Charles W. Hartin

Are facilities following best practices of pediatric abdominal CT scans

BACKGROUND Established guidelines for pediatric abdominal CT scans include reduced radiation dosage to minimize cancer risk and the use of intravenous (IV) contrast to obtain the highest-quality diagnostic images. We wish to determine if these practices are being used at nonpediatric facilities that transfer children to a pediatric facility. METHODS Children transferred to a tertiary pediatric facility over a 16-mo period with abdominal CT scans performed for evaluation of possible appendicitis were retrospectively reviewed for demographics, diagnosis, radiation dosage, CT contrast use, and scan quality. If CT scans were repeated, the radiation dosage between facilities was compared using Student t-test. RESULTS Ninety-one consecutive children transferred from 29 different facilities had retrievable CT scan images and clinical information. Half of CT scans from transferring institutions used IV contrast. Due to poor quality or inconclusive CT scans, 19 patients required a change in management. Children received significantly less radiation at our institution compared to the referring adult facility for the same body area scanned on the same child (9.7 mSv versus 19.9 mSv, P = 0.0079). CONCLUSION Pediatric facilities may be using less radiation per CT scan due to a heightened awareness of radiation risks and specific pediatric CT scanning protocols. The benefits of IV contrast for the diagnostic yield of pediatric CT scans should be considered to obtain the best possible image and to prevent additional imaging. Every facility performing pediatric CT scans should minimize radiation exposure, and pediatric facilities should provide feedback and education to other facilities scanning children.

Metallic foreign body in the appendix of 3-year-old boy

Foreign body-induced appendicitis is a rare but well-known entity. This condition was discovered during the first appendectomy performed almost 275 years ago. For the pediatric surgeon, evaluation of a patient for swallowed foreign bodies is common, and most foreign bodies traverse the gastrointestinal tract without incident. However, when the foreign body becomes incarcerated in the appendix, a prophylactic appendectomy is recommended to prevent appendicitis. We present the case of an asymptomatic 3-year-old boy with a metallic foreign body lodged in the appendix that was treated with a fluoroscopically assisted laparoscopic appendectomy and discuss treatment of sharp vs blunt foreign bodies of the appendix.

Laparoscopic excision of a newborn rectal duplication cyst

Congenital rectal duplication cyst is a rare entity treated with surgical excision. Without treatment, a rectal duplication cyst may cause a variety of complications, most notably, transforming into a malignancy. We report on a 7-week-old girl who was found to have a rectal duplication cyst. The rectal duplication cyst was successfully excised laparoscopically. Rectal duplication cysts are rare alimentary tract anomalies generally discovered during childhood. Complications include symptoms arising from the cyst and the possibility of malignant degeneration. They are typically managed by surgical excision.

Magnetic resonance as an aid in the diagnosis of a transverse vaginal septum

Transverse vaginal septum is a rare, often overlooked congenital abnormality that is typically not diagnosed until adolescence. We present the case of a transverse vaginal septum and partial bicornuate uterus in a 16-year-old adolescent girl with developmental delay and cerebral palsy. Magnetic resonance is an excellent diagnostic tool to delineate the specific anatomy before surgery. The effects of delayed diagnosis and the utility of magnetic resonance in diagnosis will be discussed.

Stapled tapering coloplasty to manage colon interposition graft redundancy for long gap esophageal atresia

Long gap esophageal atresia continues to be a therapeutic challenge for the pediatric surgeon. Although numerous methods have been described to achieve esophageal continuity in infants with esophageal atresia, esophageal replacement is often required if these methods fail. A common method of esophageal replacement in children is the use of a colon graft. Complications include cervical anastomotic leak, stricture, redundant intrathoracic colon with stasis, and cologastric reflux. We present an 11-year-old male with swallowing difficulties because of redundancy of the colon after undergoing colon interposition for long gap atresia. The patient underwent a successful transhiatal mobilization of the intrathoracic colon and stapled tapering coloplasty. The patient currently remains symptom-free.

Life-threatening hemorrhage from a congenital hemangioma caused by birth trauma

Pediatric surgeons frequently diagnose and treat vascular malformations. We present the case of a boy born with a large congenital hemangioma of the flank that ruptured during birth, resulting in life-threatening hemorrhage, requiring emergent excision. Prenatal diagnosis may help to identify such lesions, and pediatric surgeons must be ready to treat emergent complications of vascular malformations.

Communicating anal canal duplication cyst in an adolescent girl.

A 12-year-old girl presented to the emergency department with a 1-week history of rectal pain followed by fever and pressure during bowel movements. MRI demonstrated a 4-cm presacral, loculated fluid-filled cyst. On examination, the patient was extremely tender in the perianal area, which precluded performing an adequate rectal examination. An image-guided aspiration of the suspected abscess was then performed and 20 ml of purulent fluid was obtained. She was then discharged home on intravenous meropenem. Several days later, the patient returned to the emergency room complaining of persistent pain and reaccumulation of fluid on CT. A formal examination under anaesthesia demonstrated an accessory opening posterior to the native anus outside the external sphincter. Upon probing, a communication was demonstrated with an opening in the rectum approximately 2 cm proximal to the dentate line. Some purulent fluid was evacuated and a vessel loop was placed through the tract connecting the anterior and posterior anal openings. Rather than a fistula-in-ano and abscess, it appeared that the patient had an anal canal duplication (ACD) with an accessory anal orifice. An elective excision of the ACD was therefore performed via a posterior sagittal approach. A 4-cm anal duplication cyst was excised from the parasagittal muscle fibres down to the wall of the rectum (Fig. 1). A mucosectomy was required on a portion of the anterior cyst, which shared a common wall with the posterior rectal wall. Pathological examination demonstrated features consistent with an enteric duplication lined with simple columnar epithelium. Discussion

Laparoscopy for perforated Richter hernia with incarcerated foreign body

Children often place nonedible objects into their mouths. Occasionally, these objects are inadvertently swallowed, and fortunately, the majority passes spontaneously without intervention. We present the case of a 10-month-old girl who presented with an incarcerated Richter hernia through an indirect inguinal defect containing a wall of sigmoid colon perforated by a swallowed lollipop stick. Although this is a rare case, we conclude that prompt laparoscopic abdominal exploration is an extremely valuable tool in making an accurate diagnosis in difficult-to-reduce or incarcerated hernia cases.

Laparoscopic diagnosis of magnetic malrotation with fistula and volvulus.

Ingestion of multiple magnets in the pediatric population can cause risk for serious viscous injury.

Myositis ossificans requires multiple diagnostic modalities

Myositis ossificans is a type of bone-forming lesion that arises in soft tissue and mimics malignancy. We present a case of myositis ossificans in a 16-year-old girl with anxiety disorder, Asperger syndrome, and no known history of trauma. A variety of diagnostic tools including magnetic resonance, ultrasound, and biopsy are used to make the diagnosis. The histologic and radiographic findings used to distinguish this disorder from malignant conditions are discussed.