Anthony C. Chin

Acute pancreatitis in children: spectrum of disease and predictors of severity

BACKGROUND The aim of this study was to describe the spectrum of disease in children with acute pancreatitis and assess predictors of severity. METHODS Children (≤ 18 years) admitted to a single institution with acute pancreatitis from 2000 to 2009 were included. The accuracy of the Ranson, modified Glasgow, and pediatric acute pancreatitis severity (PAPS) scoring systems for predicting major complications was assessed. RESULTS The etiology of pancreatitis in these 211 children was idiopathic (31.3%), medication-induced (19.9%), gallstones (11.8%), trauma (7.6%), transplantation (7.6%), structural (5.2%), and hemolytic-uremic syndrome (3.3%). Fifty-six patients (26.5%) developed severe complications. Using the cutoff thresholds in the PAPS scoring system, only admission white blood cell count more than 18,500/μL (odds ratio [OR], 3.1; P = .010), trough calcium less than 8.3 mg/dL (OR, 3.0; P = .019), and blood urea nitrogen rise greater than 5 mg/dL (OR, 4.1; P = .004) were independent predictors of severe outcome in a logistic regression model. The sensitivity (51.8%, 51.8%, 48.2%) and negative predictive value (83.2%, 83.5%, 80.5%) of the Ranson, modified Glasgow, and PAPS scores were, respectively, insufficient to guide clinical decision making. CONCLUSION Commonly used scoring systems have limited ability to predict disease severity in children and adolescents with acute pancreatitis. Careful and repeated evaluations are essential in managing these patients who may develop major complications without early signs.

Unilateral groin surgery in children: will the addition of an ultrasound‐guided ilioinguinal nerve block enhance the duration of analgesia of a single‐shot caudal block?

Background:  Inguinal hernia repair, hydrocelectomy, and orchidopexy are commonly performed surgical procedures in children. Postoperative pain control is usually provided with a single‐shot caudal block. Blockade of the ilioinguinal nerve may lead to additional analgesia. The aim of this double‐blind, randomized controlled trial was to evaluate the efficacy of an adjuvant blockade of the ilioinguinal nerve using ultrasound (US) guidance at the end of the procedure with local anesthetic vs normal saline and to explore the potential for prolongation of analgesia with decreased need for postoperative pain medication.

Total gastrectomy: options for the restoration of gastrointestinal continuity

Total gastric resection and the subsequent selection of the optimum procedure for reconstruction of the oesophageal-intestinal tract is a highly debated topic. Many different types of reconstruction have been proposed, but attempts to objectively validate the potential advantages of these techniques of have not produced any definitive conclusions. The main aim of reconstruction should be to maintain the nutritional status and quality of life of the patient, with the additional goal of achieving similar function to normal gut. In this review, we discuss the prospectively randomised studies of gastrointestinal reconstruction that were done between 1987 and 2002.

Nonconvulsive seizures are common in children treated with extracorporeal cardiac life support.

Objectives: The prevalence of electrographic seizures or nonconvulsive status epilepticus and the effect of such seizures in children treated with extracorporeal cardiac life support are not known. We investigated the occurrence of electrographic abnormalities, including asymmetries in amplitude or frequency of the background rhythm and interictal activity in children undergoing extracorporeal cardiac life support and their association with seizures. We compared mortality and radiologic evidence of neurologic injury between patients with seizures and those without seizures. Design: Retrospective review of medical records and the Extracorporeal Life Support Organization database. Setting: PICU at a single institution. Patients: All pediatric patients up to 18 years old, who had extracorporeal cardiac life support and continuous electroencephalography monitoring between the years 2006 and 2011. Interventions: None. Measurements and Main Results: Nineteen patients treated with extracorporeal cardiac life support underwent continuous electroencephalography monitoring. Seizures occurred in four patients (21%) and were exclusively nonconvulsive in three patients. Two of these four patients had nonconvulsive status epilepticus. Interictal discharges on electroencephalography were associated with seizures (odds ratio, 19.5 [95% CI, 1.29–292.75]; p = 0.03). Only 50% of the seizures were detected in the first hour of monitoring, whereas all seizures were detected within 24 hours. All patients with seizures had structural abnormalities seen on neuroimaging. Seizures were not significantly associated with increased mortality. To evaluate for ascertainment bias, we compared outcomes between patients who underwent extracorporeal cardiac life support and received continuous electroencephalography monitoring and those patients who underwent extracorporeal cardiac life support during the study period but did not receive electroencephalography (n = 30). Conclusions: Seizures are common in children during extracorporeal cardiac life support, and most seizures are nonconvulsive. In patients undergoing extracorporeal cardiac life support, clinical features are unreliable indicators of the presence of seizures. The presence of seizures is suggestive of CNS injury. This study is limited by the exclusion of neonates, a feature of the clinical use of electroencephalography at our institution. Although seizures were not associated with increased mortality, further prospective studies in larger populations are needed to assess the long-term morbidity associated with seizures during extracorporeal cardiac life support.

Current diagnosis and management of urachal remnants.

PURPOSE The purposes of this study are to review our experience with patients who were found to have urachal remnants. We discuss their diagnosis and management and we also evaluate post-operative complications in our cohort of patients with this entity. METHODS We performed a retrospective review of all patients diagnosed with a urachal remnant (UR) between January 2006 and December 2010. Patient variables included age, gender, presenting symptoms and signs, diagnostic modality, and type of urachal remnant. Operative management, post-operative complications, and non-operative follow-up were abstracted. RESULTS We identified 103 pediatric patients with either a urachal cyst (n = 38), urachal diverticulum (n = 13), urachal sinus (n = 11), patent urachus (n = 21), or a non-specific atretic urachal remnant (n = 20). Seventy-eight patients had symptomatic URs. Thirty-four symptomatic patients underwent surgical excision of the UR and 44 symptomatic patients were observed. Eighteen URs were incidentally diagnosed in asymptomatic patients, none of whom underwent surgical excision. In 7 patients symptoms could not be determined from the records. No patients with non-specific atretic remnants were operated upon. Nineteen of the observed patients were reimaged subsequently. In fifteen (78.9%) of these patients, the URs had resolved spontaneously. None of the patients who were observed required subsequent excision of the UR. Post-operative complications occurred in 14.7% of patients in whom URs were excised. CONCLUSION Review of our patients diagnosed with URs indicates there is a subset of patients in whom spontaneous resolution could be expected. Complications are not uncommon after surgical excision.

Utility of the computed tomography severity index (Balthazar score) in children with acute pancreatitis

BACKGROUND Previous studies in children with acute pancreatitis have demonstrated that clinical scoring systems such as the Ranson, modified Glasgow, and pediatric acute pancreatitis scores are of value in predicting severity of the disease. The aim of this study was to determine the predictive value of the computed tomography severity index (CTSI or Balthazar score) in pediatric patients. METHODS All children (≤ 18 years) admitted to our institution with acute pancreatitis from 2000 through 2009 were reviewed. Contrast-enhanced computed tomographic (CT) images at presentation were retrospectively reviewed by 2 pediatric radiologists. Peripancreatic fluid and the extent of necrosis were assessed to determine the CTSI. The predictive value of the CTSI was calculated and compared with clinical scoring systems. RESULTS Of 211 children with acute pancreatitis, 64 underwent contrast-enhanced CT at presentation. The median age was 12.3 years. Etiology of pancreatitis was idiopathic (35.9%), gallstone (17.2%), medication-induced (20.3%), posttransplant (9.4%), traumatic (6.3%), structural (1.6%), and other (9.4%). The sensitivity, specificity, positive predictive value, and negative predictive value of the CTSI (using a cutoff score of 4+) were 81%, 76%, 62%, and 90%, respectively, which compared favorably to the results of the pediatric acute pancreatitis (53%, 72%, 41%, 80%), Ranson (71%, 87%, 67%, 89%), and modified Glasgow (71%, 87%, 67%, 89%) scores. CONCLUSION The CTSI is superior to clinical scoring systems for identifying children with acute pancreatitis at heightened risk for developing serious complications.

Hazardous complications of multiple ingested magnets: report of four cases.

Foreign body ingestion is a common occurrence in the pediatric population. Frequent culprits include coins, toys, sharp objects and bones, which most often pass spontaneously. Magnet ingestion, however, can be a serious matter, especially when more than one is taken in. The extremely strong magnetic force between multiple magnets may result in numerous complications including bowel necrosis, perforation, obstruction, fistula formation, volvulus and death. We present the largest series reported to date, with four cases of multiple magnet ingestion at our institution with varied presentations and findings. We review the literature, and discuss the importance of having a high index of suspicion.

Laparoscopic Excision of Choledochal Cysts with Total Intracorporeal Reconstruction

PURPOSE There are numerous published reports of laparoscopic resection of choledochal cysts (CDCs), but almost all involve extracorporeal reconstruction of a biliary drainage system. We describe and evaluate the technique of laparoscopic CDC resection with total intracorporeal reconstruction. METHODS We reviewed all patients who underwent a laparoscopic CDC resection from March 2005 to January 2010 at Rocky Mountain Childrens Hospital and Childrens Hospital of New York-Presbyterian. We obtained data on operative time, characteristics of reconstruction, time to initiation of diet, length of stay, complications, and outcome. RESULTS Thirteen patients (median age 5 years, range 1-16) underwent a laparoscopic CDC excision with total intracorporeal reconstruction. Four ports were used in all cases and no patients required conversion to an open procedure. Operative time ranged from 130 to 325 minutes (median 240 minutes). Median time to initiation of diet was 1 day (range 1-4 days). Median length of stay was 5 days (range 4-8 days). There were no cases of cholangitis; however, 1 patient developed a small bowel obstruction requiring re-operation. CONCLUSION Laparoscopic resection of CDCs with total intracorporeal reconstruction is a safe and effective technique. The minimal handling of the bowel appears to minimize postoperative ileus, allows for early postoperative feeding and discharge.

Previous portal hypertension surgery negatively affects results of mesenteric to left portal vein bypass

PURPOSE The mesenteric to left portal vein bypass (MLPVB) has been successfully used to treat extrahepatic portal vein obstruction (EHPVO) in children. We examined the effect of failed prior surgical or radiological procedures intended to treat complications of portal hypertension on the success rate of subsequent MLPVB surgery. METHODS Sixty-two patients younger than 18 years with EHPVO underwent MLPVB between 1997 and 2006. Children were divided into 3 groups: those with no prior surgery related to portal hypertension, those with prior portosystemic shunts, and those with either splenectomy or mesenteric vascular embolization procedures. The effect of prior procedures on the patency rate of the MLPVB was then examined. RESULTS Of 62 children, 11 (17.7%) had significant procedures to treat symptoms of portal hypertension: 6 had at least 1 portosystemic shunt attempt, 3 had isolated splenectomy, and 2 had embolization of the splenic artery or coronary and peripancreatic varices. Patients with previous portal hypertension surgery were significantly older and larger than those with no surgery. Patients with no prior interventions had a significantly higher MLPVB patency rate (88.2%, 45/51) than those with no prior interventions (63.6%, 7/11). Prior splenectomy alone was not found to adversely affect MLPVB. Patients with prior embolization procedures or unsuccessful shunts had significantly poorer successful outcomes (0% and 66.7%) than those with no prior interventions (88.2%; P < .005). CONCLUSIONS The results demonstrate that prior portosystemic shunts or mesenteric embolizations have a deleterious effect on outcome after MLPVB and should be avoided whenever possible. This study suggests that patients with symptomatic EHPVO should undergo MLPVB as a primary intervention rather than as a rescue procedure to optimize MLPVB patency.

Early effects of lipopolysaccharide on cytokine release, hemodynamic and renal function in newborn piglets

Background: Gram-negative sepsis in newborns is associated with high mortality and morbidity. Lipopolysaccharide (LPS) and cytokines released upon exposure to gram-negative sepsis are well known to be involved in the pathophysiology. Objective: In this report we investigate cytokine release, hemodynamic, and renal function induced by LPS in a newborn animal model with the intention to further examine early changes in gram-negative sepsis. Methods: Five 7- to 10-day-old domestic piglets were anesthetized and catheters placed in the jugular veins, left ventricle, and femoral artery. Urine output was monitored via suprapubic cystostomy. Mean arterial pressure, heart rate, and arterial blood gases were continuously monitored. Thirty minutes after line placement and obtaining baseline values, 0.06 µg/kg LPS were administered intravenously. One, 2, and 3 h later samples were taken to monitor tumor necrosis factor (TNF)-α, interleukin (IL)-1β, endothelin, and nitric oxide (NO)/nitrate via ELISA. In addition, blood flow was assessed by the microsphere method. Results: Our data show an initial surge of TNF-α and IL-1β at 1 h after exposure to LPS. NO/nitrate, endothelin, and hemodynamic as well as metabolic changes became apparent mostly 3 h after exposure, by which time TNF-α and IL-1β fell back to baseline. Conclusions: Our sepsis model suggests a brief initial TNF-α and IL-1β surge following LPS challenge; however, their effects become apparent by the time the levels are already subsiding. The emergence of vasoactive substances, NO and endothelin, precedes the first substantial clinical symptoms.