David M. Powell

Malrotation of the intestines in children: The effect of age on presentation and therapy

Because of the devastating consequences of midgut volvulus as a result of malrotation, we reviewed the charts of 70 consecutive children to define the spectrum of presentation. Although 27 patients (39%) had presenting symptoms within the first ten days of life, 35 (50%) were older than 2 months of age. In general, the older children had a longer course of vague, antecedent symptoms such as intermittent, nonbilious vomiting and chronic abdominal pain. Associated congenital anomalies were common, with 32 patients (46%) presenting with 56 anomalies, the most prevalent of which were intestinal atresia, imperforate anus, duodenal web, and cardiac and orthopedic anomalies. Upper gastrointestinal (GI) series revealed the diagnosis in 29 cases (41%), as did contrast enema in 24 (34%). It is important to note that volvulus, intestinal gangrene, and mortality occurred regardless of age or chronicity of symptoms. Fifteen patients (21%) were discovered serendipitously while being evaluated and treated for seemingly unrelated conditions. No morbidity of mortality occurred in those patients who underwent subsequent semielective Ladds procedure. The majority of morbidity and all seven mortalities occurred in patients with volvulus and intestinal necrosis. This study emphasizes the need for consideration of Ladds procedure for children of all ages. In addition, due to the broad range of initial symptoms, a high index of suspicion is required in evaluating children with possible malrotation. Because it remains impossible to predict which patients will have catastrophic complications (based on age or type of presentation), we urge that even incidentally discovered patients with intestinal malrotation undergo Ladds procedure.

VIDEO-ASSISTED THORACIC SURGERY (VATS) FOR CHILDREN WITH PULMONARY METASTASES FROM OSTEOSARCOMA

AbstractBackground: Video-assisted thoracic surgery (VATS) may complement open thoracotomy in children with osteosarcoma requiring pulmonary metastasectomy. Methods: The records of children with metastatic pulmonary osteosarcoma considered for initial VATS intervention (n=9) were reviewed. Results: Two children did not have VATS exploration: one child with multiple bilateral nodules and another child with a deep parenchymal nodule. VATS provided diagnostic biopsy material in all cases when used (n=7). Two children had benign inflammatory lesions; four children had VATS-directed wedge resections of solitary malignant lesions; and one child had VATS biopsy of diffuse parenchymal and pleural pulmonary disease not amenable to resection. The mean operative time and hospital length of stay were 1.78 ± 0.54 h and 3.5 ± 1.8 days, respectively. There were two complications of VATS: bleeding in a child, requiring a transfusion, and a latent pneumothorax in a patient after removal of the chest tube. Conclusion: VATS is safe, serves as an excellent diagnostic modality, complements the open thoracotomy, and may enable the surgeon to avoid more extensive procedures in selected cases.

Aortic bifurcation rupture after blunt abdominal trauma in a child: a case report

Blunt trauma to the abdomen resulting in aortic injury is rare in children with only a few case reports in the past 40 years. We describe the diagnosis and management of a 2-year-old boy who survived an aortic bifurcation rupture after blunt trauma.

Laparoscopic Mesenteric Lymph Node Biopsy in the Diagnosis of Mycobacterium avium Complex

Infection with the acid-fast bacilli Mycobacterium avium and Mycobacterium intracellulare, collectively referred to as the Mycobacterium avium complex (MAC) is a substantial diagnostic and clinical problem in children with human immunodeficiency virus (HIV) infection. Because blood cultures in patients with M. avium infection (MAI) are frequently negative, tissue biopsy and culture are often required to confirm the diagnosis or rule out malignancy. The use of laparoscopic mesenteric lymph node biopsy in three children presenting with clinical symptoms and radiographic findings (abdominal lymphadenopathy) consistent with MAC infection is described here. Three ports were utilized and positioned dependent upon CT findings. Adequate specimens for diagnosis were obtained without morbidity in all three children. This experience supports the use of laparoscopy as the preferred method of confirming intra-abdominal MAC infection in HIV infected children.