Alan Mortell

Transhepatic central venous catheter for long-term access in paediatric patients

Vascular access in paediatric patients with chronic and/or life-threatening illness is crucial to survival. Access is frequently lost in this group because of thrombosis, infection, or displacement, and vascular options can quickly be exhausted. The last resort access procedure is generally a direct atrial catheter inserted via a thoracotomy. A viable alternative is the percutaneous transhepatic Broviac catheter (Bard Access Systems, Salt Lake City, UT). We retrospectively reviewed the charts of 5 patients who underwent percutaneous transhepatic Broviac insertion for long-term access over a 4-year period in a single institution. Four of the patients (80%) had a significant cardiac abnormality, with 1 patient requiring long-term parenteral nutrition after complicated necrotizing enterocolitis. All patients had significant caval thrombosis, which precluded them having placement of a standard percutaneous or openly placed central catheter. Of the 5 patients, 2 (40%) died of cardiac-related illnesses. Of the 3 surviving patients, 2 had functioning catheters electively removed because they were no longer required. One catheter was removed at thoracotomy for right atrial perforation because of catheter erosion. Vascular access in paediatric patients with chronic and/or life-threatening illness is crucial to survival. Transhepatic central venous catheters are a feasible, reliable, and relatively easily placed form of central access in patients with multiple venous thromboses requiring long-term access. This route should be considered in paediatric patients requiring central access in preference to a thoracotomy.

Publication patterns on neonatal surgery over 65 years

BACKGROUND/PURPOSE Staying abreast of the literature in a given speciality is difficult. The aim of this study is to analyze the publication patterns of the neonatal surgical literature over the last six decades. MATERIALS A search strategy for the Web of Science database was designed using MeSH defined terms for 10 index neonatal surgical conditions, with output analyzed over two time-periods. RESULTS There were 6215 and 6144 publications for periods 1 (1945-1994) and 2 (1995-2010), respectively. There were 24 and 546 articles published in 1945 and 2010, respectively. The mean citation counts of the top 50 publications are 228 and 156 for periods 1 and 2, respectively. There were 6 and 11 authors with two or more publications in the top 50 list in periods 1 and 2, respectively. Three of the pediatric surgery journals cumulatively have published 30.9% of the total articles. CONCLUSIONS Publication patterns for neonatal surgical conditions have changed significantly over time. The majority of articles are published outside of pediatric surgical journals. Pediatric surgeons should not limit their reading to these journals.

The Adriamycin rat/mouse model and its importance to the paediatric surgeon

The teratogenic effect of Adriamycin (doxorubicin) in the rat model, and more recently in the mouse, has provided paediatric surgeons with a reliable, easily reproducible method of studying the embryology and molecular biology for a range of complex congenital anomalies. Concomitantly these animal models have stimulated interest among embryologists for the effect on the notochord, shedding more light on the important organizational role of this structure in the developing embryo. Finally, as more is learnt of the pathogenesis of the various malformations induced by Adriamycin, future therapeutic interventions involving gene therapy, drugs or surgery may arise. This article reviews the establishment of the Adriamycin rat and mouse models, examines their impact on various congenital malformations, and suggests targets for further research.

Scrotal exploration for acute scrotal pain: A 10-year experience in two tertiary referral paediatric units

Abstract Objective.Acute scrotal pain is a common presentation to the paediatric emergency department. Testicular torsion is one of the most common causes of acute scrotal pain. Testicular torsion is a surgical emergency requiring immediate surgical exploration to prevent permanent testicular damage or loss. The aim of this study was to determine the surgical outcome of all scrotal explorations and to assess the use of colour Doppler ultrasound (CDUS) in the assessment of acute scrotal pain in two tertiary referral paediatric units. Material and methods. A retrospective review of a prospectively maintained database was carried out for all scrotal explorations between 1999 and 2010. Results.In total, 155 scrotal explorations were carried out for acute scrotal pain. The mean age was 9.1 years (range 0–15 years). The pathology in 46.5% (n = 72) was testicular torsion, 30.3% (n = 47) were torsion of a testicular appendage, 16.1% (n = 25) were epididymitis, 3.3% (n = 5) had no obvious pathology identified and other pathology accounted for 4%. There was a significant difference in age of presentation between those with testicular torsion and those with torsion of a testicular appendage (9 vs 10 years, p = 0.0074). CDUS was performed by a trained radiologist on 40 patients. Overall sensitivity, specificity, positive predictive value and negative predictive value for CDUS predicting testicular torsion were 96.9%, 88.9%, 96.9% and 89%, respectively. Overall, 36 patients (23%) with acute scrotal pain (50% of patients in the group with confirmed testicular torsion at exploration) required orchidectomy. Conclusion. This study supports the practice of immediate surgical exploration with a clinical suspicion of testicular torsion in a paediatric population.

Oesophageal inflammatory paediatric chylothorax.

Paediatric chylothoraces are rare, particularly outside the operative setting. Cases of spontaneous chylothorax are often demanding diagnostically and frequently associated with patient morbidity. We present a challenging case of paediatric chylothorax associated with inflammatory oesophageal perforation likely related to foreign body ingestion.