Brian F. Gilchrist

Selective use of ultrasonography for acute appendicitis in children

BACKGROUND To evaluate the role of ultrasonography in children with equivocal signs of acute appendicitis, and correlate with initial clinical impression and pathological findings. METHODS This is a prospective evaluation of all children presenting with a possible diagnosis of appendicitis during a 14-month study period. Patients with unequivocal clinical signs of appendicitis underwent appendectomy without ultrasonography. Patients with equivocal signs had documentation of the clinical impression and subsequent abdominal ultrasound. Statistical analysis of results was performed using the chi-square test (P <0.05 significant). RESULTS Two hundred fifteen consecutive children were enrolled. Signs were unequivocal in 116 and equivocal in 99. Seven patients in the first group had a normal appendix at operation. Of the 99 patients with equivocal signs, there were 28 true positives, 3 false positives, 64 true negatives, and 4 false negatives. In equivocal cases, sensitivity of the initial clinical impression versus ultrasound was 50% and 88%, respectively (P <0.05). Specificity was 85% and 96%, respectively. The positive and negative predictive values improved from 63% to 90% and 78% to 94%, respectively, with the use of ultrasonography. CONCLUSIONS The low false positive rate (6%) in clinically obvious cases of appendicitis does not, in our opinion, warrant ultrasonography. In clinically equivocal cases, ultrasonography is a fast, sensitive, and specific diagnostic modality to diagnose or rule out appendicitis, avoiding the need for prolonged observation and/or hospitalization.

Catastrophic cardiac injuries encountered during the minimally invasive repair of pectus excavatum

This paper presents four severe cardiac injuries that occurred in patients who underwent the minimally invasive repair of pectus excavatum (MIRPE). These complications occurred in different clinical settings, namely in a patient with an extremely severe form of pectus, in a patient who had previously undergone an open repair, after a previous open heart surgery, and at the time of bar removal. The purpose of this article is to review the circumstances leading to these cardiac injuries, share what we have learned from these patients, and hopefully help avoid these complications in the future.

Methylene blue: dangerous dye for neonates.

Methylene blue is a basic dye commonly used in histologic microbiologic, and tissue staining. This report describes an instance of methylene blue toxicity in a premature neonate.

Endoscopic Tracheal Obstruction with an Expanding Device in a Fetal Lamb Model: Preliminary Considerations

Tracheal obstruction to promote lung growth may be a less aggressive alternative to open fetal surgery in the antenatal treatment of congenital diaphragmatic hernia. Herein, we explore the feasibility of placing an occluding device through fetal tracheoscopy. A self-expanding umbrella allowed adequate sealing of the tracheal lumen even as the tracheal diameter more than doubled between 110 and 138 days of gestation (term = 145 days) in a sheep model. Distal intratracheal pressures after umbrella placement, and lung weight at delivery, were comparable to those after formal tracheal ligation.

The growing teratoma syndrome

Growing teratoma syndrome is defined as enlarging masses of mature teratoma following chemotherapy for malignant nonseminomatous germ-cell tumors. Typically, there is associated normalization of initially elevated serum tumor markers. We describe clinical and imaging findings in a case of growing teratoma syndrome originating from immature teratoma of the ovary in a 12-year-old girl. Familiarity with this unusual entity is important to avoid confusion with advancing malignancy.

Pyloroplasty in association with nissen fundoplication in children with neurologic disorders

Previous studies have suggested that delayed gastric emptying occurs in severely mentally retarded patients with gastroesophageal reflux. Based on this data, pyloroplasty was employed in such patients. A retrospective analysis of 99 consecutive patients who underwent primary fundoplication for GER was performed. Gastric emptying, as measured by successful removal of the nasogastric tube or elevation of the gastrostomy tube, was studied. Children with neurologic disorders had no clinically significant difference in gastric emptying after fundoplication (3.31 days) when compared with neurologically normal patients (2.21 days). When added to Nissen fundoplication, pyloroplasty did not hasten the return of gastrointestinal function in the severely impaired patients (4.91 days). A prospective study employing gastric isotope bolus feedings before and after Nissen fundoplication will determine if pyloroplasty improves gastric emptying when used in conjunction with Nissen fundoplication for patients with severe neurologic disorders.

External compression as initial management of giant omphaloceles

The authors describe a noninvasive technique for the management of giant omphaloceles. Two patients with giant omphaloceles were managed with external compression. Dry sterile dressings were used, buttressed by an Ace bandage in the first case and by a handcrafted Velcro abdominal binder in the second. The binder was tightened every 2 or 3 days. Renal, cardiovascular, respiratory, and gastrointestinal parameters were measured regularly to determine whether the binder was too tight. The first patient had only occasional emesis, and the defect was repaired after 40 days of compression. The second patient experienced intermittent hypertension, occasional emesis, and mild oxygen desaturation, which resolved when the binder was loosened slightly. The fascia muscle and skin were closed after 30 days of external compression. Both patients are currently living at home and doing well. This form of external compression is an effective, inexpensive, and low-risk method for the gradual reduction of giant omphaloceles, and should be considered for patients born with this problem.

Child abuse as a cause of traumatic chylothorax

Chylothorax is an uncommon condition that may be associated with significant morbidity and mortality. The authors report a case of traumatic chylothorax attributed to child abuse and describe our management with tube thoracostomy and nutritional support with medium-chain triglycerides. Child abuse should be suspected in any case of chylothorax when no other etiology is evident and particularly when other signs of abuse are present.

Tonsil Tummy Tumult

A ppendicitis in children remains a difficult diagnosis to make. Despite better imaging modalities, falsenegative rates still approach 10%.1,2 The diagnosis of acute appendicits can humble the most savvy clinician. A plethora of anatomical variances, concomitant pathologies, and individual inflammatory idiosyncracies confound the diagnosis. One common childhood disease, however, simple as it may be, can lead to an erroneous diagno-