 13 nonvalve shunts, 11 were effective. The mean bladder volume was 57 ± 41 mL with a valve shunt and 8.8 ± 4.7 mL with a nonvalve shunt (P < .05) (normal term lambs, 65 ± 18 mL, n = 5). Histology of the shunted bladders showed increased fibrosis in the submucosal and muscle layers. This was less obvious in lambs with a valve shunt.

Conclusion

A pressure controlled shunt for fetal obstructive uropathy improves bladder volume but does not prevent bladder wall fibrosis.     

Posttransplantation portal thrombosis secondary to splenorenal shunt persistence

Purpose

The aim of this study was to analyze our experience with portal vein thrombosis after liver transplantation with a persistent splenorenal shunt.

Materials and methods

The study population included 780 liver transplantations from 1990 to 2009. We analyzed the existence of portal vein thrombosis in the immediate posttransplant period, selecting cases with a persistent splenorenal shunt requiring surgery.

Results

The incidence of posttransplant portal vein thrombosis was 1.41% (n = 11), of which 3 (27%) had a splenorenal shunt as a possible cause (0.38% of the total). Two cases required liver retransplantation due to portal vein thrombosis, and the third a thrombectomy. In all cases the shunt was also closed. During the early postoperative follow-up of these 3 patients, 2 needed repeat surgeries because of a new portal vein thrombosis (thrombectomy) in one and a bilioperitoneum in the other. After a median follow-up of 11 months, the patients showed a good evolution with no primary graft dysfunction.

Discussion

The portal steal phenomenon secondary to persistence of a splenorenal shunt promotes the occurrence of portal vein thrombosis. Although it is a rare cause of graft dysfunction, it must be treated early, because it can lead to a small-for-size syndrome.     

The ex utero intrapartum therapy procedure for high-risk fetal lung lesions

Background

Indications for the ex utero intrapartum therapy (EXIT) procedure have expanded to include any fetal anomaly in which resuscitation of the neonate may be compromised.

Methods

We reviewed the medical records of 9 patients after resection of lung lesions during the EXIT procedure.

Results

The mean gestational age at EXIT procedure was 35.4 weeks. All lung masses maintained large sizes late into gestation with mean mass volume/head circumference ratio of 2.5 at presentation and 2.2 at EXIT. Seven of 9 fetuses demonstrated hydropic changes (n = 6) and/or polyhydramnios (n = 5), and underwent prenatal intervention including thoracentesis, thoracoamniotic shunt placement, amnioreduction, and/or betamethasone administration. Overall survival after EXIT for lung mass resection was 89%. The average time on placental bypass was 65 minutes. Postnatal complications included reoperation for air leak (n = 1), reoperation for bleeding (n = 1), and death from sepsis and prematurity (n = 1). Venoarterial extracorporeal membrane oxygenation was used in 4 neonates for persistent pulmonary hypertension. Maternal prenatal complications included polyhydramnios (n = 5), preterm labor (n = 4), and chorioamnionitis (n = 1). One mother required perioperative blood transfusion.

Conclusion

The EXIT procedure allows for controlled resection of large fetal lung lesions at delivery, avoiding acute respiratory decompensation related to mediastinal shift, air trapping, and compression of normal lung.     

The use of laparoscopy in ventriculoperitoneal shunt revisions

Introduction

Ventriculoperitoneal shunts (VPSs) are routinely placed in children with hydrocephalus. However, they often encounter problems, and revisions are frequent. We sought to evaluate our institutional experience with laparoscopic-assisted VPS revisions.

Methods

With institutional review board approval, a retrospective chart review of 17 consecutive patients who underwent 19 laparoscopic-assisted VPS revisions was conducted. Data extracted included patient demographics, indications for laparoscopic-assisted revision, complications, and shunt outcomes.

Results

The median age at revision was 12 years (0.4-20 years). Ten children (58.8%) had 2 or more previous VPS revisions. Indications for laparoscopic revision included adhesive obstruction, broken shunt retrieval, cerebrospinal fluid pseudocyst, diagnostic laparoscopy, and conversion from ventriculoatrial shunt to VPS. Three patients required repeat VPS revision for distal shunt failure, whereas 2 patients required repeat VPS revision for proximal dysfunction. Failures occurred 5 to 258 days after laparoscopic-assisted revision. Median follow-up was 21 weeks (interquartile range, 6-57 weeks). No patients developed abdominal infections postoperatively.

Conclusion

Laparoscopy is useful in select patients with distal VPS failure. Patients with multiple previous revisions, prior abdominal surgery, previous intraperitoneal infections, broken devices, or cerebrospinal fluid pseudocysts may benefit from this approach. Further prospective studies with long-term follow-up are needed to determine which patients benefit most from the laparoscopic-assisted approach.     

Prenatal urinary matrix metalloproteinase profiling as a potential diagnostic tool in fetal obstructive uropathy

Background/Purpose

The diagnostic evaluation, patient stratification, and prenatal counseling for congenital obstructive uropathy remain sub-optimal. Matrix metalloproteinase (MMP) expression profiles are emerging as a valuable diagnostic tool in assorted disease processes. We sought to determine whether congenital obstructive uropathy impacts MMP expression in fetal urine.

Methods

Fetal lambs (n = 25) were divided in two groups: group I (n = 12) underwent a sham operation and group II (n = 13) underwent creation of a complete urinary tract obstruction. Gelatin zymography panels for 4 MMP species were performed on fetal urine in both groups at comparable times post-operatively. Statistical analysis was by the Fisher's exact test (P < .05).

Results

Overall fetal survival was 80% (20/25). A variety of significant differences in MMP expression between the two groups were identified. The following profiles were present only in obstructed animals: any MMP other than MMP-2 (P = .029), including any MMP other than 63 kDa and 65 kDa (P = .009); 2 or more MMPs excluding MMP-2s (0.029); and 3 or more MMPs (P = .029).

Conclusions

Limited matrix metalloproteinase expression is present in the urine of normal ovine fetuses. Fetal obstructive uropathy impacts urinary MMP expression in various distinguishable patterns. Prenatal urinary MMP profiling may become a practical and valuable diagnostic tool in the evaluation of congenital obstructive uropathy.     

Infectious risk to ventriculo-peritoneal shunts from gastrointestinal surgery in the pediatric population

Purpose

The infectious implication of abdominal surgeries on ventriculo-peritoneal (VP) shunts, including simultaneous shunt placement and management of shunt infections, has been ill defined in children.

Methods

We conducted a 9-year retrospective review of pediatric patients with VP shunts who underwent abdominal surgeries.

Results

Forty-two patients fit criteria. The median age at shunt placement was 1.75 years, and the median time between shunt placement and abdominal surgery was 24 days. The most common procedures included gastrostomy (17), fundoplication (15), and appendectomy (3). Seven patients had simultaneous abdominal surgery and shunt placement. All patients received preoperative antibiotics. Two children developed shunt infections, both occurred after appendectomy. Both were treated with antibiotics, with one requiring shunt removal. Median length of stay was 24 days but 28 days for those with infections. Thirty-eight patients were discharged home, 3 to chronic care facilities, and 1 died.

Conclusions

Infections did not occur in children with VP shunts undergoing elective abdominal procedures or procedures simultaneously with shunt insertion. Infections were seen only with emergent appendectomies, suggesting that performing gastrointestinal procedures at the time of VP shunt insertion is safe. Children with VP shunts undergoing emergent surgery for peritoneal infection warrant close observation for shunt infection.     

Effects of early vesicostomy in obstructive uropathy on bladder development

Purpose

Creation of a vesico-amniotic shunt for obstructive uropathy removes the normal fetal urination cycle. It is unclear how this affects bladder function at term. The authors measured the bladder volume and reviewed the bladder histology after fetal vesicostomy.

Methods

The authors created an obstructive uropathy in fetal lambs at 60 days’ gestation by ligating the urethra and urachus. Vesicostomy (female) or urethrostomy (male) were performed 21 days after obstruction to release the obstruction. The fetuses were killed at term (145 days).

Results

Thirteen fetuses were shunted. Seven fetuses miscarried after shunting. Six survived, and 3 had a successful shunt with a very small bladder (5 to 7 mL). Two had incomplete shunts that failed some time after shunting. These both had huge bladders (399 mL). In one, the obstruction was unsuccessful. Histologic examination showed that the obstruction caused bladder muscle hypertrophy. Shunted lambs had severe fibrosis of the bladder wall and very poor bladder compliance.

Conclusions

Shunt operations after obstructive uropathy may salvage the kidney but fail to preserve bladder function. The fetus needs a normal urination cycle for normal bladder development. This requirement exists even when the obstruction is successfully bypassed.     

Role of transanal endorectal pull-through in complicated Hirschsprung's disease: experience in 18 patients

Background/Purpose

In Hirschsprung's disease (HD) redo pull-through (PT) is indicated for anastomotic complications and for persistent aganglionosis after previous definitive surgery. This study was undertaken to evaluate the role of transanal approach to redo PT procedure in the management of complicated cases of HD over the last 7 years.

Patients and Methods

Between November 1998 and September 2005, 225 patients with HD were operated using the transanal endorectal PT (TEPT) approach. Eighteen patients had a redo PT owing to persistent aganglionosis.The present study evaluates the role of TEPT approach in patients with persistent aganglionosis (n = 18). Three patients needed a colostomy (n = 2) or ileostomy (n = 1) before the final operation. All the 18 patients underwent transanal mobilization (TEPT) of the colon. Six patients required additional mobilization of the proximal colon (n = 4) and the ileum (n = 2) during the redo PT operation.

Results

Median follow-up was 43 months (range, 3-72 months). Sixteen patients have had a good outcome with stool pattern 1 to 4 times daily. One patient had obstructive symptoms for 4 months postoperatively but then settled. One patient has occasional soiling.

Conclusions

In this series, TEPT and posterior midline split of the muscle cuff were used with good results. This has the advantage of avoiding injury to the pelvic muscles and nerves. The TEPT approach is combined with transabdominal mobilization of the intestine depending on the length of the aganglionic segment. The outcome has been favorable, but long-term follow-up is necessary for full assessment of those patients.     

Retrieval of immature oocytes from unstimulated ovaries followed by in vitro maturation and vitrification: A novel strategy of fertility preservation for breast cancer patients

Background

We report a novel fertility preservation strategy that may be useful for young breast cancer patients who present with time constraints or concerns about the effect of ovarian stimulation.

Methods

The protocol involves retrieval of immature oocyte from unstimulated ovaries followed by in vitro maturation (IVM), and vitrification of oocytes or embryos.

Results

Thirty-eight patients (age 24-45 years) underwent vitrification of oocytes (n = 18) or embryos (n = 20). The mean ages were 33.1 ± 5.0 years and 34.7 ± 4.8 years, respectively. The mean days required to complete the egg collection was 13 days. The median numbers of vitrified oocytes and embryos per retrieval were 7 (range 1-22) and 4 (range 1-13), respectively.

Conclusions

The strategy of immature oocyte retrieval without ovarian stimulation followed by IVM and oocyte or embryo vitrification, which does not increase the serum estradiol level and delay cancer treatment, represents an attractive option of fertility preservation for many breast cancer patients.     

Urethroplasty for strictures after phallic reconstruction: a single-institution experience

Background

Treatment recommendations for strictures after phalloplasty are lacking.

Objective

Our aim was to evaluate the outcome of urethroplasty for strictures after phalloplasty and to provide treatment recommendations based on this experience.

Design, setting, and participants

One hundred and eighteen urethroplasties were performed in 79 patients. Mean patient age was 37.6 yr. Mean follow-up was 39 mo.

Intervention

Different types of urethroplasty were used: meatotomy, Heineke-Mikulicz principle (HMP), excision and primary anastomosis (EPA), free graft urethroplasty (FGU), pedicled flap urethroplasty (PFU), two-stage urethroplasty (TSU), and perineostomy followed by urethral reconstruction (PUR).

Measurements

Stricture recurrence was defined as the need for additional instrumentation or surgery.

Results and limitations

Mean stricture length was 3.6 cm. Stricture location was at the meatus, phallic urethra, anastomosis, fixed part, and different locations in 18, 28, 48, 15, and 9 urethroplasties, respectively. Stricture recurrence was observed in 44 urethroplasties (41.12%). Stricture recurrence rate for meatotomy, HMP, EPA, FGU, PFU, TSU, and PUR was 25%, 42.11%, 42.86%, 50%, 40%, 30.3%, and 61.9%, respectively.

Conclusions

The main stricture location after phalloplasty is the anastomosis between the phallic and the fixed part. Urethroplasty for strictures after phalloplasty is associated with a relatively high recurrence rate.

Trial registration

EC UZG 2007/434.     

Long-term outcome in patients with prenatally diagnosed cystic lung disease: special reference to ventilation and perfusion scan in the affected lung

Background/Purpose

The natural history of cystic lung disease (CLD) such as congenital cystic adenomatoid malformation (CCAM) and pulmonary sequestration has been altered by the advent of prenatal diagnosis. Although recent advances including fetal therapy have gradually improved outcome, the long-term course and the function of the residual lung have not been well clarified.

Methods

Twenty-two patients with CLD who had been prenatally diagnosed and treated between 1990 and 2004 were reviewed. The clinical outcome and growth measurements were established, and, where possible, all infants underwent ventilation and perfusion lung scan.

Results

Mediastinal shift was present in 14 fetuses. Fetal hydrops was present in 5 fetuses. Antenatal intervention was performed for hydrops in 2 fetuses (cyst-amniotic shunt and aspiration). Twenty-one infants underwent appropriate excisional surgery. Final diagnosis included CCAM (n = 12) and pulmonary sequestration (n = 7). No late death was observed. Common complications were failure to thrive (n = 5), frequent respiratory tract infection (n = 4), and asthmatic attack (n = 4). A significant decrease in lung ventilation and perfusion on the affected side was observed in patients with hydrops, lobectomy, and CCAM.

Conclusion

Long-term follow-up including respiratory care and growth assessment should be performed in prenatally diagnosed patients with CLD, especially those who present with hydrops.     

Outcome in Children Bridged and Nonbridged to Cardiac Transplantation

Background

Heart transplantation (HTx) in children with end-stage heart disease has become an accepted treatment option.

Objective

To evaluate our results of pediatric cardiac transplantation with vs without bridge methods.

Patients and Methods

The study included 31 patients (34 transplantations) younger than 18 years who underwent orthotopic HTx between March 1995 and December 2008. Ten patients were girls, and 21 were boys. Preoperative diagnoses included cardiomyopathy (n = 20), congenital heart disease (n = 7), hypertrophic cardiomyopathy (n = 2), restrictive cardiomyopathy (n = 1), and ischemic cardiomyopathy (n = 1). Mean (SD) ischemia time was 185 (72) minutes. Thirty-day mortality was 6%, and was due to primary graft failure (n = 2). Overall follow-up was 4.36 (3.93) years. Eleven patients underwent bridge techniques before HTx, and 11 patients required perioperative extracorporeal membrane oxygenation or ventricular assist device support.

Results

In the group that received extracorporeal membrane oxygenation, 8 patients (73%) were successfully weaned and discharged with excellent functional class. There were no differences in operative mortality, functional class, survival, rejection, and infection rates between the bridged and nonbridged groups. Overall actuarial 1- and 5-year survival rates were 93% and 83%, respectively. All survivors had good functional class.

Conclusion

Our findings demonstrate satisfactory medium-term outcome of HTx in selected pediatric patients with end-stage heart disease. Using bridge methods in children at high risk can increase the opportunity to receive a donor heart. These bridge methods achieve similar postoperative outcomes.     

Portal vascular anomalies in Down syndrome: spectrum of clinical presentation and management approach

Purpose

The occurrence of portal vascular anomalies in Down syndrome has been sporadically reported in the literature. These rare disorders have a wide spectrum of anatomical and clinical presentations. The aim of this communication was to describe the clinical course, imaging features, and management approaches in patients with this association.

Methods

We conducted a comprehensive search of the databases of the Vascular Anomalies Center and the Department of Radiology at Children's Hospital Boston for patients with Down syndrome and portal vascular anomalies. Medical records and imaging studies of varying modalities were reviewed.

Results

Three children with Down syndrome and portal anomalies (portosystemic shunt, simple arterioportal shunt, complex arterioportal shunt) were managed at our institution. The portosystemic shunt was clinically insignificant and resolved without any intervention. The simple arterioportal shunt was successfully treated with embolization. The complex arterioportal shunt was associated with major congenital cardiac defects and the child ultimately expired despite a decrease in the arterioportal shunting after embolization.

Conclusions

Three is a wide spectrum of clinical and anatomical features of portal vascular shunts in Down syndrome. The management approach should be tailored based on the severity of symptoms. Percutaneous embolization can offer a safe, effective, and minimally invasive alternative to the surgical approach in selective cases.     

Growth and nutritional aspects of infantile short bowel syndrome for the past 2 decades

Purpose

The aim of this retrospective study is to describe characteristics of the first year of infantile short bowel syndrome (SBS), with regard to nutritional correlates and growth. Differences in outcome between decade 1980 (1980 to 1990) and decade 1990 (1990 to 2000) were studied.

Methods

Children with infantile SBS, who had been admitted in their first year of life between January 1975 and January 2002, were included. Patient characteristics, duration of parenteral nutrition (PN), type of enteral nutrition, and every quarterly term weight and height for age were collected. Data of decade 1980 and decade 1990 were compared, using appropriate statistical analysis.

Results

Twenty-eight patients were identified for decade 1980 vs 62 patients in decade 1990. Length of stay was significantly shorter in decade 1990 (116 vs 182 days; P = .018). Residual bowel length was not significantly longer in the latter decade (74 cm vs 60 cm; not significant [ns]). Mean weight for age (SD score [SDS]) in the first year of SBS in decade 1980 was significantly lower than in decade 1990 (0.9 SDS; P = .035).

Conclusions

Improved care of patients with SBS and the slightly longer residual bowel length (ns) in decade 1990 resulted in shorter length of stay, shorter duration of PN, and significantly higher SDS for weight for age compared with decade 1980.     

Long-term health condition in major pediatric trauma: a pilot study

Purpose

Major trauma is the leading cause of death in children of developed countries. However, little is known about its long-term health consequences in survivors. Our aim was to describe the health condition in children at long-term after major trauma.

Methods

Prospective cohort study of severely injured children (Injury Severity Score ≥16, age <16) admitted to a Dutch level I trauma center in 1999 to 2000 (N = 40). About 7 years after trauma (median, 7.3; range, 6.3-8.2 years), survivors' health condition was assessed with the following: guides to the evaluation of permanent impairment of the American Medical Association (AMA-guides), Glasgow Outcome Scales (GOS/GOSE), Vineland Adaptive Behavior Scales (VABS), Child Behavior Checklist (CBCL), and Strengths and Difficulties Questionnaire (SDQ).

Results

Of 40 children, 28 were followed up. Most (n = 16; 57%) had no impairments (AMA guides); minor to severe impairments were found in 12 of the respondents. About 80% (n = 22) had good recovery (GOS 5 and GOSE 7/8); the remaining had moderately disability (GOS 4 or GOSE 5/6). The mean scores on the VABS and the frequency of behavioral problems on the CBCL (24%) and the SDQ (20%) were comparable to healthy peers.

Conclusions

This long-term follow-up study after major trauma revealed that most children had a health condition comparable to healthy peers; about 40% of the respondents was physically impaired or restricted in daily activities. Our experiences with different measures may be helpful to apply age-appropriate outcome measures for the clinical follow-up of children after major trauma and to design future longitudinal studies.     

Methods to reduce the contraction of tissue-engineered buccal mucosa for use in substitution urethroplasty

Background

We previously described the production and clinical outcomes of tissue-engineered buccal mucosa (TEBM) used to treat recurrent urethral strictures. In this study, two patients developed a recurrent stricture and there was also evidence of graft contraction.

Objective

Assess possible preclinical methods to reduce contraction of TEBM.

Design, setting and participants

Using the model of TEBM in use clinically (ie, oral keratinocytes and fibroblasts cultured on de-epidermised acellular dermal scaffold), three methods of reducing TEBM contraction were investigated in vitro.

Interventions

The techniques assessed were pretreatment of de-epidermised dermis (DED) with glutaraldehyde, culture with β-aminopropionitrile (β-APN; a lysyl oxidase inhibitor), and physical restraint of TEBM grafts during culture.

Measurements

Contraction was assessed using serial digital image analysis. The cytotoxicity of the pharmacologic manipulations was assessed using monolayer cultures of oral mucosa cells.

Results and limitations

Control TEBM lost a mean of 45.4% of its original surface area over 28 d of culture. Treating TEBM with glutaraldehyde, β-APN, or mechanical restraint during culture all significantly inhibited graft contraction. Glutaraldehyde treatment was most effective (only 5.5% loss of area with 0.1% glutaraldehyde), followed by mechanical restraint for at least 7 d (21.4% loss of area), and then β-APN (28.7% loss of area). None of the treatments had any significant effect on cell viability. This in vitro study identifies solutions for graft contracture to explore in the clinic.

Conclusions

Glutaraldehyde pretreatment and restraint of TEBM grafts during culture both reduce graft contraction.     

Can a pressure-limited vesico-amniotic shunt tube preserve normal bladder function?

Introduction

We have previously shown that a vesico-amniotic shunt (V-A shunt) produces fibrotic bladders with poor compliance in normal fetal lambs. We hypothesized that using a ventriculo-peritoneal shunt (V-P shunt) as a V-A shunt in normal bladders may preserve the filling/emptying cycle and normal bladder development.

Materials and methods

The V-A shunting in normal fetal lambs was performed at 74 days of gestation using a V-P shunt (group A) and a free-draining shunt tube (group B). Sham-operated lambs were used as controls (group C). They were all delivered at term (145 days), and the pressure-volume curve, bladder volume, and histologic features of the bladder wall were compared.

Result

The mean bladder volume in group B (n = 5), 5 ± 2.4 mL, was significantly smaller (P < .01) than that in group A (n = 6), 53 ± 14 mL, and group C (n = 10), 57.3 ± 12 mL. The bladder wall thickness in group A was 338 + 94.2 μm; group B, 741 ± 128 μm; and group C, 374 ± 120 μm. Group B bladders had very poor compliance with thick bladder wall (P < .01). Histologically, group B bladders showed prominent submucosal fibrotic change, but group A bladders were similar to controls.

Conclusion

This study shows that a pressure-limited shunt tube for V-A shunting preserves the normal fetal bladder development.     

Appendicitis in the child with a ventriculo-peritoneal shunt: a 30-year review

Purpose

Each year, about 270 children are treated at our hospital for appendicitis, and there are 200 ventriculo-peritoneal (VP) shunt procedures. The incidence of primary peritonitis after a VP shunt is 8% to 12%. The purpose of this article is to try and differentiate these 2 entities.

Methods

From 1973 to 2003 inclusive, appendicitis was diagnosed in 8 children with a VP shunt at our hospital; there were 7 boys and 1 girl with 5 acute appendicitis and 3 ruptured appendices. The first case was diagnosed on purely clinical grounds, whereas the last 7 were confirmed by ultrasonography and/or computed tomography.

Results

All 8 had appendectomy and the shunt was exteriorized in the 3 children with a ruptured appendix. There were no postoperative problems, and the 8 children remained well.

Conclusion

Acute appendicitis can and does rarely occur in children with VP shunts; however, in such situations, the correct diagnosis can be confirmed by imaging. The shunt must be temporarily exteriorized if the appendix is ruptured.     

Prospective randomized trial of paravertebral block for patients undergoing breast cancer surgery

Background

The goal of the current study was to evaluate the effect of regional anesthesia using paravertebral block (PVB) on postoperative pain after breast surgery.

Methods

Patients undergoing unilateral breast surgery without reconstruction were randomized to general anesthesia (GA) only or PVB with GA and pain scores assessed.

Results

Eighty patients were randomized (41 to GA and 39 to PVB with GA). Operative times were not significantly different between groups. Pain scores were lower after PVB compared to GA at 1 hour (1 vs 3, P = .006) and 3 hours (0 vs 2, P = .001) but not at later time points. The overall worst pain experienced was lower with PVB (3 vs 5, P = .02). More patients were pain-free in the PVB group at 1 hour (44% vs 17%, P = .014) and 3 hours (54% vs 17%, P = .005) postoperatively.

Conclusions

PVB significantly decreases postoperative pain up to 3 hours after breast cancer surgery.