Alain Ouimet

Blunt abdominal trauma in children: the practical value of ultrasonography.

The occult nature of blunt abdominal trauma justifies the need for reliable diagnostic adjuncts to physical examination. From June 1988 to June 1991, 259 children admitted to the general surgery/trauma service underwent abdominal ultrasonographic scanning (US). A total of 116 abdominal lesions were found in 81 patients. Ultrasonography alone had a sensitivity of 89%, a specificity of 96%, and an overall accuracy of 94%, as determined against the overall diagnostic workup and clinical course (mean follow-up, 17.4 weeks). In 44% of the patients, US was used alone; in 49% one or two additional tests were performed, and in only 7% were three or more tests required. Compared with computed tomography, US is more versatile, easier to perform in children, and more cost effective, even with the addition of a functional imaging modality. Although not demonstrated by this preliminary, retrospective study, Doppler US appears to be the logical complement to abdominal ultrasonography in the evaluation of children with blunt abdominal trauma.

Blunt Pancreatic Injuries in Children: The Role of Percutaneous External Drainage in the Treatment of Pancreatic Pseudocysts

During the past 10 years, 26 cases of blunt pancreatic trauma were diagnosed in our institution. In 42.3% (11/26) the accident was bicycle-related. Seventy-three percent of patients were seen within 48 hours of injury. The most frequent clinical presentations included abdominal pain, tenderness and vomiting. Diagnosis of pancreatic injury was suggested by hypermylasemia in most cases. Associated trauma was seen in seven patients (26.9%) and it was intraabdominal in four (15.3%). Computerized tomography (CT) scan is the single most useful radiologic investigation in evaluating pancreatic trauma. Ultrasound, although less accurate than CT scan in determining the severity of the initial injury, is useful in the evaluation and treatment of pancreatic pseudocysts. Pancreatic pseudocysts developed in ten patients. Spontaneous resolution occurred in five (50%). In three patients, percutaneous external drainage (PED) was successful in treating pancreatic pseudocysts without complications or recurrence at 11, 19, and 31 months. PED is a suitable form of treatment in selected cases of pancreatic pseudocysts. Results in children are better than in the adult population, probably due to the absence of primary pancreatic pathology. We believe that PED should be considered the primary therapeutic procedure for traumatic pancreatic collections prior to more invasive surgical treatment, when there is no evidence of pancreatic duct transection on CT scan.

Endoscopic retrograde cholangiopancreatography is useful and safe in children

PURPOSE Endoscopic retrograde cholangiopancreatography (ERCP) is a recognized diagnostic and therapeutic tool in the adult population. Its use in children has been more common in the last years. There are little data on safety and usefulness of that procedure in children. The aim of this study was to review the experience with ERCP in a tertiary university center dedicated to children. METHOD We conducted a retrospective chart review of patients seen at the Centre Hospitalier Universitaire Ste-Justine (Montreal, Quebec, Canada) who had undergone an ERCP between September 1990 and July 2007. Data on demographics, diagnosis, anesthesia type, treatments, and complications were collected. RESULTS Thirty-eight ERCPs were performed on 29 patients. There were 21 girls (72%), and median age at time of procedure was 10.3 years old (range, 3-17 years). Most had only one procedure performed. Two children had 2 interventions, and 1 child with papillary stenosis had 8 interventions linked to stent treatment. The ampulla was cannulated, and the procedure was successfully completed in 97% (37/38) of cases. General anesthesia and sedation were performed in 74% and 26% of procedures, respectively. Indications for ERCP were 29 recurrent or chronic pancreatitis (76%), 8 common bile duct obstructions (21%), and 1 choledochal cyst (3%). Endoscopic treatment was done in 29% of cases. The complication rate was 13.5%, and 4 clinical acute pancreatitis resolved with conservatory treatment. No severe pancreatitis, perforation, or bleeding was noted. Of the patients, 79% had their follow-up at the Centre Hospitalier Universitaire Ste-Justine for a median length of 43 months (range, 1-53 months). CONCLUSION Endoscopic retrograde cholangiopancreatography is used as a diagnostic and therapeutic procedure in children with a complication rate similar to that seen in adults. The need for general anesthesia is much more frequent with children. When performed by well-trained endoscopists, ERCP is useful and safe in children.

Timing and surgical management of neonatal testicular torsions

BACKGROUND The timing and surgical management of neonatal testicular torsions (NTTs) remain controversial, varying from immediate orchiectomy with empirical contralateral orchiopexy to expectant management with resulting atrophy of the affected testicle. The goal of the present study is to review the management of this entity at our institution. MATERIALS AND METHODS A retrospective study of all patients with NTT from 1989 to 2007 was undertaken. The age, clinical presentation, investigation, management, and short- and long-term outcomes were noted. RESULTS Forty-four patients were included. Most presented with a firm testicular mass, scrotal discoloration, and hydrocele (42), whereas a few presented with testicular atrophy (2). The median age at presentation was 1 day of age (range, 0-84 days), with NTT occurring on the right side in 22 patients and the left side in 20. Two patients (5%) had bilateral torsion at presentation. In 33 patients, the diagnosis was confirmed by Doppler ultrasonography, whereas 11 patients did not undergo any additional investigation. Surgical management included ipsilateral orchiectomy and contralateral orchiopexy (IOCO) (27), orchiopexy of the contralateral testis (CO) (7), bilateral orchiopexy (4), orchiectomy of the ipsilateral testis (1), orchiopexy of the ipsilateral testis (2), and observation (1). The 2 bilateral torsions underwent bilateral orchiectomy (2). The median age at surgery was 25 days (range, 1-912 days). Postoperative complications occurred in 8 patients (18%), mainly in those with IOCO (4) and CO (4) operated before 12 days of age, and included recurrent hydrocele (3), wound infection (2), urinary tract infection (1), and others (2). Upon follow-up, patients who underwent CO developed ipsilateral testicular atrophy (6). No patients were readmitted for recurrence of torsion or other complications. CONCLUSION At our institution, the most frequent management of unilateral neonatal testicular torsions is IOCO or CO, but this carries an 18% complication rate, particularly if surgery is performed early. There seems to be no advantage to early intervention, and the need for orchiectomy is debatable because torsion leads to ipsilateral testicular atrophy. Contralateral orchiopexy done to decrease the incidence of bilateral asynchronous torsion should, at the very least, be deferred until the risks of anesthesia and surgery are improved, given its rarity. Given the fact that most patients underwent IOCO or CO, we cannot conclude which strategy is the best for neonatal testicular torsions. A prospective study is welcomed.

Partial splenectomy for benign cystic lesions of the spleen

Cystic lesions of the spleen are uncommon, about 600 cases being reported in the world literature. This report concerns three pediatric patients treated by partial splenectomy for benign cyst. In the world literature most of the cystic lesions of the spleen are treated by splenectomy and more recently by partial splenectomy. The infected lesions are treated by splenectomy or by incision and drainage only. Partial splenectomy has evident advantage over splenectomy. Although in the world literature we have not found a single case of infected splenic benign cyst treated by partial splenectomy, we believe that this procedure also has an advantage over drainage as the infected and necrotic part of the cyst is removed, thereby reducing morbidity and further possible complications.

Predictive indicators for bowel injury in pediatric patients who present with a positive seat belt sign after motor vehicle collision

PURPOSE Abdominal wall bruising (AWB) is a frequent finding in children wearing seat belts involved in motor vehicle collision (MVC) and is highly suspicious but not indicative of intestinal injury. The aim of this study was to find objective clinical and radiologic predictors for the need of an abdominal exploration in these children. MATERIALS AND METHODS A retrospective chart review of children admitted from 1998 and 2008 with AWB after MVC was conducted. Demographics, vital signs, physical examinations, radiologic investigations, associated injuries, management, and outcome were extracted. Univariate and multivariate statistical analyses were done. RESULTS Fifty-three children with a median age of 9 years (range, 3-16 years) were included. Forty-four patients (83%) had abdominal pain on arrival, and 25 (47%) had free intraabdominal fluid on ultrasound/scan. Intraabdominal injuries were noted in 29 patients (55%), and the most common were mesenteric or bowel injuries (25%), splenic injuries (13%), and hepatic injuries (8%). Ten patients (19%) needed therapeutic laparotomy, and all were victims from collision involving 2 moving vehicles, had abdominal pain, free intraabdominal fluid, and tachycardia. Five patients (50%) operated on had lumbar fracture compared to only 4 patients (9%) in the nonoperative group. Pulse rate higher than 120 (P = .048), lumbar fracture (P = .008), and free intraabdominal fluid (P <or= .001) were significant predictors for intestinal perforation. Overall survival was 98% with 1 death because of head trauma. CONCLUSION Intraabdominal injuries in children with AWB after MVC are frequent. Associated lumbar fracture, the presence of free intraabdominal fluid, and pulse rate higher than 120 are significant predictors of intestinal injuries. An abdominal exploration should be considered in these patients.

Fetus in fetu or not

A case of sacrococcygeal teratoma is presented with characteristics of fetus in fetu. The clinical implications of teratomatous tissue in an inguinal node are presented.

Cat-scratch disease: An unusual presentation

A 2-year-old child was found to have mesenteric lymphoadenopathy during investigation of a fever of unknown origin. The lymphadenopathy persisted at follow-up 2 months later. Workup for an infectious etiology was negative. A laparotomy and excisional biopsy was performed to eliminate lymphoma. Pathology showed enlarged lymph nodes containing granulomas with giant cells and central caseating necrosis. Warthin-Starry staining showed cat-scratch bacilli within the necrotic material. Cat-scratch disease is a well-recognized cause of regional adenopathy in children and usually resolves without treatment. Intraabdominal involvement, consisting of hepatic and splenic lesions, often associated with retroperitoneal adenopathy, has been reported. Isolated mesenteric adenopathy is an unusual presentation of this disease but should be included in the differential diagnosis of intraabdominal lymphadenopathy.

Total anomalous pulmonary venous return complicating portoenterostomy for biliary atresia

Cardiovascular anomalies such as absent inferior vena cava and preduodenal portal vein are reported in cases of biliary atresia and make hepatic portoenterostomy a technical challenge. The authors present the case of a severe cardiac anomaly that significantly altered the functional outcome of a Kasai procedure. Baby M., an 8-week-old boy born with total anomalous pulmonary venous return (TAPVR), underwent hepatic portoenterostomy for biliary atresia. Over the next 3 months he remained icteric and febrile, and failed to gain weight. After multiple antibiotic treatments for suspected cholangitis, he underwent reexploration of the portoenterostomy, with no improvement in his overall condition. His prognosis was considered dismal because correction of the cardiac anomaly is associated with a high mortality rate (> 90%). The cardiac surgeon agreed to attempt a cure of the TAPVR, provided liver transplantation is contemplated if the patient survived. Within 48 hours postoperatively, his hepatic function had improved drastically. He became afebrile, had an improved appetite and weight gain, and was finally discharged 203 days after admission. One year later, he is thriving and remains anicteric. The exact reason for this drastic improvement is not well understood, but the right-sided cardiac failure caused by the TAPVR had a significant effect on the functional outcome of the portoenterostomy.