E. Stevers Golladay

Respiratory complications in cervical thymic cysts

Thymic cysts are considered uncommon lesions in the differential diagnosis of pediatric neck masses. They have been described as asymptomatic and of little clinical consequence. Recent reports have stressed the possibility of respiratory compromise associated with these lesions. We reviewed our experience with cervical thymic cysts with emphasis on respiratory problems. Ten pediatric patients underwent surgery and were found to have cervical thymic cysts. Ages ranged from newborn to 14 years. There were four boys and six girls. Two were found to have the thymic cysts at time of neck exploration for Graves disease and hyperparathyroidism. Of the remaining eight patients, all had mobile cystic masses, located anterior to but extending beneath the lower third of the sternocleidomastoid muscle. The size of the mass ranged from 3.0 to 8.5 cm. Preoperative diagnosis included cystic hygroma/branchial cleft cyst (five), lymphoma (one), teratoma (one), and thymic cyst (one). All had a history of rapidly developing neck mass. Seven of the eight gave a history of upper respiratory tract infection (URI) prior to the development of the mass. Five had imaging studies that showed tracheal compression. Three of these required airway management in the early postoperative period. All were excised through a neck incision, with two requiring sternal extension. Histology showed cholesterol crystals, Hassalls corpuscles, and giant cell reaction diagnosis of thymic cysts. There has been no recurrence and no permanent respiratory sequela in the ten patients. Cervical thymic cysts are benign lesions that may be more common than literature suggests.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of nutritional rehabilitation on gastroesophageal reflux in neurologically impaired children

The impact of nutritional rehabilitation on gastroesophageal reflux (GER) in 10 malnourished neurologically impaired children (NIC) was studied (mean age, 9.1 +/- 3.1 years). None of the children had an antireflux procedure (ARP), and all were fed exclusively through a percutaneous endoscopic gastrostomy (PEG). Malnutrition was defined as triceps skin fold thickness (TSF) below the fifth percentile for age and sex. GER was established using standard criteria for a 24-hour pH probe study. All children were treated with an H2 antagonist and a prokinetic agent, along with aggressive nutritional rehabilitation. When TSF was > or = 50th percentile, medications were stopped, and the 24-hour pH probe study was repeated. The mean weight gain was 8.8 +/- 3.7 kg over 8.4 +/- 2.3 months. The 24-hour pH probe study showed marked improvement after nutritional rehabilitation in six of 10 children. These children remained asymptomatic throughout long-term follow-up, without the use of medications. Two children had abnormal pH probe results and worsening clinical symptoms when taken off medications after nutritional rehabilitation. They were reexamined after reinstituting the prokinetic drug; results of the pH probe study were normal, and there was no clinical symptomatology. The patients were then given long-term medication. Two children (one with erosive esophagitis and one with persistent symptoms) underwent ARP. We conclude that despite accompanying GER, successful nutritional rehabilitation can be achieved in malnourished NIC, using PEG feeding and antireflux medication. Although some NIC with GER may need an ARP or long-term medication, in most malnourished NIC nutritional rehabilitation is associated with resolution of GER.

Complications of TPN catheter-induced vena caval thrombosis in children less than one year of age

Recent large series have reported a 5% to 10% incidence of major venous thrombosis associated with central indwelling total parenteral nutrition (TPN) catheters. Previous authors suggested that this was well tolerated by children and resulted in few clinically important sequelae. Our experience differs significantly and forms the basis of this report. Between 1979 and 1981, 117 Broviac TPN catheters (Evermed, Medina, Washington) were placed in children less than 1 year of age. Catheters were introduced into the superior vena cava (SVC) by way of a common facial vein cutdown. Catheter position was confirmed radiographically in the operating room. Eight infants (7%) subsequently developed superior vena caval thrombosis. All presented with edema of the head and neck associated with facial plethora, chemosis, and prominent cutaneous venous pattern. In five of the eight children the clinical signs resolved spontaneously following catheter removal and there were no apparent sequelae. The remaining three (38%), however, suffered significant morbidity. Two developed intracardiac extension of their thrombus. The first child suffered extensive pulmonary embolization. In the second child, the thrombus prolapsed through the tricuspid valve inciting congestive heart failure. This thrombus subsequently became infected, necessitating urgent cardiotomy. The third infant developed bilateral chylothoraces due to pulmonary lymphangiectasia associated with SVC thrombosis. These proved unresponsive to medical or surgical management and resulted in the death of this newborn. Although the majority of infants developing catheter-induced central venous thrombosis respond to catheter removal and suffer no subsequent ill effects, these children are at risk for major complications. These complications can be associated with not only significant morbidity but with mortality as well. The generalization that such thrombosis is well tolerated in the infant is unwarranted.

Invasive Aspergillosis in Children

Aspergillosis may complicate the course of the child in an immunocompromised state. When sinus or pulmonary infections present in immunocompromised children, one third of these patients are diagnosed accurately premortem as resulting from aspergillosis and two thirds remain undiagnosed. Mortality remains quite high, despite prompt treatment. Four children in our hospital during the last 4 years have had invasive aspergillosis presenting other than sinus or pulmonary infections. Each presented with extensive soft tissue infection. Three presented after traumatic devascularizing injuries to the leg in which massive soil and fecal contamination occurred. One child presented with absolute neutropenia secondary to treatment of acute lymphocytic leukemia. The child had a chest wall lesion develop at the site of an EKG electrode. All patients had a punctate black skin lesion with a halo of intense erythema surrounded by a zone of blanching. These lesions rapidly expanded. Initial extensive debridement of the lesions, combined with systemic chemotherapy with amphotericin B failed to halt the progression of the disease. Histology showed vascular invasion with hyphal forms. Each patient then responded well to radical debridement (three hemipelvectomies and one chest well resection). The child in an immunocompromised state who develops a red papule, then a black eschar with surrounding erythema, should have immediate biopsy that can easily demonstrate the characteristic hyphal forms. Early radical surgical debridement and antifungal therapy can be lifesaving. The initial debridement should include tissues well beyond any apparent involvement.

Surgically induced immunologic alterations in the child

Surgery is generally believed to be an immunodepressant. This assumption is based, in part, upon studies of compromised patients undergoing major operation. Similar studies in normal adults following elective procedures are contradictory and little information is available regarding the pediatric surgical patient. This paper presents a study of immune function in children undergoing elective operation. Fifty healthy preoperative children (mean age: 20 months) were randomly selected. Ninety-five percent underwent inguinal herniorrhaphy. Operative time averaged 45 minutes (range: 30 to 90 minutes). Anesthesia consisted of Halothane and Nitrous Oxide in all cases. Approximately 2.5 cc of heparinized blood and 0.5 cc of serum were obtained immediately prior to and 2 hours following operation. Half of the children underwent assays of neutrophil function including absolute count, random migration, chemotaxis, phagocytosis, and bacterial killing. Serum was examined for opsonization of Staphylococcus aureus using the chemiluminescence method. The remaining children underwent lymphocytic quantitation including absolute count, total T cells, total B cells, T-helper cells, T-suppressor cells, and T-helper/suppressor ratio. Absolute neutrophil count increased 2.4 times preoperative values (P less than 0.01). There were, however, no significant alterations in neutrophil functional capabilities. Similarly, there was no alteration in serum opsonic capacity. There was a significant decrease in absolute lymphocyte count (6560-4013, P less than 0.01) postoperatively, and T cells, T-helper, T-suppressor, and B cells were all significantly affected (P less than 0.01 to 0.02). There was no change in the T-helper/suppressor ratio.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of empyema in children

The antibiotic era has changed the incidence, causal factors, and gravity of empyema. Between 1977 and 1988, 27 children with empyema were surgically managed. Ten cases occurred after an operation (8 esophageal and 2 abdominal). There were 15 girls and 12 boys. The age range was newborn to 12 years. Symptoms included fever, cough, tube drainage postoperatively, anorexia, weight loss, chest pain, tachypnea, and lymphadenitis. Multiple aerobic and anaerobic organisms were cultured. Treatment included thoracentesis and antibiotics, tube thoracostomy, tube thoracostomy and bronchoscopy, decortication, or decortication with lobectomy. The total hospital stay averaged 28.3 days, and after decortication, 11.6 days. Empyemas in children frequently have multiple organisms and should be treated with broad-spectrum antibiotics while awaiting culture results. Thoracentesis and tube thoracostomy are often ineffective in curing the disease. Decortication can abbreviate hospital stay if performed promptly for persistent pleural sepsis.

Surgically correctable fetal hydrops

Hydrops fetalis is classically the result of immune mediated intrauterine hemolysis. Increasingly, however, nonimmunologic abnormalities have been associated with fetal anasarca. A number of these are potentially surgically correctable. Four such infants have been treated at the Arkansas Childrens Hospital since 1981. Fetal hydrops was detected prenatally in three, as well as lesions which might be corrected. All three were delivered by cesarean section with vigorous resuscitation required. Following stabilization, each underwent operation with excision of an intrathoracic mass (teratoma and leiomyosarcoma) in two and closure of omphalocele in the remaining neonate. A fourth infant was transferred following spontaneous premature vaginal delivery with hydrops and respiratory distress. This was associated with adenomatoid malformation which was subsequently excised. Anasarca and respiratory distress resolved postoperatively in all. With evidence of nonimmune hydrops, a thorough evaluation for surgically correctable lesions is indicated. A planned aggressive approach to delivery, resuscitation and stabilization followed by prompt surgical intervention can improve the morbidity associated with nonimmune hydrops fetalis having surgically correctable malformations.

Postoperative neonatal necrotizing enterocolitis.

Neonatal necrotizing enterocolitis (NEC) classically occurs in stressed premature newborns within the first ten days of life. Although it has been sporadically described in other settings, it has not been frequently cited as a postoperative complication. This paper presents eleven surgical infants whose postoperative course was complicated by the development of NEC. During the last 5 yr, 11 newborns (mean 2.4 kg.) have been treated for postoperative NEC. Each of these had undergone a major operation within the first week of life. Diagnoses included gastroschisis (7), omphalocele (1), jejunal atresia (1), aganglionosis (1), and malrotation with duodenal web (1). The mean age at onset of symptoms was 36 days (range 5–136 days) and an average of 29 days postoperatively (range 5–120 days). NEC was documented in each case by the presence of pneumatosis intestinalis or surgical and/or autopsy specimen. Four infants responded to medical therapy. Seven required operation, three of whom had involvement of the entire midgut. Five of the eleven neonates (46%) died of overwhelming sepsis. Of the remaining six, two require T.P.N. for survival (15 and 16 months old) and two additional require frequent hospitalization for diarrhea (morbidity 67%). NEC resulted in substantial morbidity and mortality in these surgical neonates. It occurred late in the postoperative period and pursued a virulent course. In only three infants could etiologic factors be identified. Two occurred after attempts at closure of abdominal wall defects and the third suffered hypoxia prior to the onset of symptoms. In each of these, NEC became apparent early postoperatively (Avg. 7th postoperative day). In the remaining eight, however, contributing factors could not be identified and onset of symptoms occurred late (Avg. 39th postoperative day). The preponderance of abdominal wall defects suggests a possible increased susceptibility in these infants. NEC should be included in the differential diagnosis of gastrointestinal symptoms in postoperative neonates.

Prevention of prolapse in pediatric enterostomas with purse string technique

Abstract Eighty-five intestinal stomas (40 small bowel enterostomies and 45 colostomies) were performed by a purse string technique with no instances of prolapse.

Crotalid envenomation in children: Selective conservative management

Snake bites in children remain an uncommon injury. In general, there is a wide disagreement by knowledgeable authorities on a uniform approach to therapy. In the last 5 years, 29 children have been treated in our institution for snake bites, all with signs of envenomation. Treatment consisted of diagnostic laboratory studies, intravenous fluids, tetanus prophylaxis, antibiotics, bed rest, elevation, and observation. There were no deaths. A fasciotomy was required in three children. Cryotherapy initiated elsewhere resulted in tissue loss. Seven children received antivenin. All developed signs and symptoms to serum sickness. From this experience, it appears that the majority of snake bites in children, especially copperhead bites, can be treated selectively and conservatively. Care must be exercised in using antivenin as it is associated with a high rate of serum sickness. Cryotherapy adds to the morbidity of the bite and is not to be used.