Search

Appendicoliths are commonly found obstructing the lumen of the appendix at the time of appendectomy. To identify factors that might contribute to their formation we investigated the composition of appendicoliths using laser ablation inductively coupled plasma mass spectroscopy, gas chromatography, polarized light microscopy, X-ray crystallography, and protein mass spectroscopy. Forty-eight elements, 32 fatty acids, and 109 human proteins were identified within the appendicoliths. The most common elements found in appendicoliths are calcium and phosphorus, 11.0 + 6.0 and 8.2 + 4.2 % weight, respectively. Palmitic acid (29.7%) and stearate (21.3%) are the most common fatty acids. Some stearate is found in crystalline form—identifiable by polarized light microscopy and confirmable by X-ray crystallography. Appendicoliths have an increased ratio of omega-6 to omega-3 fatty acids (ratio 22:1). Analysis of 16 proteins common to the appendicoliths analyzed showed antioxidant activity and neutrophil functions (e.g., activation and degranulation) to be the most highly enriched pathways. Considered together, these preliminary findings suggest oxidative stress may have a role in appendicolith formation. Further research is needed to determine how dietary factors such as omega-6 fatty acids and food additives, redox-active metals, and the intestinal microbiome interact with genetic factors to predispose to appendicolith formation.

Surgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life.Epidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries.An estimated 314,609 (95% UI, 239,619-402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year.Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.

Echinococcus infections are rare in the United States but may present a growing public health threat. We present the case of an 8-year-old female patient from Southern California who was diagnosed with hepatic echinococcosis after the incidental discovery of large hepatic cysts.

PURPOSE The purpose of this study was to investigate factors impacting transplant-free survival among infants with biliary atresia. METHODS A multi-institutional, retrospective cohort study was performed at nine tertiary-level children's hospitals in the United States. Infants who underwent Kasai portoenterostomy (KP) from January 2009 to May 2017 were identified. Clinical characteristics included age at time of KP, steroid use, surgical approach, liver pathology, and surgeon experience. Likelihood of transplant-free survival (TFS) was evaluated using logistic regression, adjusting for patient and surgeon-level factors. Secondary outcomes at 1 year included readmission, cholangitis, reoperation, mortality, and biliary clearance. RESULTS Overall, 223 infants underwent KP, and 91 (40.8%) survived with their native liver. Mean age at surgery was 63.9 days (± 24.7 days). At 1 year, 78.5% experienced readmission, 56.9% developed cholangitis, 3.8% had a surgical revision, and 5 died. Biliary clearance at 3 months was achieved in 76.6%. Controlling for patient and surgeon-level factors, each additional day of age toward operation was associated with a 2% decrease in likelihood of TFS (OR 0.98, 95% CI 0.97-0.99). CONCLUSION Earlier surgical intervention by Kasai portoenterostomy at tertiary-level centers significantly increases likelihood for TFS. Policy-level interventions to facilitate early screening and surgical referral for infants with biliary atresia are warranted to improve outcomes.

Our multi-institutional university consortium implemented a gastroschisis pathway in 2015 to standardize and improve care by promoting avoidance of routine intubation and paralysis during silo placement, expeditious abdominal wall closure, discontinuation of antibiotics/narcotics within 48 h of closure, and early initiation/advancement of feeds.Adherence to the gastroschisis pathway was prospectively monitored. Outcomes for the contemporary cohort (2015-2018) were compared with a historical cohort (2007-2012).Good adherence to the pathway was observed for 70 cases of inborn uncomplicated gastroschisis. The contemporary cohort had significantly lower median mechanical ventilator days (2 versus 5; p 0.01) and antibiotic days (5.5 versus 9; p 0.01) as well as earlier days to initiation of feeds (12 versus 15; p 0.01). However, no differences were observed in length of stay (28 versus 29 days; p = 0.70). A skin closure technique was performed in 66% of the patients, of which 46% were performed at bedside without intubation, the assistance of an operating-room team, or general anesthesia.In this study, adherence to a clinical pathway for gastroschisis across different facilities was feasible and led to reduction in exposure to mechanical ventilation and antibiotics. The adoption of a bedside skin closure technique appears to facilitate compliance with the pathway.Level II/III TYPE OF STUDY: Prospective comparative study with historical cohort.

An incidental appendectomy is performed by some surgeons during operative treatment for intussusception to eliminate future appendicitis as a diagnostic consideration. However, an appendectomy can increase the risk of infection and other noninfectious complications making an incidental appendectomy controversial. We examined outcomes for surgical intervention for intussusception with appendectomy (SWA) compared to surgical reduction alone (SRA).The Pediatric Health Information System database, 8/2008-9/2015, was retrospectively analyzed for patients under the age of five who required an operative intervention for intussusception without bowel resection. Demographic data and postoperative outcomes were analyzed. Available data included need for postoperative enema, subsequent small bowel obstruction, recurrent intussusception, length of stay (LOS), and adjusted total cost (ATC).Fifty-seven percent (748/1312) of patients had appendectomy performed during surgical reduction, 564 (43%) did not. ATC ($10,594 vs. $8939, p 0.001) and LOS (3.0 vs. 2.48, p 0.001) are higher in the SWA group. Rates of readmission are similar, but post-operative small bowel obstruction may be higher in the SWA group (1.3% vs. 0.35%, p = 0.06).There is a higher mean LOS and ATC in the SWA group. This study suggests that appendectomy during surgery for uncomplicated intussusception should be reconsidered and requires further investigation.retrospective comparative study.III.

BACKGROUND Ventriculoperitoneal shunt (VPS) placement into the reoperative abdomen can be challenging due to intraperitoneal adhesions. Laparoscopic guidance may provide safe abdominal access and identify an area for optimal cerebrospinal fluid drainage. The study aim was to compare laparoscopic-assisted VPS placement to an "open" approach in patients with prior abdominal surgery. MATERIALS AND METHODS A retrospective review was performed of children undergoing VPS placement into a reoperative abdomen from 2009-2019. Clinical data were collected, and patients undergoing laparoscopy (LAP) were compared to those undergoing an open approach (OPEN). RESULTS A total of 120 children underwent 169 VPS placements at a median age of 8 y (IQR 2-15 y), and a mean number of two prior abdominal operations (IQR 1-2). Laparoscopy was used in 24% of cases. Shunt-related complications within 30 d were lower in the LAP group (0% versus 19%, P = 0.001), as were VPS-related postoperative emergency department visits (0% versus 13%, P = 0.003) and readmissions (0% versus 13%, P = 0.013). Shunt malfunction rates were higher (42% OPEN versus 25% LAP, P = 0.03) and occurred sooner in the OPEN group (median 26 versus 78 wk, P = 0.01). The LAP group demonstrated shorter operative times (63 versus 100 min, P < 0.0001), and the only bowel injury. Time to feeds, length of stay, and mortality were similar between groups. CONCLUSIONS Laparoscopic guidance during VPS placement into the reoperative abdomen is associated with a decrease in shunt-related complications, longer shunt patency, and shorter operative times. Prospective study may clarify the potential benefits of laparoscopy in this setting.

Background: Surgical care is an important, yet often neglected component of child health in LMICs. This study examines the potential impact of scaling up surgical care at first-level hospital in LMICs on the first 8000 days of life. Methods: Epidemiological data from the Global Burden of Disease (GBD) 2019 Study and a counterfactual method developed for the Disease Control Priorities; 3rd Edition (DCP3) were used to estimate the number of avertable deaths in the under 20-year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries. Findings: An estimated 314 609 (95% UI, 239 619-402 005) deaths per year in the under 20-year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the avertable deaths are in the under-five year age group (80·9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of avertable deaths after age 5 years. Sixty-one percent of the avertable deaths occur in lower-middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year. Interpretation: Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 8000 days of life. Funding: None to declare. Declaration of Interest: None to declare.

The aims of this study were to identify ultrasound-based predictors of ovarian torsion in girls without an adnexal mass and establish a set of normal values for ovarian volume ratio (OVR).A retrospective review was performed of all premenarchal patients ≥3 years of age with a normal pelvic ultrasound between January 2016 and January 2019. A comparison group of premenarchal girls presenting between 2011 and 2019 with torsion in the absence of an adnexal mass was utilized.Five-hundred and four premenarchal girls underwent pelvic ultrasound evaluation with a normal examination. The mean OVR was 1.6 ± 0.7 (range 1.0-6.5). OVR did not vary with age (r = -0.06) as compared to ovarian width which increased steadily with age (r = 0.53, p 0.001). OVR was increased in girls with torsion (7.6 vs 1.4, p 0.0001), and by receiver operating characteristic (ROC) analysis a cutoff value of2.5 demonstrated the best diagnostic accuracy of any predictive variable (sensitivity 100%, specificity 94%, AUC 0.991, p 0.001).OVR is an excellent predictor of ovarian torsion in premenarchal girls without an adnexal mass. Unlike ovarian width, OVR does not increase with age, and a cutoff OVR 2.5 demonstrates high sensitivity and specificity for identifying ovarian torsion in this population.Study of diagnostic test.Level III.

BACKGROUND/PURPOSE This study aimed to compare preoperative management strategies for patients undergoing trephination for pilonidal disease and evaluate risk factors for recurrence. METHODS A retrospective review was performed of children undergoing index surgical treatment with trephination for pilonidal disease between September 2017 and April 2019. Intraoperative and postoperative management were standardized. Demographic and perioperative data were collected and analyzed. RESULTS One-hundred twenty patients were identified with a median follow-up time of 7.5 months (interquartile range 4.1-13.2 months). Overall, 24 (20%) patients had a postoperative recurrence of pilonidal disease. Patients with multiple preoperative surgery clinic visits were less likely to have recurrent disease compared to those seen only once preoperatively (11% vs 26%, p = 0.040). Compared to patients without recurrence, those who recurred went to the operating room sooner from the time of initial surgical consultation (32 days vs 54 days, p

Serum D-dimer has been proposed as a biomarker to aid in the diagnosis of pediatric traumatic brain injury (TBI). We investigated the accuracy of D-dimer in predicting the absence of TBI and evaluated the degree by which D-dimer could limit unnecessary computed tomography scans of the head (CTH).Retrospective review of patients with suspected TBI from 2011 to 2013 who underwent evaluation with CTH and quantitative D-dimer. D-dimer levels were compared among patients with clinically-important TBI (ciTBI), TBI, isolated skull fracture and no injury.Of the 663 patients evaluated for suspected TBI, ciTBI was identified in 116 (17.5%), TBI in 77 (11.6%), skull fracture in 61 (9.2%) and no head injury in 409 (61.7%). Patients with no head injury had significantly lower D-dimer values (1531±1791pg/μL) compared to those with skull fracture, TBI and ciTBI (2504±1769, 2870±1633 and 4059±1287pg/μL, respectively, p0.005). Using a D-dimer value750pg/μL as a negative screen, no ciTBIs would be missed and 209 CTHs avoided (39.7% of total).Low plasma D-dimer predicts the absence of ciTBI for pediatric patient with suspected TBI. Incorporating D-dimer into current diagnostic algorithms may significantly limit the number of unnecessary CTHs performed in this population.Study of diagnostic test.I.

Patients with congenital diaphragmatic hernia (CDH), gastroschisis, and omphalocele are prone to abnormalities of intestinal rotation and thus future midgut volvulus. Controversy exists whether routine preemptive Ladd procedure in this subgroup of asymptomatic patients is of value to reduce future volvulus.The Pediatric Health Information System (PHIS) database was queried for neonates with CDH, gastroschisis, and omphalocele between January 2009 and September 2015. Standard univariate and multivariate analysis was completed to compare risk of volvulus between patients treated with a preemptive Ladd versus no Ladd (p0.05).Seven thousand seven hundred forty-nine neonates with CDH (40%), gastroschisis (38%), omphalocele (14%), and abdominal wall malformation (NOS) (9%) were identified. Overall, 3.6% (n=279) had a preemptive. Thirty-two patients had subsequent volvulus. Ladd procedure did not reduce volvulus readmissions for any diagnosis and was associated with a significantly increased risk of volvulus for omphalocele patients (9.1% vs 0.1%, p0.001). Overall, a Ladd procedure during the index admission was associated with a higher risk for volvulus (1.4% vs. 0.4%, p=0.021) and was associated with a 3.28 increased odds ratio of future volvulus (95% CI 1.12-9.68).Ladd procedure performed prophylactically in patients with CDH, gastroschisis, and omphalocele did not reduce subsequent volvulus.III, Retrospective Comparative Study.

The aim of this study was to characterize differences between pre- and postmenarchal females with ovarian torsion.A single-center review was conducted of all nonneonatal pediatric patients with ovarian torsion from 2011 to 2018. Clinical data were compared between pre- and postmenarchal patients.One hundred and twenty-seven patients were identified, and 25% were premenarchal. Premenarchal patients were more likely to have a delay in diagnosis (38% vs 20%, p = 0.042), develop ovarian necrosis (34% vs 17%, p = 0.036), and present without an associated adnexal mass (44% vs 0%, p 0.001). All patients without a mass (n = 14) were premenarchal and presented with ovarian asymmetry. Patients without an associated mass underwent oophoropexy in the majority of cases. There were no differences in postoperative complication or recurrence rates between groups.Premenarchal females with ovarian torsion can present differently than females postmenarche and often have a delay in diagnosis. Premenarchal females are more likely to undergo torsion without an associated adnexal mass and are at higher risk for ovarian necrosis. Oophoropexy is an appropriate treatment in the absence of an adnexal mass. A high-index of suspicion for ovarian torsion should be maintained for premenarchal females presenting with abdominal pain and an otherwise negative workup.Retrospective comparative study.Level III.

OBJECTIVES: To perform a multicenter study to assess growth failure in hospitalized infants with gastroschisis. STUDY DESIGN: This study included neonates with gastroschisis within sites in the University of California Fetal Consortium (UCFC). The study’s primary outcome was growth failure at hospital discharge, defined as a weight or length z-score decrease > 0.8 from birth. Regression analysis was performed to assess changes in z-scores over time. RESULTS: Among 125 infants with gastroschisis, the median gestational age was 37 weeks (IQR 35–37). Length of stay was 32 days (23–60); 55% developed weight or length growth failure at discharge (28% had weight growth failure, 42% had length growth failure, and 15% had both weight and length growth failure). Weight and length z-scores at 14 d, 30 d, and discharge were less than birth (p

To estimate how many children and adolescent worldwide do not have access to surgical care.We estimated the number of children and adolescents younger than 19 years worldwide without access to safe, affordable and timely surgical care, by using population data for 2017 from the United Nations and international data on surgical access in 2015. We categorized countries by World Bank country income group and obtained the proportion of the population with no access to surgical care from a study by theAn estimated 1.7 billion (95% credible interval: 1.6-1.8) children and adolescents worldwide did not have access to surgical care in 2017. Lack of access occurred overwhelmingly in low- and middle-income countries where children and adolescents make up a disproportionately large fraction of the population. Moreover, 453 million children younger than 5 years did not have access to basic life-saving surgical care. According toThere were substantial gaps in the availability of surgical services for children worldwide, particularly in low- and middle-income countries. Future research should focus on developing specific measures for assessing paediatric surgical access, delivery and outcomes and on clarifying how limited surgical access in the poorest parts of the world affects child health, especially mortality in children younger than 5 years.Estimer le nombre d'enfants et d'adolescents, à l'échelle mondiale, qui n'ont pas accès à des soins chirurgicaux.En utilisant les données démographiques de 2017 des Nations Unies et des données internationales de 2015 sur l'accès aux soins chirurgicaux, nous avons évalué le nombre d'enfants et d'adolescents de moins de 19 ans, à l'échelle mondiale, qui n'ont pas accès à des soins chirurgicaux sûrs, abordables et en temps opportun. Nous avons regroupé les pays en suivant la classification par niveau de revenu de la Banque mondiale, et nous avons calculé la proportion de la population n’ayant pas accès à des soins chirurgicaux à partir d'une étude réalisée par la Commission duEnviron 1,7 milliard (intervalle de crédibilité de 95%: 1,6–1,8) d'enfants et d’adolescents n'avaient pas accès à des soins chirurgicaux en 2017. Ce problème frappe de manière particulièrement écrasante les pays à revenu faible ou intermédiaire, où les enfants et adolescents constituent une part disproportionnellement importante de la population. Par ailleurs, 453 millions d'enfants de moins de 5 ans n'avaient pas accès à des interventions chirurgicales vitales de base. Selon les critères de la Commission duIl existe des carences considérables en termes de disponibilité des soins chirurgicaux pour les enfants dans le monde, plus particulièrement dans les pays à revenu faible ou intermédiaire. De nouvelles recherches devraient être menées sur la conception de mesures spécifiques pour évaluer l'accès aux soins chirurgicaux pédiatriques, la prestation de ces soins et leurs résultats et sur la manière dont un accès limité aux soins chirurgicaux dans les régions les plus pauvres du monde affecte la santé des enfants, en particulier la mortalité des enfants de moins de 5 ans.Estimar cuántos niños y adolescentes en todo el mundo no tienen acceso a la atención quirúrgica.Estimamos el número de niños y adolescentes menores de 19 años en todo el mundo sin acceso a una atención quirúrgica segura, asequible y oportuna, utilizando datos de población para 2017 de las Naciones Unidas y datos internacionales sobre el acceso quirúrgico en 2015. Clasificamos a los países por grupos de ingresos del Banco Mundial y obtuvimos la proporción de la población sin acceso a la atención quirúrgica de un estudio de laSe estima que 1.700 millones (intervalo creíble del 95 %: 1,6-1,8) de niños y adolescentes en todo el mundo no tenían acceso a la atención quirúrgica en 2017. La falta de acceso se produjo abrumadoramente en los países de ingresos bajos y medios, donde los niños, niñas y adolescentes constituyen una fracción desproporcionadamente grande de la población. Además, 453 millones de niños menores de 5 años no tienen acceso a la atención quirúrgica básica que salva vidas. Según los criterios de laEn todo el mundo había considerables diferencias en la disponibilidad de servicios quirúrgicos para los niños, en particular en los países de ingresos bajos y medios. Las investigaciones futuras deben centrarse en el desarrollo de medidas específicas para evaluar el acceso quirúrgico pediátrico, la natalidad y los resultados, y en aclarar cómo el acceso quirúrgico limitado en las partes más pobres del mundo afecta la salud infantil, especialmente la mortalidad en niños menores de 5 años.لتقدير عدد الأطفال والمراهقين في جميع أنحاء العالم والذين لا يحصلون على رعاية جراحية.لقد قمنا بتقدير عدد الأطفال والمراهقين الذين تقل أعمارهم عن 19 عاماً في جميع أنحاء العالم والذين لا يحصلون على رعاية جراحية آمنة وبأسعار معقولة وفي الوقت المناسب، وذلك باستخدام البيانات السكانية لعام 2017 من الأمم المتحدة والبيانات الدولية حول الحصول على الرعاية الجراحية عام 2015. قمنا بتصنيف البلدان حسب مجموعة دخل الدول من البنك الدولي وحصلنا على نسبة عدد السكان الذين لا يحصلون على الرعاية الجراحية من دراسة أجرتها لجنة لانسيت في الجراحة العالمية.ما يقدر بحوالي 1.7 مليار طفل ومراهق (95% من الفترات ذات المصداقية: 1.6 - 1.8) في جميع أنحاء العالم لم يتمكنوا من الحصول على الرعاية الجراحية عام 2017. وقد حدث نقص كبير في الوصول إلى الخدمات في البلدان منخفضة ومتوسطة الدخل، حيث يشكل الأطفال والمراهقون جزءاً كبيراً غير متناسب من السكان. علاوة على ذلك، فإن 453 مليون طفل دون سن الخامسة لم يتمكنوا من الحصول على الرعاية الجراحية الأساسية المنقذة للحياة. ووفقاً لمعايير لجنة لانسيت العالمية للجراحة، فإن أقل من 3% من عدد الأطفال في البلدان منخفضة الدخل وأقل من 8% في البلدان ذات الدخل المتوسط الأدنى حصلوا على الرعاية الجراحية.كانت هناك فجوات كبيرة في توافر الخدمات الجراحية للأطفال في جميع أنحاء العالم، ولا سيما في البلدان منخفضة ومتوسطة الدخل. يجب أن يركز البحث المستقبلي على تطوير تدابير محددة لتقييم حصول الأطفال على الرعاية الجراحية وتقديم الخدمة والنتائج، وتوضيح مدى محدودية الحصول على الرعاية الجراحية في أفقر أجزاء العالم التي تؤثر على صحة الطفل، خاصة معدل وفيات الأطفال دون سن الخامسة.旨在估计全球无法获得外科护理的儿童和青少年人数。.我们使用了 2017 年联合国人口统计数据和 2015 年全球获得外科护理人数的数据，估算出全球无法获得安全、经济实惠与及时外科护理的 19 岁以下儿童和青少年人数。我们根据世界银行国家收入分组对国家进行分类，并从《柳叶刀》全球外科委员会的一项研究中获取了无法获得外科护理的人口比例。.估计全球有 17 亿（95% 置信区间：1.6-1.8）儿童和青少年在 2017 年无法获得外科护理。在低收入和中等收入国家，无法获得外科护理服务的儿童和青少年占较大比例，形势较为严峻。此外，无法获得基本救生外科护理的 5 岁以下儿童人数为 4.53 亿。根据《柳叶刀》全球外科委员会的标准，在低收入国家，获得外科护理的儿童族群不足 3%，而在中低收入国家，获得外科护理的儿童族群不足 8%。.针对儿童的外科护理服务在世界范围内存在着巨大差异，尤其是在低收入和中等收入国家。今后的研究应侧重于制定评估获取儿科手术、分娩和并发症的具体措施，并阐明在世界上最贫穷的地区，获取外科护理受限对儿童健康，特别是对 5 岁以下儿童死亡率的影响。.Оценка количества детей и подростков во всем мире, не имеющих доступа к хирургической помощи.Авторы оценили количество детей и подростков младше 19 лет во всем мире, не имеющих доступа к безопасной, доступной и своевременной хирургической помощи, опираясь на демографические данные ООН за 2017 год и международные данные о доступе к хирургической помощи за 2015 год. Страны были разделены по группам доходов согласно определению Всемирного банка, после чего авторы рассчитали долю населения, не имеющего доступа к хирургической помощи, на основании исследования, проведенного Комиссией по глобальной хирургии журналаПримерно 1,7 миллиарда детей и подростков (95%-й ДИ: 1,6–1,8) во всем мире не имели доступа к хирургической помощи в 2017 году. В абсолютном большинстве случаев такой недостаток доступа характерен для стран с низким и средним уровнем дохода, где дети и подростки составляют непропорционально большую долю населения. Кроме того, 453 миллиона детей младше 5 лет не имели доступа к базовой хирургической помощи, необходимой для спасения жизни. Согласно критериям Комиссии по глобальной хирургии журналаВ мировом масштабе имеются значительные пробелы в доступности хирургической помощи для детей, в частности в странах с низким и средним уровнем дохода. В будущем необходимо сосредоточить усилия исследователей на разработке особых мер для оценки доступности детской хирургической помощи, практики оказания таких услуг и их исходов, а также на прояснении взаимосвязи между ограниченным доступом к хирургической помощи в беднейших странах мира и здоровьем детей, особенно как он влияет на смертность детей младше 5 лет.

We present an unusual case of total colonic aganglionosis with well-documented skip lesions and discuss our staged approach for diagnosis and surgical management. To date, there have been few reported cases of total colonic aganglionosis with skip areas. This type of presentation challenges the accepted theory regarding the etiology of colonic aganglionosis. Although skip lesions in Hirschsprung disease are extremely rare, their existence must be appreciated especially when a patient's clinical and pathologic findings do not support classic Hirschsprung disease. If not considered, additional areas of aganglionosis can be missed at initial presentation, leading to a delay in definitive treatment. This case illustrates how careful mapping of bowel via multiple biopsies can identify and thereby preserve intervening segments of bowel with normal ganglions cells to yield the maximal amount of bowel possible.

Purpose Antiinflammatory medications are thought to reduce the effectiveness of pleurodesis performed for the treatment of spontaneous pneumothorax. We reviewed our experience with children undergoing video-assisted thorascopic surgery (VATS) with pleurodesis for pneumothorax to determine if ketorolac administration influences patient outcomes. Methods A retrospective review of patients who underwent VATS pleurodesis for spontaneous pneumothorax from 2009 to 2013 at a pediatric hospital was performed. Length of stay, radiographic pneumothorax resolution prior to discharge, and ipsilateral recurrence rates were compared in patients who did and did not receive perioperative ketorolac. Results Over a 50-month period, 51 patients underwent VATS with mechanical pleurodesis for spontaneous pneumothorax. The average age was 15.5years, and 76% were male. Ketorolac was administered to 26/51 patients. There were no differences in average length of stay (11.3 vs 10.9days, p=0.36), incidence of residual pneumothorax at discharge (22/41 vs 19/41, p=0.48), or ipsilateral recurrence (5/10 vs 5/10, p=1). Conclusions Despite the intrinsic antiinflammatory properties of ketorolac, our data suggests that its use for patients undergoing pleurodesis for spontaneous pneumothorax does not detrimentally influence the outcomes of surgery. Therefore, we conclude that ketorolac can be used for pain control in this population. Large-scale studies are warranted to validate these findings.

Patients who undergo living related left lateral segment liver transplants have been reported to have a high incidence of biliary complications and some studies suggest that most patients will ultimately need operative revision. We reviewed our experience with living related transplantation in pediatric recipients to examine the occurrence of biliary complications and the utility of percutaneous biliary procedures in their management. Over a 10-yr period, 48 living donor transplants were performed in 47 patients. Sixteen patients (33%) had biliary complications. Complications included 10 leaks (20%) and eight strictures (17%). Although leaks were treated predominantly with operation, other biliary complications were treated almost exclusively non-operatively. Self limited leaks that lead to biloma accumulation were most often treated via percutaneous catheter drainage and all strictures were treated using percutaneous transhepatic biliary cholangioplasty and stenting. Sixty-seven percent of biliary complications underwent non-operative biliary intervention. Most strictures were focal anastomotic strictures and were successfully treated with cholangioplasty although multiple interventions were necessary and patients required stenting for an average of 13 months. Three of eight strictures were diffuse in nature and these included the only patient who required retransplantation. Graft survival with respect to biliary complications was 94%; 1 yr, 5 yr and overall patient survival for those with biliary complications was 88, 88 and 81%, and for the entire living related group was 84, 81 and 77%, respectively. Although biliary complications are frequent in pediatric living related transplantation, they are not associated with decreased patient survival. Excepting significant bile leaks, the majority can be treated non-operatively via biliary cholangioplasty and stenting. Strictures are especially amenable to this technique which, in our experience, has been successful at decreasing or postponing the need for retransplantation.

Purpose: After reconstruction of jejunal atresias at the ligament of Treitz, many patients do not respond to simple tapering and anastomosis requiring repetitive operations because of dysfunction of dilated proximal bowel. A new operative approach using lateral duodenectomy and duodenojejunostomy (LDAD) is reported. Methods: Three infants with atresias within 10 cm of the ligament of Treitz were treated with LDAD, and their records are reviewed retrospectively. The entire duodenum is visualized after creating a malrotation; this is followed by opening the dilated duodenum and resecting dilated proximal jejunum. The resection is extended proximally, incorporating the lateral duodenal incision, excising the lateral duodenal wall, and preserving the ampulla. The residual duodenum is fashioned into a tube and anastomosed to the spatulated distal jejunum. Results: Three infants underwent this procedure over a 4-year period. Two had undergone tapering enteroplasties previously but were unable to tolerate oral feedings; 1 infant had LDAD primarily. All were ultimately successfully managed by LDAD and were feeding within 14 days. Follow-up is from 14 to 49 months. Conclusion: Although experience is limited to 3 patients, the prompt return of intestinal function with LDAD may justify primary use of this more radical procedure in difficult-to-treat proximal atresias. J Pediatr Surg 35:353-356. Copyright © 2000 by W.B. Saunders Company.

Background: Inhibition of apoptosis may allow cells with drug-induced damage to escape programmed cell death. The bcl-2 protein inhibits apoptosis and bcl-2 overexpression has been associated with drug resistance. It is our hypothesis that higher levels of bcl-2 expression will be seen in colon cancer cells resistant to PYY treatment. Methods: Caco2 and HCT116 colon cancer cells were treated with 2 μM PYY for 24 hours. Protein was extracted from cells surviving PYY treatment; bcl-2 expression was measured by enzyme-linked immunosorbent assay (ELISA) and confirmed by Western blotting. Results: Caco2 and HCT116 cells surviving PYY treatment demonstrated increased bcl-2 from 20.54 ± 2.7 to 28.63 ± 2.20 units/mL (P

To present our initial experience with single-incision laparoscopy in the pediatric urologic population.Four patients underwent eight single-incision laparoscopic procedures. One patient underwent bilateral nephrectomies, a hernia repair, and an orchiectomy. The remaining three patients underwent unilateral nephrectomies. All procedures were performed in children using the Covidien SILS port system via an umbilical incision.Procedures in three of four patients, representing seven of eight cases, were successfully performed via a single incision. Operative times ranged from 114 minutes to 360 minutes. There were no conversions to traditional laparoscopy. One nephrectomy was converted to an open procedure secondary to bleeding. There were no complications postoperatively, and at follow-up, all wounds were well healed.Single-incision laparoscopic urologic surgery is safe and feasible in the pediatric population. The umbilical (trans or peri) approach confers improved cosmesis over traditional laparoscopy, and the scar is essentially concealed.

The objective of this study was to determine if distortion of the left subclavian artery course distinguishes double aortic arch with atretic left dorsal aorta from right aortic arch with mirror image branching. We performed a retrospective case series at a tertiary care center. Twenty-six patients undergoing magnetic resonance imaging for suspicion of a vascular ring were identified, 6 of whom had an atretic left dorsal aorta confirmed by surgical inspection. Six patients with the diagnosis of right aortic arch with mirror image branching were identified for comparison. The course of the left subclavian artery was assessed using surface-rendered magnetic resonance angiography (MRA) and axial fast spin echo images. All patients with double aortic arch had clinical symptoms suggestive of esophageal or tracheal compression. Six patients had double aortic arch, 3 of whom had an atretic left dorsal aorta. In these 3 patients, the branching patterns on MRA mimicked right aortic arch mirror image branching except for the distortion of the initial course of the left subclavian artery. Surgical observation confirmed the presence of an atretic left dorsal aorta that resulted in tension on the left subclavian artery pulling it posteriorly and inferiorly and completing the vascular ring. Patients with right aortic arch mirror image branching demonstrated no such subclavian artery distortion, and these patients did not have clinical symptoms suggestive of a vascular ring. Our results demonstrate that left subclavian artery distortion due to traction by an atretic left arch is an important diagnostic finding in the evaluation 6 patients with suspected vascular rings.

Penetrating aortic ulceration is uncommon in the infrarenal aorta. We describe a patient with a penetrating infrarenal aortic ulcer manifesting as blue toe syndrome, and a second patient with a similar lesion identified as an incidental finding. These two patients were treated for penetrating infrarenal aortic ulceration within the past 9 months at two university-affiliated hospitals, a regional Veterans Administration Medical Center, and a County Medical Center. Both lesions demonstrated aneurysm changes with varying degrees of mural thrombus. The lesion filled with fresh thrombus proved labile, with embolization manifesting as blue toe syndrome. We support the aggressive treatment of aneurysmal penetrating aortic ulcer with aortic graft replacement to eliminate the potential for distal embolization and to obviate the risk of rupture and death.

Purpose: Renal failure occurs in children with moderate frequency. Surgical aspects of establishing and maintaining dialysis access in small infants are exceptionally challenging. The purpose of this review is to evaluate the authors' experience with dialysis access for infants less than 10 kg, particularly with respect to the surgical care required. Methods: A retrospective review was conducted between 1991 and 1999 of all pediatric dialysis patients weighing 10 kg or less (n = 29). Age at start of dialysis, duration of dialysis, modes of dialysis, and complications specific to peritoneal (PD) and hemodialysis (HD) were examined. Results: The mean age at start of dialysis was 10.4 months and continued for an average duration of 16.3 months. Seventy-two percent of all patients required both modes of dialysis. HD and PD duration averaged 7.8 and 10.5 months, respectively. Catheter durability was 3.1 and 4.5 months per catheter for HD and PD, respectively. There was no significant difference in complications when comparing HD and PD. Patients who weighed 5 to 10 kg had significantly longer PD catheter durability than patients 0 to 5 kg ( P =.001). Forty-one percent of patients terminated dialysis after transplantation, whereas 24% died awaiting transplantation. Conclusion: Despite a large number of operations required, infants less than 10 kg can be bridged successfully, by surgical intervention and subsequent dialysis, to transplantation. J Pediatr Surg 35:1543-1548. Copyright © 2000 by W.B. Saunders Company.

The in vitro interaction of modulators of topoisomerase I and II with cisplatin in human ovarian carcinoma cells might be synergistic. The interactions were evaluated by median effect analysis of survival data derived from continuous exposure to drug combinations for 10 days in colony-forming assays. The interaction between cisplatin and the topoisomerase I inhibitor camptothecin and the topoisomerase I activator beta-lapachone was additive, as was that between cisplatin and the topoisomerase II inhibitor novobiocin. Despite the clinical efficacy of the combination of etoposide (a topoisomerase II inhibitor) and cisplatin, the combination index at 50% cell kill indicated antagonism between these two drugs. Thus, biochemical synergism at the cellular level is not a prerequisite of improved therapeutic efficacy.