Charles V. Coren

Pearls and perils in the management of prolonged, peculiar, penetrating esophageal foreign bodies in children

BACKGROUND/PURPOSE Most retained esophageal foreign bodies (FB) are identified soon after ingestion and are easily extracted. A minority of FB ingestions are not identified for weeks to years and present significant problems for retrieval. The purpose of this study was to describe the diagnostic and therapeutic strategies needed to care for children who have chronic esophageal FBs. METHODS Five children were identified as having retained esophageal FBs 2 months to 2 years after ingestion. During the same 3-year period, 100 children who had acute FBs were identified and had their foreign bodies removed endoscopically. The average age of the children was 3 years (range, 2.4 to 3.5). RESULTS The average age of the five children identified in this study was 3 years. The items ingested included coins, a heart pendant, a clothespin spring, and a toy soldier. Complications from chronically retained foreign bodies were bronchoesophageal fistula, mediastinitis, esophageal diverticulum, and lobar atelectasis. One patient died from an aortoesophageal fistula. In all children, endoscopic removal was attempted. Barium esophagram was then performed, and foreign bodies were eventually removed via right thoracotomy. CONCLUSIONS Long-retained esophageal FBs are extremely morbid and life threatening. History most often identifies excess salivation, new onset asthma, and/or recurrent upper respiratory infections. Three diagnostic adjuncts are helpful in identifying the presence of a long retained FB: (1) Chest x-ray (PA and lateral), (2) barium swallow, and (3) esophagoscopy. Indications for thoracotomy for removal of foreign body include (1) Poor endoscopic visualization of FB because of inflammatory tissue and (2) Herald bleeding during endoscopy.

Radiology–Pathology Conference: Juvenile granulosa cell tumor☆

Juvenile granulosa cell tumor (GCT) of the ovary is a rare neoplasm occurring in premenarchal girls and young women. Juvenile GCT that occurs in premenarchal girls usually produces sexual precocity as a consequence of estrogen secretion. Juvenile GCTs are more likely to grow to a relatively large size with a much smaller likelihood of peritoneal spread, unlike their counterpart, epithelial ovarian neoplasms. We report the radiology and pathology of a patient with juvenile GCT and review the literature of this rare tumor.

Hemipelvectomy, a Lifesaving Operation in Severe Open Pelvic Injury in Childhood

Near-complete traumatic hemipelvectomy probably carries an extremely high mortality rate. The usual techniques which have been used to control major hemorrhage associated with pelvic fractures such as transperitoneal vascular ligation, intra-arterial embolization, and packing are not applicable (14). Successful management requires prompt recognition of the nature of this injury so that surgical efforts may be directed at resuscitation and expeditious operative completion of the traumatic amputation. When this decision is made appropriately, the dual goals of control of hemorrhage and prevention of sepsis can be achieved. We report the management of a 7-year-old boy who sustained this injury after being struck by a tractor-trailer. In spite of massive resuscitation, hemorrhage could not be controlled and the child remained in shock. When it was recognized that he had sustained an incomplete traumatic left hemipelvectomy, it was surgically completed, permitting prompt control of the hemorrhage and restoration of hemodynamic stability. Intestinal and urinary diversion allowed an uneventful postoperative recovery without significant infection. Although hemipelvectomy appears to be a radical procedure in children with major pelvic injuries, it may be lifesaving and should therefore be considered in those with severe unilateral pelvic injury and uncontrollable hemorrhage. The potential for physical rehabilitation in the group of young, mostly male patients who have survived this injury appears to be unexpectedly good.

Radiology-pathology conference: incidental posterior mediastinal ganglioneuroma.

We report the radiology and pathology findings on a patient with an incidental posterior mediastinal ganglioneuroma and review the literature on this uncommon tumor.

Results of levatorplasty for anal incontinence

Since the introduction of the levatorplasty, 44 patients were operated upon for anal incontinence on our service. In 31 patients, a levatorplasty was performed. The selection of the levatorplasty as operative procedure was based on the availability of a functional levator as demonstrated by physical examination, anorectal manometry, and defecography. The 31 patients ranged from infancy to 76 years of age and 30 of them were followed up to 7 years with an average of 3 years. In 18 patients with fecal incontinence following operative procedures for anorectal malformations, satisfactory continence was restored in 8, improvement was found in 6, and 4 patients remain incontinent. In 13 patients with incontinence following operative procedures or trauma, the postoperative results were satisfactory in 9 patients, 2 improved, and 2 failed. The review showed that the levatorplasty was most successful in patients in whom the revised but normally innervated levator replaces a destroyed external sphincter in the presence of an intact internal sphincter. Only one half of all patients with major incontinence following an operative procedure for anorectal malformations had an adequate levator that allowed successful restoration of function. The review showed that the levatorplasty can improve or restore anal continence in a variety of conditions in properly selected patients.

Oral Congenital Cystic Choristomas: A Case Report

Solitary choristomas containing gastrointestinal mucosa occur rarely in the tongue and the oral mucosa and usually present as an asymptomatic mass. This report documents the occurrence of two congenital intraoral cystic choristomas in a 5-month-old male infant. The cysts were located on the dorsum of the base of the tongue and left floor of mouth anterior to the lingual cyst. Both cysts were lined by nonkeratinizing squamous epithelium and gastric, intestinal, and respiratory epithelium. The cysts were excised by an oral approach.

Neonatal necrotizing enterocolitis

PURPOSE: A retrospective, 12-year review of neonatal necrotizing enterocolitis was undertaken at a county hospital, with emphasis on presentation signs and symptoms. METHODS: Eighty-two patients with presence of intramural air were included in the study. The following signs and symptoms were studied: evidence of respiratory distress, use of umbilical catheters, white blood cell count and temperature at presentation, time interval from birth to diagnosis and time interval from diagnosis to operative intervention, presence of intramural air, air in biliary tree or free air, changes in abdominal girth, and presence of occult or gross blood in stools. Comparison was done among infants who had surgical or medical treatment, premature and full-term infants, and infants who had neonatal necrotizing enterocolitis less than or more than 20 days after birth. RESULTS: Eleven patients had a fatal outcome, with an overall survival of 87 percent. Sixty-four patients were treated medically and 18 had operative treatment. Mortality of the surgically treated group was 44 percent. Neonates who had surgical intervention had a left shift of the white blood cell count more commonly present, and all had documented abdominal distention. There were 62 premature and 20 full-term neonates in the group. Full-term neonates developed neonatal necrotizing enterocolitis earlier after birth (5.3 days compared with 15.3 days in the premature neonate group). Full-term neonates had a better prognosis in our series. Presentation of symptoms more than 20 days after birth did not change outcome. CONCLUSION: Our results reflect the experience of a community-based hospital. Clinical acumen remains the cornerstone of diagnosis and management.

Unusual presentation of a cutaneous bronchogenic cyst in an asymptomatic neonate

Cutaneous presentations of bronchogenic cysts are rare in all age groups. Previous reports of cutaneous manifestations of bronchogenic cysts have been described as nodular, adherent masses, most frequently with a suprasternal location. We report a unique presentation of an infant with a pedunculated, anterior chest wall mass, which was identified as a bronchogenic cyst.

Radiology-Pathology Conference: mature teratoma arising from an intra-abdominal undescended testis in a 7-month-old infant

We report a rare case of an intra-abdominal testicular mature teratoma in a 7-month-old male infant presenting with a palpable abdominal mass and unilateral undescended testis. We describe the pathology, clinical presentation, and imaging findings of this entity. Clinical features accompanied by characteristic radiologic findings guide a provisional diagnosis that is confirmed by histologic analysis following surgical removal of the tumor. The pathogenesis and radiologic findings of testicular mature teratomas in the prepubertal population share many similarities to that of mature ovarian teratomas commonly seen in females of reproductive age. Awareness of this entity will permit the radiologist to suggest timely diagnosis and intervention when presented with a similar case.

Prenatal and neonatal sonographic imaging of a central diaphragmatic hernia.

A case of a central diaphragmatic hernia diagnosed prenatally is reported. The prenatal sonographic findings included central herniation of most of the liver into the chest and hydrops. The hernia was successfully repaired. However, the infant died secondary to respiratory distress syndrome.