Laparoscopic pneumovesical ureteral tapering and reimplantation for megaureter

Objective

To evaluate the efficacy of laparoscopic pneumovesical ureter reimplantation for congenital malformation involving the vesicoureteral junction in children.

Methods

From January 2005 to October 2010, 45 cases (comprising 61 ureters) were diagnosed as megaureter caused by vesicoureteral junction obstruction. A pneumovesical laparoscopic Cohen procedure was performed in all cases. Twelve of the ureters underwent excisional ureteral tapering. Ureteral diameters were obtained using ultrasonography and were divided into 4 groups according to the degree of dilatation.

Results

The procedure was completed in all but 2 patients, who were converted to open surgery. The mean operation time was 3.5 h (range, 2–8 h) for unilateral ureter cases, 3.7 h (range, 3.5–4.5 h) for duplicated ureter cases, and 5.4 h (range, 3.5–9 h) for bilateral cases. The mean duration of urethral catheter placement and hospital stay was 6.7 days (range, 3–14 days) and 8.3 days (range, 4–15 days), respectively. Thirty-five of the patients (48 ureters) were followed up by ultrasonography for 1–67 months (mean, 19.3 months). Ultrasound scans revealed improvement in the degree of dilatation of 32 ureters. In 1 patient, the ultrasound scan showed deterioration of ureteral dilatation. This patient developed stenosis at the neoureteral opening and underwent reoperation 6 months later. Fourteen patients were followed up by micturating cystourethrogram (MCU).Of these, 3 cases (4 ureters) exhibited reflux (2 unilateral cases of grade 1 reflux and grade 3 reflux, respectively, and 1 bilateral case of bilateral grade 1 reflux).

Conclusions

Pneumovesical ureteral reimplantation for vesicoureteral junction obstruction is feasible and effective. In this series, ultrasound scans showed improvement in most ureteral dilatation cases on follow-up.     

The effect of colchicine and low-dose methotrexate on intestinal ischemia/reperfusion injury in an experimental model

Aim

Intestinal ischemia/reperfusion (I/R) injury is a serious clinical condition. Colchicine and low-dose methotrexate have anti-inflammatory features. An experimental model was conducted to investigate the effect of colchicine and methotrexate on intestinal I/R injury.

Methods

Twenty-four rats were included. Only laparotomy was done in control group (CG, n = 6). In experimental groups, superior mesenteric artery was occluded. After 1 h ischemia, reperfusion (1 h) was started by de-occlusion. 30 min before reperfusion, saline in sham group (SG, n:6), colchicine (1 mg/kg) in colchicine group (CNG, n:6), and methotrexate (0.1 mg/kg) in methotrexate group (MTXG, n:6) were infused intraperitoneally. Small intestines were harvested for evaluation of intestinal mucosal injury (Chiu score) and oxidative stress markers (nitric oxide: NO, malondialdehyde: MDA, superoxide dismutase: SOD).

Results

Biochemically, MDA levels were significantly low in CG compared to SG, CNG, and MTXG (p < 0.05). NO levels were significantly low and SOD levels were significantly high in CG compared to MTXG (p < 0.05). Histopathologically, Chiu score was significantly low in CG compared to SG, CNG, and MTXG (p < 0.05), and significantly high in MTXG compared to SG and CNG (p < 0.05).

Conclusion

The present experimental model caused I/R injury in rat intestines. Contrary to literature, it was found that methotrexate worsens and colchicine does not attenuate intestinal I/R injury.     

Base deficit correlates with mortality in pediatric abusive head trauma

Background/purpose

Children suffering from abusive head trauma (AHT) have worse outcomes compared to non-AHT, but the reasons for this are unclear. We hypothesized that delayed medical care associated with AHT causes prolonged pre-hospital hypotension and hypoxia as measured by admission base deficit (BD), and that this would correlate with outcome.

Methods

We performed a 10-year retrospective chart review of children admitted for AHT at two academic level-I trauma centers. Statistics were performed using Student's t test, chi-square analysis, and multivariate logistic regression, and considered significant at p < 0.05.

Results

Four-hundred twelve children with AHT were identified, and admission BD was drawn for 148/412 (36%) children, including 104 survivors and 44 non-survivors. Non-survivors had significantly higher BD compared to survivors (12.6 ± 1.6 versus 5.3 ± 0.6, p < 0.001). Non-survivors were more likely to be intubated pre-hospital and get cardiopulmonary resuscitation (CPR) (p < 0.001). Mortality increased with rising BD, according to CPR status. There was no difference in patterns of brain injury between survivors and non-survivors (p > 0.05).

Conclusions

BD correlates with mortality in children suffering severe AHT. Non-survivors are also more likely to be intubated pre-hospital and require CPR, with no difference in pattern of brain injury, suggesting that secondary injury is a major determinant of outcome in severe AHT.     

Surgical treatment of type IV-A choledochal cyst in a single institution: Children vs. adults

Background

The treatment of type IV-A choledochal cyst is particularly difficult and remains a challenge because of the rareness and the various presentations of the disease involving not only the extrahepatic but also the intrahepatic biliary tract. The purpose of this study is to analyze our clinical experience for surgical treatment of type IV-A choledochal cyst, and compare between children and adults.

Methods

During a 10-year period of time (2000–2010), clinical data of 81 consecutive patients with type IV-A choledochal cyst were retrospectively analyzed. We divided these patients into two groups, the child group (age ≤ 18 years) and the adult group (age > 18 years). According to whether the patient received additional liver resection, patients were divided into a extrahepatic cystectomy (EHC) group and an additional liver resection (LR) group. The long-term outcomes after surgery were evaluated in two groups.

Results

Of all 81 patients, there were 17 children and 64 adults; 16 children and 35 adults belonged to EHC group, one child and 29 adults belonged to LR group. The morbidity of biliary stricture and/or lithiasis in the adults was significantly higher than that in the children (p = 0.041 < 0.05). In the EHC group, the reoperation rate of adults was significantly higher than that of children (p = 0.019 < 0.05). For adult patients, the morbidity of biliary stricture and/or lithiasis and the reoperation rate in EHC group was significantly higher than that in LR group (p = 0.037 < 0.05 and p = 0.026 < 0.05 respectively). Five adults were found to have cholangiocarcinoma within a follow-up period, while no child was found to. However, for adult patients, no significant discrepancy was observed between EHC group and LR group (p = 0.366 > 0.05).

Conclusions

The present study suggests that the children have better outcomes than adults for patients with type IV-A choledochal cyst after EHC, while LR brings better outcomes than EHC for adult patients.     

Minimally invasive versus open repair of Bochdalek hernia: a meta-analysis

Background

Diaphragmatic hernia can be repaired by open or minimally invasive surgery (MIS), although it is unclear which technique has better outcomes. Our objective was to compare the outcomes of these procedures in a systematic review and meta-analysis.

Methods

We sought all publications describing both techniques through MEDLINE, Embase, and CENTRAL. Our primary outcome of interest was recurrence. We conducted statistical analyses using Review Manager 5.2.

Results

We did not identify any randomized controlled trials. Our pooled estimate of results from 10 studies showed that total recurrence was higher after MIS (OR: 2.81 [1.73, 4.56], p < 0.001). Subgroup analyses indicated higher recurrence after MIS for patch repairs (OR: 4.29 [2.13, 8.67], p < 0.001), but not for primary repairs. Operative time was longer for MIS (MD: 55.25 [40.21, 70.28], p < 0.001), while postoperative ventilator time and postoperative mortality were higher after open surgery (MD: 1.33 [0.05, 2.62], p = 0.04; OR: 7.54 [3.36, 16.90], p < 0.001, respectively).

Conclusions

Recurrence rate is higher after MIS than open repair when a patch is used. Operative time is also longer with MIS. Poorer outcomes after open surgery may be a result of selection bias rather than surgical technique. Surgeons should carefully consider the potential morbidity associated with MIS when deciding on a repair method.     

The effect of platelet rich fibrin on growth factor levels in urethral repair

Aim

Platelet rich fibrin (PRF) is an autologous source of growth factors and promotes wound healing. An experimental study was performed to evaluate the effect of PRF on growth factor levels in urethral repair.

Materials and Methods

Eighteen Wistar albino rats were included in the study. Rats were allocated in three groups (n:6): control (CG), sham (SG), and PRF (PRFG). In SG, a 5 mm vertical incision was performed in the penile urethra and repaired with 10/0 Vicryl® under a microscope. In PRFG, during the urethral repair as described in SG, 1 cc of blood was sampled from each rat and centrifuged for 10 minutes at 2400 rpm. PRF obtained from the centrifugation was placed on the repair site during closure. Penile urethras were sampled 24 hours after PRF application in PRFG and after urethral repair in SG. Transforming growth factor beta receptor (TGF-β-R-CD105), vascular endothelial growth factor (VEGF) and its receptor (VEGF-R), as well as endothelial growth factor receptor (EGFR), were evaluated in subepithelia of the penile skin and urethra. Groups were compared for growth factor levels and growth factor receptor expression with the Kruskal Wallis test.

Results

TGF-β-R levels were significantly decreased in SG when compared to CG (p < 0.05). In PRFG, TGF-β-R was increased in both subepithelia of penile skin and urethra with respect to SG (p < 0.05). When VEGF levels and its receptor expression were compared between SG and PRFG, VEGF levels were found to be increased in penile skin subepithelium, whereas VEGF-R expressions were decreased in urethral subepithelia in PRFG (p < 0.05). There was no difference between groups for EGFR levels (p > 0.05).

Conclusion

Use of PRF after urethral repair increases TGF-β-R and VEGF expressions in urethral tissue. PRF can be considered as an alternative measure to improve the success of urethral repair.     

Outcome of CDH infants following fetoscopic tracheal occlusion — influence of premature delivery

Purpose

To evaluate the mortality and morbidity of infants with congenital diaphragmatic hernia who had undergone fetal endoscopic tracheal occlusion (FETO) and whether this was influenced by premature birth.

Methods

The gestational age at delivery, lung–head ratio (LHR) pre and post FETO, neonatal outcomes, and respiratory, gastro-intestinal, neurological, surgical, and musculoskeletal problems at follow up of consecutive infants who had undergone FETO were determined. Elective reversal of FETO was planned at 34 weeks of gestation.

Results

The survival rate of the 61 FETO infants was 48%, with 84% delivered prematurely. Thirty-one delivered < 35 weeks of gestation. Their survival rate was 18%. Twenty-three of 24 infants who had emergency balloon removal were born < 35 weeks of gestation. Survival was related to gestational age at delivery (OR 0.55, 95% CI 0.420, 0.77, p < 0.001) and the duration of FETO (OR 0.73, 95% CI 0.59, 0.91, p < 0.005). Infants born prior to 35 weeks of gestation compared to those born at ≥ 35 weeks required a longer duration of ventilation (median 45 days versus 12 days, p < 0.001), and a greater proportion had surgery for gastro-oesophageal reflux (50% versus 9%, p = 0.011).

Conclusion

These results emphasize the need to reduce premature delivery following FETO.     

Urologic and anorectal complications of sacrococcygeal teratomas: Prenatal and postnatal predictors

Purpose

Anorectal and urologic sequelae are observed in long-term survivors of sacrococcygeal teratoma (SCT). In this study we evaluate the incidence and predictors of anorectal and urologic complications in SCT.

Methods

A retrospective review was performed for all SCT patients who underwent resection at a single institution between 2000 and 2012. Enrollment criteria included a minimum of 12 months follow-up. Categorical variables were analyzed by Fisher’s exact test and continuous variables by Mann Whitney test (p < 0.05).

Results

Forty-five patients were studied. Anorectal complications occurred in 29%, including severe chronic constipation (n = 13) and fecal incontinence (n = 4). Urologic complications occurred in 33%, including neurogenic bladder (n = 12), vesicoureteral reflux (n = 5), and urinary incontinence (n = 7). Prenatal imaging by fetal MRI demonstrated mass effect with obstruction of the bowel (n = 4) or bladder and collecting system (n = 7) in a subset of patients with postnatal complications (anorectal 4/4, PPV 100%; urologic 6/7, PPV 86%). Postnatal complications were associated with obstructive findings on prenatal imaging, prenatal therapeutic interventions, Altman classification, perineal reconstruction, and tumor recurrence. No anorectal or urologic complications occurred in patients with Altman type I tumors.

Conclusions

Urologic and anorectal complications are common in patients with SCT. Higher Altman classification and prenatal imaging suggestive of intestinal or urologic obstruction should prompt focused prenatal counseling and postnatal screening for anorectal and urologic dysfunction.     

In vitro smooth muscle contractility before and after relief of experimental obstruction in the rat: Application to the surgical management of ileal dilatation

Purpose

Bowel dilatation occurs proximal to an obstruction and predisposes to intestinal dysmotility. The present study sought to determine whether or not changes in smooth muscle contractility and the thickness of the proximal, dilated bowel wall can be reversed following relief of the obstruction.

Materials and methods

Three groups of seven male Wistar rats were studied. In 8-week-old animals in a control group and a sham-operated group, a small segment of bowel (designated as R1 for controls and R2 for shams) was resected 5.0 cm from the cecum. In the third (operated) group, a narrow, isoperistaltic intestinal loop was created proximal to an end-to-end anastomosis of the ileum in 4-week-old animals. When these animals were 6 weeks old, the loop was re-anastomosed to the distal small bowel (after resection of the loop's distal portion, referred to as R3). Two weeks later, a small segment of bowel was resected proximal to the anastomosis (R4). We evaluated the thickness of the smooth muscle layers and the in vitro contractile responses of circular smooth muscle ileal strips (R1–R4) to electrical stimulation and pharmacological stimulation (with KCl, acetylcholine (ACh), substance P, N^G-nitro-l-arginine methyl ester (L-NAME) and histamine).

Results

The amplitudes of contraction in response to electrical and Ach-mediated stimulation were higher for R3 than for R4 (P < 0.001), R1 and R2 (both P < 0.05). Compared with R1 and R2, the smooth muscle layer was three times as thick in R3 (P < 0.001) and 2.5 times as thick in R4 (P < 0.01).

Conclusion

Our study provides evidence of the possible recovery of intestinal motility (in response to neurotransmitters involved in gut function) after the relief of an obstruction. If ileal motility can conceivably return to normal values, conservative surgical procedures in pediatric patients should be preferred (in order to leave a sufficient length of bowel and avoid short bowel syndrome).     

Outcome of antegrade continent enema (ACE) procedures in children and young adults

Objective

Intractable incontinence affects a large number of children and young adults in the US. The goal of this study is to evaluate the long-term outcomes of surgical access for administration of antegrade continence enemas (ACE) in affected children and young adults.

Methods

Patients who underwent surgical procedure to enable administration of ACE from 1994 to 2011 were retrospectively reviewed. Data collected included patient demographics, primary diagnosis, surgical technique, conduit used, complications, follow-up duration, and social continence.

Results

Sixty eighty patients underwent surgery to enable ACE; mean follow up was 61 months. Enteral conduit (EC) was performed in 19 patients, tube cecostomy catheters (CC) in 49. Meningomyelocele was diagnosed in 60% of patients. Mean age was 11 (1.67–53) years. Complications included tube dislodgement (43%), granulation tissue (46%), site infection (13%), leakage (32%), break in the tube (6%) and tract stenosis (6%). Complete social continence was achieved in 68%, partial continence was achieved in 29%, and no benefit was achieved in 3% of patients. The rate of complications and incontinence resolution following CC was 78% and 66%, and following EC 89% and 74%. The differences were not statistically significant. CC patients developed granulation tissue more frequently (53%) and leaks of fecal material less frequently (20%) compared to EC patients (26% and 53%) (p < 0.05 and < 0.01). Although children 7 years or younger developed more overall complications (94%) than older patients (69%; p < 0.05), there was not a significant difference in the frequency of any one complication or in the rate of continence, between the two groups. Multivariate analysis showed that EC is three times more likely to be complicated by fecal leakage. CC patients are at greater risk to develop granulation tissue (p < 0.05).

Conclusions

Most patients achieved social continence and improved hygiene with the aid of ACE. Younger children also benefited greatly from institution of ACE. CC was associated with fewer major complications such as leak of fecal contents than EC but required regular tube changes.     

Predictors of early lung function in patients with congenital diaphragmatic hernia

Purpose

Long-term pulmonary outcomes of congenital diaphragmatic hernia (CDH) have demonstrated airflow obstruction in later childhood. We examined pulmonary function data to assess what factors predict lung function in the first three years of life in children with CDH.

Methods

This was a retrospective study of patients treated for CDH who underwent infant pulmonary function testing (IPFT) between 2006 and 2012. IPFT was performed using the raised volume rapid thoracoabdominal compression technique and plethysmography.

Results

Twenty-nine neonates with CDH had IPFTs in the first 3 years of life. Their mean predicted survival using the CDH Study Group equation was 63% ± 4%. Fourteen infants (48%) required extracorporeal membrane oxygenation (ECMO). The mean age at IPFT was 85.1 ± 5 weeks. Airflow obstruction was the most common abnormality, seen in 14 subjects. 12 subjects had air trapping, and 9 demonstrated restrictive disease. ECMO (p = 0.002), days on the ventilator (p = 0.028), and days on oxygen (p = 0.023) were associated with restrictive lung disease.

Conclusion

Despite following a group of patients with severe CDH, lung function revealed mild deficits in the first three years of life. Clinical markers of increased severity (ECMO, ventilator days, and prolonged oxygen use) are correlated with reduced lung function.     

Inter-rater reliability of surgical reviews for AREN03B2: A COG renal tumor committee study

Purpose

The Children's Oncology Group (COG) renal tumor study (AREN03B2) requires real-time central review of radiology, pathology, and the surgical procedure to determine appropriate risk-based therapy. The purpose of this study was to determine the inter-rater reliability of the surgical reviews.

Methods

Of the first 3200 enrolled AREN03B2 patients, a sample of 100 enriched for blood vessel involvement, spill, rupture, and lymph node involvement was selected for analysis. The surgical assessment was then performed independently by two blinded surgical reviewers and compared to the original assessment, which had been completed by another of the committee surgeons. Variables assessed included surgeon-determined local tumor stage, overall disease stage, type of renal procedure performed, presence of tumor rupture, occurrence of intraoperative tumor spill, blood vessel involvement, presence of peritoneal implants, and interpretation of residual disease. Inter-rater reliability was measured using the Fleiss' Kappa statistic two-sided hypothesis tests (Kappa, p-value).

Results

Local tumor stage correlated in all 3 reviews except in one case (Kappa = 0.9775, p < 0.001). Similarly, overall disease stage had excellent correlation (0.9422, p < 0.001). There was strong correlation for type of renal procedure (0.8357, p < 0.001), presence of tumor rupture (0.6858, p < 0.001), intraoperative tumor spill (0.6493, p < 0.001), and blood vessel involvement (0.6470, p < 0.001). Variables that had lower correlation were determination of the presence of peritoneal implants (0.2753, p < 0.001) and interpretation of residual disease status (0.5310, p < 0.001).

Conclusion

The inter-rater reliability of the surgical review is high based on the great consistency in the 3 independent review results. This analysis provides validation and establishes precedent for real-time central surgical review to determine treatment assignment in a risk-based stratagem for multimodal cancer therapy.     

Primary malignant pancreatic neoplasms in children and adolescents: A 20 year experience

Background

Malignant pancreatic neoplasms in children and adolescents are rare. The clinical presentation, pathologic characteristics, management, and outcomes at two institutions are discussed.

Methods

We retrospectively reviewed all pediatric patients (age < = 18 years) treated for malignant pancreatic neoplasms at two institutions between 1991 and 2011.

Results

Thirty-one patients were identified with median age of 14.7 years (4–18 years). The most common histology was solid pseudopapillary tumor (SPT) (n = 22, 71%) followed by neuroendocrine tumors (n = 4, 13%), pancreatoblastoma (n = 4, 13%), and one unclassified spindle cell neoplasm (3%). Most patients presented with abdominal pain (n = 22, 71%). Complications included pancreatic leak, pseudocyst formation, pancreatitis, pancreatic insufficiency, and small bowel obstruction. The overall 1- and 5-year survival was 96% (95% CI 74%–99%) and 78% (95% CI 43%–93%). Median follow-up among patients alive at the end of follow-up was 20 months (< 1 month–16.2 years). Patients with SPT had better overall survival compared to patients with neuroendocrine tumors or pancreatoblastomas (Log-rank; p = 0.0143).

Conclusion

The majority of pediatric and adolescent patients present with SPTs which are usually resectable and associated with an excellent prognosis. Other histologic subtypes more often present with distant metastases and portend a worse prognosis.     

Bowel symptoms in children with anorectal malformation — a follow-up with a gender and age perspective

Background

Gender specific outcome for children with anorectal malformations (ARM) is rarely reported although it is important for medical care and in parent counseling.

Purpose

To assess bowel function according to the Krickenbeck system in relation to ARM-subtype, gender and age.

Method

All children born with ARM in 1998–2008 and referred to two centers in two different countries were followed up. The bowel function in 50 girls and 71 boys, median age 8 years, was analyzed.

Results

Among those with a perineal fistula, incontinence occurred in 42% of the females and in 10% of the males (p = 0.005) whereas constipation occurred in 62% of the females and 35% of the males (p < 0.001). No bowel symptoms differed between the females with perineal and vestibular fistulas (p > 0.3 for every symptom). Sacral malformations were associated with incontinence only in males with rectourethral fistulas. Constipation among the males differed between the age groups: 58% versus 26% (p = 0.013). Bowel symptoms did not change with age among the females.

Conclusion

Gender differences in outcome for children with ARM must be considered. Males with perineal fistulas had less incontinence and constipation than the females with perineal fistulas. The females with perineal and vestibular fistulas had similar outcomes.     

Pepsin levels and oxidative stress markers in exhaled breath condensate of patients with gastroesophageal reflux disease

Aim

To evaluate the pepsin and oxidative stress markers in exhaled breath condensate (EBC) in patients with gastroesophageal reflux disease (GERD).

Patients and Method

Patients with a presumptive diagnosis of GERD with recurrent respiratory and gastrointestinal problems aged between 2 and 14 years were included in the study. All patients underwent pH monitoring. Patients with a reflux index (RI) ≥ 4 were assessed as the reflux group, and those with an RO < 4 were assessed as the non-reflux group. Pepsin levels and oxidative stress markers [NO metabolites (NOX) and total sulphydrile (TSH) levels] were measured in the EBC.

Results

There were 24 patients in the reflux group [RI 17.6 (6.6–46.4)] [median, interquartile range] and 23 in the non-reflux group [RI 0.8 (0.5–1.9) (p < 0.001). Pepsin levels in the EBC were below the level of detection. The median levels of NOx in the EBC of children with reflux [13.7 μmol/L (7.3–24.5)] were lower in than non-reflux group [21.0 μmol/L (14.0–25.2)] (p = 0.034). There was a negative correlation between reflux index and NOX levels in EBC (rs: − 0.331, p = 0.023). In contrast, there was no difference in TSH levels between the reflux and non-reflux groups [37.4 μmol/L (30.2–44.6) vs 40.1 μmol/L (37.4–44.9), respectively, (p > 0.05)].

Conclusion

Decreased levels of NOX in patients with GER disease suggest increased oxidative stress in airways of these patients.     

Determinants of wait time for infant inguinal hernia repair in a Canadian children’s hospital

Background

Longer wait time for infant inguinal hernia (IH) repair is associated with higher complication rates. We wished to determine if socioeconomic and demographic factors influence wait times for IH repair.

Methods

Children < 2 years old with IH at a Canadian children’s hospital were retrospectively reviewed. Days from diagnosis to surgical consultation (W1) and from consultation to repair (W2) were collected along with demographic, medical, and socioeconomic data. Linear regression analysis was performed.

Results

A total of 131 patients were appropriate for analysis (82.4% male). Median distance to hospital was 27.5 km (IQR = 10.5–50.4) and median income was $34,477 (IQR = 30,127–41,986). Median W1, W2, and Wtotal (W1 + W2) were 24 (IQR = 8–48), 43 (IQR = 21–69) and 79 (IQR = 38–112) days, respectively. Wait times were shorter in infants who were male (p = 0.044), symptomatic (p < 0.001), diagnosed in the ED (p < 0.001), or had an incarcerated hernia (p = 0.006). They were longer for premature infants (p = 0.009) and those with significant comorbidities (p = 0.018). Neither income (p = 0.328) nor distance from hospital (p = 0.292) was associated with longer wait times.

Conclusion

Wait times for IH repair were appropriately influenced by medical risk factors. Income and distance to hospital did not appear to influence wait times. A population-based study is needed to determine if these findings reflect a general trend within the Canadian health care system.     

Cervical spine computed tomography utilization in pediatric trauma patients

Background

Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs).

Methods

Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression.

Results

5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p < 0.05) and more frequent ICU admissions (44.3% vs. 26.1% p < 0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI = 8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI = 25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT.

Conclusions

Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED.     

Hepatocellular carcinoma in children: Epidemiology and the impact of regional lymphadenectomy on surgical outcomes

Background

Factors influencing survival in children with HCC have not been studied. The objective of this study was to identify prognostic factors in pediatric HCC, and to determine whether regional lymphadenectomy is associated with improved survival.

Methods

We performed a retrospective cohort study using the Surveillance, Epidemiology and End Results (SEER) registry. All patients < 20 years old diagnosed with HCC from 1973–2009 were included. Disease-specific survival was compared using Kaplan-Meier statistics and Cox proportional-hazards regression.

Results

We identified 238 patients (139 Male: 99 Female). Overall, 112 (47%) received an operation (resection/transplantation). Observed mortality and adjusted hazard of disease-specific death was greater for females (HR = 2.07, p = 0.013) and older children. Among operative patients, 44% were documented to have a regional lymphadenectomy. Although demographic factors did not differ between lymphadenectomy and non-lymphadenectomy groups, patients who underwent lymphadenectomy had a greater proportion of metastatic disease (24% vs. 15%) and fibrolamellar HCC (53% vs. 31%). Five-year survival for lymphadenectomy patients was superior to non-lymphadenectomy (70% vs. 57%). Adjusted mortality for lymphadenectomy was also improved relative to non-lymphadenectomy (HR = 0.26, p = 0.013).

Conclusions

HCC in children is associated with poor survival, especially among children older than 4 years and girls. In surgical candidates, regional lymphadenectomy may be associated with improved survival.     

Prenatal MRI fetal lung volumes and percent liver herniation predict pulmonary morbidity in congenital diaphragmatic hernia (CDH)

Purpose

The purpose of this study was to determine whether prenatal imaging parameters are predictive of postnatal CDH-associated pulmonary morbidity.

Methods

The records of all neonates with CDH treated from 2004 to 2012 were reviewed. Patients requiring supplemental oxygen at 30 days of life (DOL) were classified as having chronic lung disease (CLD). Fetal MRI-measured observed/expected total fetal lung volume (O/E-TFLV) and percent liver herniation (%LH) were recorded. Receiver operating characteristic (ROC) curves and multivariate regression were applied to assess the prognostic value of O/E-TFLV and %LH for development of CLD.

Results

Of 172 neonates with CDH, 108 had fetal MRIs, and survival was 76%. 82% (89/108) were alive at DOL 30, 46 (52%) of whom had CLD. Neonates with CLD had lower mean O/E-TFLV (30vs.42%; p = 0.001) and higher %LH (21.3 ± 2.8 vs.7.1 ± 1.8%; p < 0.001) compared to neonates without CLD. Using ROC analysis, the best cutoffs in predicting CLD were an O/E-TFLV < 35% (AUC = 0.74; p < 0.001) and %LH > 20% (AUC =0.78; p < 0.001). On logistic regression, O/E-TFLV < 35% and a %LH > 20% were highly associated with indicators of long-term pulmonary sequelae. On multivariate analysis, %LH was the strongest predictor of CLD in patients with CDH (OR: 10.96, 95%CI: 2.5–48.9, p = 0.002).

Conclusion

Prenatal measurement of O/E-TFLV and %LH is predictive of CDH pulmonary morbidity and can aid in establishing parental expectations of postnatal outcomes.     

Is early delivery beneficial in gastroschisis?

Purpose

Gastroschisis neonates have delayed time to full enteral feeds (ENT), possibly due to bowel exposure to amniotic fluid. We investigated whether delivery at < 37 weeks improves neonatal outcomes of gastroschisis and impact of intra/extra-abdominal bowel dilatation (IABD/EABD).

Methods

A retrospective review of gastroschisis (1992–2012) linked fetal/neonatal data at 2 tertiary referral centers was performed. Primary outcomes were ENT and length of hospital stay (LOS). Data (median [range]) were analyzed using parametric/non-parametric tests, positive/negative predictive values, and regression analysis.

Results

Two hundred forty-six patients were included. Thirty-two were complex (atresia/necrosis/perforation/stenosis). ENT (p < 0.0001) and LOS (p < 0.0001) were reduced with increasing gestational age. IABD persisted to last scan in 92 patients, 68 (74%) simple (intact/uncompromised bowel), 24 (26%) complex. IABD or EABD diameter in complex patients was not significantly greater than simple gastroschisis. Combined IABD/EABD was present in 22 patients (14 simple, 8 complex). When present at < 30 weeks, the positive predictive value for complex gastroschisis was 75%. Two patients with necrosis and one atresia had IABD and collapsed extra-abdominal bowel from < 30 weeks.

Conclusion

Early delivery is associated with prolonged ENT/LOS, suggesting elective delivery at < 37 weeks is not beneficial. Combined IABD/EABD or IABD/collapsed extra-abdominal bowel is suggestive of complex gastroschisis.