Douglas C. Rivard

Current Classification and Terminology of Pediatric Vascular Anomalies

OBJECTIVE The purpose of this article is to review new terminology to diagnose, classify, and refer patients with vascular anomalies for additional imaging, intervention, and treatment. CONCLUSION In recent decades, much has been learned regarding the histopathology, cause, and treatment of vascular anomalies. As information has been gleaned, a new classification system has emerged that divides vascular anomalies into neoplasms and malformations. Its utility is based on accurate initial diagnosis that correlates consistently with clinical presentation, disease course, and treatment.

Evaluation of ultrasonographic parameters in the diagnosis of pyloric stenosis relative to patient age and size

INTRODUCTION Pyloric thickness of 3 mm or higher and length of 15 mm or higher by ultrasonography (US) is widely accepted as diagnostic criteria for pyloric stenosis (PS). However, infants presenting at earlier ages are held to this same criteria, which may not be applicable. METHODS Retrospective review was conducted on patients evaluated with pyloric US to rule out PS from May 2010 through December 2010. Pearson correlation was used to detect an association between weight and age with pyloric thickness and length. Sensitivity and specificity for US parameters were determined. RESULTS Three hundred four patients underwent 318 ultrasounds, of which 67 had PS. Of those with PS, age and weight had a positive correlation with thickness (P < .007), and age positively correlated with length (P < .001). In patients with and without PS, there was a negative correlation for both age and weight with thickness (P < .02). Those who did not have PS held a stronger negative correlation between age and thickness (P = .002). Overall, US had a 100% sensitivity and specificity for PS. Thickness of 3 mm or higher was 100% sensitive and 99% specific, and pyloric length of 15 mm or higher was 100% sensitive and 97% specific. CONCLUSIONS Although significant associations between age and weight with pyloric thickness and length may exist, our data indicate that this does not have an impact on the diagnostic criteria for PS.

Accuracy of computed tomography in predicting appendiceal perforation

BACKGROUND Some surgeons use nonoperative management with or without interval appendectomy for patients who present with perforated appendicitis. These strategies depend on accurately delineating perforation by computed tomography (CT). Since 2005, our institution has used an evidence-based definition for perforation as a hole in the appendix or fecalith in the abdomen. This has been shown to clearly separate those with a high risk of abscess from those without. To quantify the ability of CT to identify which patients would meet these criteria for perforation, we tested 6 surgeons and 2 radiologists who evaluated blinded CT scans. METHODS A junior and senior surgical residents, 2 staff interventional radiologists, and 4 attending pediatric surgeons with 3 to 30 years of experience reviewed 200 CT scans of pediatric patients who had undergone a laparoscopic appendectomy. All CT scans were reviewed electronically, and the reviewers were blinded to the results, outcome, and intraoperative findings. None of the patients had a well-formed abscess on CT. The reviewers were asked to decide only on perforated or nonperforated appendicitis according to our intraoperative definition. Clinical admission data were reviewed and compared between groups. RESULTS In total, the reviewers were correct 72% of the time with an overall sensitivity of 62% and a specificity of 81%. The overall positive predictive value was 67%, and the negative predictive value was 77%. CONCLUSIONS This study shows that in the absence of a well-formed abscess, the triage of patient care based on a preoperative diagnosis of perforation from CT may be imprudent and subject a portion of the population to an unnecessarily prolonged course of care.

Traumatic pseudoaneurysm of the anterior tibial artery treated with ultrasound-guided thrombin injection in a pediatric patient

Pseudoaneurysms are relatively common in the adult population because of the high volume of procedures requiring large bore arterial access. This experience has allowed adult caregivers to develop simple maneuvers to treat pseudoaneurysms such as ultrasound-guided thrombin injection. However, because of the extremely low volume of pseudoaneurysms seen by pediatric caregivers, this modality has not been well documented in the pediatric population. Here, we present a case of a 13-year-old female who had a stab wound to her left leg and subsequently developed a pseudoaneurysm of the anterior tibial artery that was successfully treated with ultrasound-guided thrombin injection.

Radiation exposure - how do CT scans for appendicitis compare between a free standing children's hospital and non-dedicated pediatric facilities?

BACKGROUND We compare the amount of radiation children receive from CT scans performed at non-dedicated pediatric facilities (OH) versus those at a dedicated childrens hospital (CH). METHODS Using a retrospective chart review, all children undergoing CT scanning for appendicitis at an OH were compared to children undergoing CT imaging for appendicitis at a CH between January 2011 and November 2012. RESULTS One hundred sixty-three children underwent CT scans at 42 different OH. Body mass index was similar between the two groups (21.00±6.49kg/m(2), 19.58±5.18kg/m(2), P=0.07). Dose length product (DLP) was 620±540.3 at OH and 253.78±211.08 at CH (P < 0.001). OH CT scans accurately diagnosed appendicitis in 81%, while CT scans at CH were accurate in 95% (P=0.026). CTDIvol was recorded in 65 patients with subset analysis showing CTDIvol of 16.98±15.58 and 4.89±2.64, a DLP of 586.25±521.59 and 143.54±41.19, and size-specific dose estimate (SSDE) of 26.71±23.1 and 3.81±2.02 at OH and CH, respectively (P<0.001). CONCLUSION Using SSDE as a marker for radiation exposure, children received 86% less radiation and had improved diagnostic accuracy when CT scans are performed at a CH.

The utility of computed tomography in the management of patients with spontaneous pneumothorax

BACKGROUND Spontaneous pneumothorax may result from rupture of subpleural blebs. Computed tomography (CT) has been used to identify blebs to serve as an indication for thoracoscopy. We reviewed our experience with spontaneous pneumothorax to assess the utility of CT in these patients. METHODS A retrospective review was conducted of all patients who underwent an operation for spontaneous pneumothorax from January 1999 to October 2009. All procedures were performed thoracoscopically. RESULTS We identified 39 pneumothoraces in 34 patients who underwent evaluation and a procedure for spontaneous pneumothorax. Mean age was 16.1 years (range, 10-23 years), with an average of 1.7 spontaneous pneumothoraces before operation (range, 1-4). Preoperative chest CT scans were obtained in 26 cases. Blebs were demonstrated on 8 CT scans. The presence of blebs was confirmed at operation in all 8 patients. Of the 18 negative scans, 14 (77.8%) were found to have blebs intraoperatively, 7 of these patients were initially managed nonoperatively and developed recurrence. The sensitivity of CT for identifying blebs was 36%. CONCLUSIONS Chest CT does not appear to be precise in the identification of pleural blebs and a negative examination does not predict freedom from recurrence. Operative decisions should be based on clinical judgment without the use of preoperative CT.

Radiographic Findings in the Diagnosis of Pediatric Ileocolic Intussusception Comparison to a Control Population

Several previous studies have evaluated the usefulness of plain abdominal radiographs for the diagnosis of pediatric intussusception, although investigation of the most specific clues to diagnose intussusception has not been studied alone. The 3 most specific findings of intussusception include intraluminal mass or intussusceptum, nonvisualized air-filled cecum, and obscured liver margin or right upper-quadrant mass. In this study, a retrospective review of 73 known cases of intussusception with age- and sex-matched controls was performed. The cases were reviewed by 2 blinded, board-certified pediatric radiologists to aid in the determination of sensitivity and specificity. The sensitivity and specificity of plain radiographs to correctly diagnose ileocolic intussusception in pediatric patients compared with a control population were 77% and 97%, using a 50% or greater receiver operating characteristic curve cutoff.

Radiological Reasoning: Multiple Hepatic Masses in an Infant

OBJECTIVE A 4.5-month-old boy was found to have hepatomegaly by his primary care pediatrician on a routine well-baby check and was referred for sonography. Innumerable hepatic lesions of varying echogenicity were found in an enlarged liver. Further characterization with multiphase CT, followed by contrast-enhanced MRI, showed innumerable hepatic masses of varying size with heterogeneous enhancement. The objective of this article is to discuss appropriate evaluation of multiple hepatic masses in infants and describe the major disease entities that are considered in the differential diagnosis. CONCLUSION Hepatic lesions in infants frequently are evaluated with multiple imaging techniques in an attempt to identify imaging findings that would suggest a specific diagnosis. Although various imaging features may suggest a particular pathologic diagnosis, correlation with patients age and laboratory markers often is the most helpful factor in infants to suggest a particular disease process and formulate a management plan.

Burden of complications from needle penetration of plastic ports in children.

BACKGROUND Complications of totally implanted venous access ports are well documented. A concerning mechanical complication we have encountered is posterior penetration of plastic ports with the access needle. The purpose of this study is to investigate the burden of posterior penetrations. METHODS We performed a retrospective review of all ports placed between November 2007 and December 2011 at a single institution. RESULTS There were 247 children who received a port. 117 children (47%) received a port with a plastic posterior wall, 95 children (38%) received a port with a metal posterior wall, and 35 children (14%) had ports that were unable to be identified as plastic or metal. Posterior port penetrations occurred 8 times (3.2% overall, 6.8% of plastic ports). All perforations occurred in plastic ports of a single brand and product code. Average time from port insertion to penetration was 11.2±21.3 months (range 0.3 to 63.4 months). Other complications included catheter malfunction (14), infection (9), pain (2), inability to draw/aspirate (4), leak (3), port migration (2), and malfunctioning not otherwise specified (15). CONCLUSIONS There is an unacceptably high risk of needle penetration of the posterior wall of plastic ports. We recommend utilizing ports with metal backing to avoid this complication.

Successful percutaneous drainage of duodenal hematoma after blunt trauma

Duodenal hematoma after blunt trauma is usually treated nonoperatively with bowel rest, nasogastric tube suction, and intravenous hydration. We report a case in which obstructive symptoms persisted despite more than 2 weeks of conservative management. An ultrasound-guided percutaneous drain was placed, with successful resolution of symptoms.