Erin Rowell

Management and classification of type II congenital portosystemic shunts.

BACKGROUND Congenital portosystemic shunts (PSS) with preserved intrahepatic portal flow (type II) present with a range of clinical signs. The indications for and benefits of repair of PSS remain incompletely understood. A more comprehensive classification may also benefit comparative analyses from different institutions. METHODS All children treated at our institution for type II congenital PSS from 1999 through 2009 were reviewed for presentation, treatment, and outcome. RESULTS Ten children (7 boys) with type II PSS were identified at a median age of 5.5 years. Hyperammonemia with varying degrees of neurocognitive dysfunction occurred in 80%. The shunt arose from a branch of the portal vein (type IIa; n = 2), from the main portal vein (type IIb; n = 7), or from a splenic or mesenteric vein (type IIc; n = 1). Management included operative ligation (n = 6), endovascular occlusion (n = 3), or a combined approach (n = 1). Shunt occlusion was successful in all cases. Serum ammonia decreased from 130 ± 115 μmol/L preoperatively to 31 ± 15 μmol/L postoperatively (P = .03). Additional benefits included resolution of neurocognitive dysfunction (n = 3), liver nodules (n = 1), and vaginal bleeding (n = 1). CONCLUSION Correction of type II PSS relieves a wide array of symptoms. Surgery is indicated for patients with clinically significant shunting. A refined classification system will permit future comparison of patients with similar physiology.

Hazardous complications of multiple ingested magnets: report of four cases.

Foreign body ingestion is a common occurrence in the pediatric population. Frequent culprits include coins, toys, sharp objects and bones, which most often pass spontaneously. Magnet ingestion, however, can be a serious matter, especially when more than one is taken in. The extremely strong magnetic force between multiple magnets may result in numerous complications including bowel necrosis, perforation, obstruction, fistula formation, volvulus and death. We present the largest series reported to date, with four cases of multiple magnet ingestion at our institution with varied presentations and findings. We review the literature, and discuss the importance of having a high index of suspicion.

Laparoscopic repair of traumatic abdominal wall hernia from handlebar injury

A 14-year-old boy was seen at an outside hospital after falling over the handlebar of his bicycle and was discharged home. He was subsequently seen in our emergency department with complaints of persistent abdominal pain. A computed tomography scan of the abdomen revealed disruption of the muscles of the upper right abdominal wall containing the hepatic flexure of the colon, with a small amount of intraperitoneal free fluid noted. The patient underwent laparoscopic exploration using 3 ports (2-5 mm and 1-12 mm) and 2 separate stab incisions. The traumatic abdominal wall hernia was repaired with interrupted sutures placed with an ENDO CLOSE (Covidien, Mansfield, MA) device, and a mesenteric defect in the colon was approximated with intracorporeal sutures. The trocar sites were sutured closed. The patient recovered well and was discharged home. Follow-up examination revealed no abdominal wall defect and resolution of his symptoms. Laparoscopic repair of a traumatic abdominal wall defect and exploratory laparoscopy after trauma is feasible and safe in the pediatric patient. It should be considered as an alternative approach with potentially less morbidity than an exploratory laparotomy for handlebar injuries in a stable patient.

Fertility Preservation for Pediatric Patients: Current State and Future Possibilities

Purpose: This review provides an overview of pediatric fertility preservation. Topics covered include the patient populations who could benefit, the current state of fertility preservation options and research, and considerations related to ethics and program development. Materials and Methods: A broad Embase® and PubMed® search was performed to identify publications discussing investigational, clinical, ethical and health care delivery issues related to pediatric fertility preservation. Relevant publications were reviewed and summarized. Results: Populations who could benefit from fertility preservation in childhood/adolescence include oncology patients, patients with nononcologic conditions requiring gonadotoxic chemotherapy, patients with differences/disorders of sex development and transgender individuals. Peripubertal and postpubertal fertility preservation options are well established and include cryopreservation of oocytes, embryos or sperm. Prepubertal fertility preservation is experimental. Multiple lines of active research aim to develop technologies that will enable immature eggs and sperm to be matured and used to produce a biological child in the future. Ethical challenges include the need for parental proxy decision making and the fact that fertility preservation procedures can be considered not medically necessary. Successful multidisciplinary fertility preservation care teams emphasize partnerships with adult colleagues, prioritize timely consultations and use standardized referral processes. Some aspects of fertility preservation are not covered by insurance and out‐of‐pocket costs can be prohibitive. Conclusions: Pediatric fertility preservation is an emerging, evolving field. Fertility preservation options for prepubertal patients with fertility altering conditions such as cancer and differences/disorders of sex development are currently limited. However, multiple lines of active research hold promise for the future. Key considerations include establishing a multidisciplinary team to provide pediatric fertility preservation services, an appreciation for relevant ethical issues and cost.

Intraperitoneal bladder rupture as an isolated manifestation of nonaccidental trauma in a child.

Nonaccidental trauma is a significant cause of morbidity and mortality in children. We describe a case of a child who presented with intraperitoneal bladder rupture after sustaining blunt abdominal trauma. As per confession, the injury was apparently the result of the child being forcibly pulled into her caretakers knee while the child had a full bladder. Diagnostic findings included an acute abdomen, gross hematuria, azotemia, and free intraperitoneal fluid visualized on computed tomography. Emergency exploratory laparotomy revealed rupture at the dome of the bladder. Bladder rupture as a result of nonaccidental trauma has been reported in 3 previous cases.

Endoloop as the first line tool for appendiceal stump closure in children with appendicitis

PURPOSE The objective of this study is to compare outcomes for pediatric patients undergoing laparoscopic appendectomy (LA) performed either (1) using an endostapler (ES) to divide the appendix and mesoappendix or (2) using endoloops (ELs) to close the appendiceal stump and electrocautery to divide the mesoappendix. METHODS We conducted a retrospective chart review of all patients who underwent LA for suspected appendicitis 4 years at a free standing childrens hospital. The use of EL and ES was compared separately in patients with perforated and nonperforated appendicitis. We compared patient characteristics and outcomes. RESULTS There were no significant differences in rate of postoperative abscess, rate of subsequent small bowel obstruction requiring operation or rate of intraperitoneal hematoma between the ES and EL groups for both nonperforated and perforated appendectomy cases. Superficial wound infection was more common in the nonperforated EL group (17/309, 5.5%) than in the nonperforated ES group (2/235, 0.9%; p = 0.007). Operative time for the EL technique (52.2 ± 15.8 minutes; p = 0.047) was shorter than for the ES technique (58 ± 23.2 minutes) for patients with perforated appendicitis. CONCLUSION EL stump closure and mesoappendix cauterization during LA is safe and effective in children with appendicitis, including perforated appendicitis.

Fulminant Clostridium difficile toxic megacolon in a pediatric heart transplant recipient

Patel A, Gossett JJ, Benton T, Rowell E, Russell H, Cham E, Pahl E. Fulminant Clostridium difficile toxic megacolon in a pediatric heart transplant recipient. 
Pediatr Transplantation 2010: : E30–E34.

A review of reported surgical techniques in fertility preservation for prepubertal and adolescent females facing a fertility threatening diagnosis or treatment

BACKGROUND Ovarian tissue cryopreservation is increasing as a preferred option for fertility preservation for prepubertal and young adolescent females facing a fertility threatening diagnosis or treatment. DATA SOURCES Ovid MEDLINE and PubMed searches for terms related to ovarian tissue removal for fertility preservation revealed there is no current consensus on operative technique for surgical ovarian cortical tissue removal in adult females. Additionally, there are limited published reports of surgical approach and outcomes in the pediatric population. In total, 22 publications were reviewed for their operative approach, ovarian tissue harvesting techniques, complications and outcomes. CONCLUSIONS Reported operative approaches and techniques for ovarian tissue cryopreservation for pediatric and adolescent patients are variable. Further investigations into operative technique and tissue harvesting that maintains healthy ovarian follicles for transplant will help establish standard technical principles for surgery in pediatric and adolescent females undergoing fertility preservation.

Uterine leiomyoma causing menometrorrhagia with a concomitant mature teratoma in a 15-year-old child: a case report and review of the literature.

Uterine leiomyoma is the most common uterine tumor in adult females but is rare in the pediatric population with only 10 previous cases reported. We describe the unique case of a 15-year-old girl who presented with abdominal pain and menometrorrhagia and was found to have a uterine leiomyoma as well as a mature ovarian teratoma that required surgical resection. We review diagnostic imaging and optimal management for the 2 gynecologic masses in this teenage girl.

Optimal Technique for Laparoscopic Oophorectomy for Ovarian Tissue Cryopreservation in Pediatric Girls

For parents of a girl facing treatment that poses a threat to future fertility, the option of removal of one ovary now exists to cryopreserve the ovarian tissue prior to beginning the potentially sterilizing medical treatment. This option has an even more powerful impact, given the recent pregnancy achieved by a woman in Belgium after reimplantation of strips of ovarian tissue which had been cryopreserved when she was 14 years old [1]. The state of the science is such that for both premenarchal and post-menarchal girls, there is more hope than ever that these girls can have a biologically related child in the future and possibly achieve natural pregnancy.