Carlos Angel

Sigmoid volvulus in children and adolescents

BACKGROUND Sigmoid volvulus is an exceptionally rare and potentially life-threatening condition in the pediatric age group. STUDY DESIGN We report our experience with three children treated for sigmoid volvulus and review the cases reported in the medical literature since 1940. RESULTS Since 1940, 63 cases of sigmoid volvulus in children (including this series) have been reported. The median age was 7 years and the male to female ratio was 3.5:1. Two distinct presentations (acute and recurrent) were identified. Abdominal symptoms dominated the clinical picture. Barium enemas either confirmed or were highly suggestive of sigmoid volvulus. Reduction by barium enema was successful in 77% (10 of 13) of the attempts. Forty-nine patients underwent operative treatment, with sigmoidectomy (with or without primary anastomosis) being the most common. The overall mortality rate was 6%, operative mortality was 8.1%, and neonatal mortality was 14%. Associated conditions were frequent. Particular emphasis should be placed on ruling out Hirschsprungs disease (present in 11 of 63 patients). CONCLUSIONS Sigmoid volvulus remains a rare occurrence in children, but it should be included in the differential diagnosis of pain in children when colonic distention is present. An algorithm for treatment is proposed.

Validity of plain films in intussusception

The aim of this study was to re-evaluate the specificity of plain film findings in intussusception. The plain film findings in 80 cases of proven intussusception were reviewed. Findings documented were: (1) presence or absence of small bowel obstruction, (2) paucity of right lower quadrant gas, (3) presence of an intracolonic mass, (4) presence of a rim or target sign, and (5) presence of the classic triad of intestinal obstruction, intracolonic mass, and paucity of right lower quadrant gas. Intestinal obstruction was present in 54% of patients. In 19 patients (24%) the abdominal films were completely normal. Paucity of right lower quadrant gas was seen in 10% of patients, while specific findings of a mass or a target (rim) sign were seen in 29% of patients. The classic triad of an intracolonic mass, obstruction, and paucity of gas in the right lower quadrant occurred in only 1 patient (1%). Plain films of the abdomen were diagnostic of intussusception in only 29% of cases. A completely normal gas pattern was seen in one-quarter of our patients. This being the case, most patients with suspected intussusception will require further imaging, either by ultrasound or contrast enema. In our institution we favor the ultrasound study.

Human mitochondrial oxidative capacity is acutely impaired after burn trauma.

BACKGROUND Mitochondrial proteins and genes are damaged after burn injury in animals and are assessed in human burn patients in this study. METHODS The rates of maximal muscle mitochondrial oxidative capacity (adenosine triphosphate production) and uncoupled oxidation (heat production) for both palmitate and pyruvate were measured in muscle biopsies from 40 children sustaining burns on more than 40% of their body surface area and from 13 healthy children controls. RESULTS Maximal mitochondrial oxidation of pyruvate and palmitate were reduced in burn patients compared with controls (4.0 +/- .2:1.9 +/- .1 micromol O2/citrate synthase activity/mg protein/min pyruvate; control:burn; P < .001 and 3.0 +/- .1: .9 +/- .03 micromol O2/citrate synthase activity/mg protein/min palmityl CoA; control:burn; P = .003). Uncoupled oxidation was the same between groups. CONCLUSIONS The maximal coupled mitochondrial oxidative capacity is severely impaired after burn injury, although there are no alterations in the rate of uncoupled oxidative capacity. It may be that the ratio of these indicates that a larger portion of energy production in trauma patients is wasted through uncoupling, rather than used for healing.

Renal and peri-renal abscesses in children: Proposed physio-pathologic mechanisms and treatment algorithm

Abstract.Renal and perinephric abscess in children are uncommon. Three basic pathophysiologic mechanisms are involved, namely, hematogenous spread, ascending infection and contamination by proximity to an infected area. Six pediatric patients diagnosed with renal abscess were treated at our institution from 1990–2000. Five patients were females; ages ranged from 3–17 years (mean 11.8 years). Diagnosis, as expected, was not readily apparent at presentation. Computerized tomography and renal sonograms were the most useful imaging modalities. Gram-negative bacteria were commonly isolated; only one patient grew Staphylococcus aureus. All patients received broad-spectrum intravenous antibiotics. Additional treatments consisted of percutaneous drainage (4 patients), exploratory laparotomy (1 patient, for presumed Wilms tumor) and nephrectomy (2 patients). A new classification of the etiologic mechanisms of this condition is proposed along with a simple and practical treatment algorithm.

Intestinal zygomycosis due to Absidia corymbifera mimicking necrotizing enterocolitis in a preterm neonate.

Zygomycosis is a rare fungal disease that occurs in compromised human hosts, including the preterm infant. The three clinical forms of zygomycosis are cellulitis, disseminated, and gastrointestinal, and the last often mimics necrotizing enterocolitis (NEC), complicating the diagnosis. This report details a case of primary gastrointestinal zygomycosis due to Absidia corymbifera, mimicking NEC, in a preterm infant, and emphasizes features that may lead to earlier diagnosis and treatment of future cases.

Perioperative extracorporeal membrane oxygenation for tracheal reconstruction in congenital tracheal stenosis

Abstract The management of a critical airway in infants and toddlers with congenital tracheal stenosis (CTS) continues to be an enormous challenge to the surgeon. Until recently, this condition often proved fatal. Improvements in surgical techniques, anesthetic management, and postoperative critical care have resulted in successful outcomes in children not long ago considered untreatable. However, issues such as the best operative approach and the optimal perioperative management are still unresolved. The diagnosis of CTS, often delayed, must be considered in any infant with stridor, wheezing, cyanosis, or recurrent episodes of pneumonia. Associated anomalies are the rule, including frequently vascular rings and rarely pulmonary agenesis. These defects can be repaired with conventional ventilatory support under cardiopulmonary bypass, or using extracorporeal membrane oxygenation (ECMO). We report our experience in which ECMO was used to support two patients with CTS during the perioperative period. ECMO proved to be both safe and practical, allowing unrushed, precise repair of the tracheal stenosis and providing brief postoperative support. Perioperative outcomes were excellent, although one of our patients died months after the repair. A review of the literature and our experience in which ECMO was used to provide cardiopulmonary support during repair of CTS showed uniformly successful perioperative outcomes.

Experience with vascular control before excision of giant, highly vascular sacrococcygeal teratomas in neonates

Sacrococcygeal teratomas (SCT) are the most common neoplasms in newborns with a reported occurrence of 1 in 35,000 live births. Highly vascularized tumors in which the ratio of tumor weight to patient weight approaches 1:1 are frequently associated with hyperdynamic states, prenatal hydrops, placentamegaly, postnatal high-output cardiac failure, and carry a high perinatal mortality rate. Operative management of giant, highly-vascular sacrococcygeal teratomas in neonates can be complicated by life-threatening hemorrhage. Laparotomy, control of the aorta, and the arterial blood supply to these tumors before resection has been advocated as a safer alternative. The authors report their experience with three infants successfully treated using this approach. Hemodynamic stability was maintained during the operations. All tumors were resected successfully. The patients are alive without evidence of recurrence, 8.5 months to 18 months (average, 14.3 months) after the operation. Alpha-fetoprotein levels dropped to normal range after the removal of SCT and have remained normal in follow-up. Vascular control before excision of giant, highly-vascular SCT in neonates is safe, decreases intraoperative blood loss, and postoperative morbidity.

Brain abscess: an unusual complication of multiple esophageal dilatations

Lye ingestion in children continues to be a problem and may result in severe esophageal strictures. Esophageal dilatations to treat these strictures usually result in bacteremia. A case of 13-year-old boy who developed a brain abscess after multiple esophageal dilatations is presented and discussed and the literature on the subject is reviewed.

Insulin Sensitivity is Related to Fat Oxidation and Protein Kinase C Activity in Children With Acute Burn Injury

Impaired fatty acid oxidation occurs with type 2 diabetes and is associated with accumulations of intracellular lipids, which may increase diacylglycerol (DAG), stimulate protein kinase C activity, and inactivate insulin signaling. Glucose and fat metabolism are altered in burn patients, but have never been related to intracellular lipids or insulin signaling. Thirty children sustaining >40% total body surface area burns were studied acutely with glucose and palmitate tracer infusions and a hyper-insulinemic euglycemic clamp. Muscle triglyceride, DAG, fatty acyl CoA, and insulin signaling were measured. Liver and muscle triglyceride levels were measured with magnetic resonance spectroscopy. Muscle samples from healthy children were controls for DAG concentrations. Insulin sensitivity was reduced and correlated with whole body palmitate &bgr;-oxidation (P = .004). Muscle insulin signaling was not stimulated by hyper-insulinemia. Tissue triglyceride concentrations and activated protein kinase C-&bgr; were elevated, whereas the concentration of DAG was similar to the controls. Free fatty acid profiles of muscle triglyceride did not match DAG. Insulin resistance following burn injury is accompanied by decreased insulin signaling and increased protein kinase C-&bgr; activation. The best metabolic predictor of insulin resistance in burned patients was palmitate oxidation.

Post-operative intussusception: often an elusive diagnosis.

Sir, Although radiologists have a high index of suspicion in diagnosing spontaneous intussusception in children, the diagnosis of postoperative intussusception remains elusive. This entity is an uncommon, yet potentially fatal postsurgical complication which can occur after virtually any type of abdominal surgery [1±6]. Physician awareness of this condition is imperative, but reports of postoperative intussusception in the radiologic literature are sparse [1±3]. For this reason, we present our two cases. In our first patient, a 16-year-old male, exploratory laparotomy was performed for abdominal distention after a gunshot wound to the left neck. This procedure revealed 1700 ml of chylous ascites but was otherwise believed negative. After the operation, the patient had intermittent episodes of vomiting and abdominal distention. Barium enema, small bowel follow-through, and CT of the abdomen and pelvis were interpreted as showing no evidence of obstruction. However, loops of small intestine were markedly distended on both plain films and the CT study. After 2 weeks of symptoms, the patient was transferred to our institution where review of the imaging studies demonstrated evidence of small bowel obstruction and an ileo-colonic intussusception, best visualized on the small bowel follow-through (Fig. 1). Our second case was that of a 4-year-old boy who underwent exploratory laparotomy for abdominal distention and hypotension after a lawn mower accident involving major trauma to the left lower extremity. The laparotomy was unremarkable, but on the 3rd postoperative day, the patient developed progressive abdominal distention, nausea, and vomiting. On the 7th postoperative day, a CT study of the abdomen and pelvis revealed a small bowel obstruction with a target appearance of a loop of small bowel suggesting intussusception (Fig. 2). Intraoperative manual reduction of an ileo-ileal intussusception was subsequently performed. Postoperative intussusception often is overlooked because the clinical presentation can be confused with the much more common postoperative adynamic ileus. The diagnosis of postoperative intussusception also often is delayed because of its rarity (0.5±0.8% of all laparotomies) and minimal symptoms [4, 6]. Pain in these patients usually is alleviated by routine postoperative pain medication; vomiting is less noticeable because a nasogastric tube typically is present; a mass is difficult to palpate in an already tender postoperative abdomen; and rectal bleeding occurs in less than 60% of cases [6]. Symptoms of postoperative intussusception begin at a mean of 10 days (range 3±36 days) after original surgery and 90% occur in the first 2 weeks [4]. In contrast, postoperative obstruction due to adhesions develops 2 weeks or more after operation in 75 % of patients [4]. A specific causative agent for postoperative intussusception often is not found. Intestinal tubes, intestinal suture lines, and inverted appendiceal stumps can serve as lead points. In addition, edema of the bowel secondary to any number of causes, but especially handling of the bowel during laparotomy, also is considered an etiologic factor [4]. In this regard, it has been noted that postoperative intussusception has a higher incidence after long surgical procedures and extensive handling of the intestines [4]. In conclusion, radiologists should be aware of postoperative intussusception and consider the diagnosis in any patient with postoperative obstruction, especially within the first 2 weeks after surgery.