Gad Lotan

Blunt pancreatic trauma in children

PurposeTo report our experience with blunt pancreatic trauma in pediatric patients and evaluate several various management strategies.MethodsTen children admitted over the last 10 years with pancreatic blunt trauma were included in the present series.ResultsThe average time from injury to hospital admission was 2.4 days. All injuries resulted from accidents: bicycle handlebar injuries (5), being kicked by a horse (2), falls from a height (2), and injury sustained during closure of an electric gate (1). Additional systemic and abdominal injuries were recorded in 7 patients. The amylase levels at the time of patient admission were normal in 3 patients, mildly raised in 4 patients, and elevated in 3 patients. Abdominal computed tomography was performed in 10 patients, ultrasonography in 5, and endoscopic retrograde cholangiopancreatography (ERCP) in 4. Pancreatic injuries comprised 4 grade I, 3 grade II, and 3 grade III injuries. Grade I and II injuries were successfully managed by conservative treatment. The 3 children with grade III trauma and pancreatic ductal injury in the neck (1), body (1), and tail (1) of the gland were surgically treated, having an uneventful postoperative stay of 8–14 days and no complications during the 1-year follow-up period.ConclusionThe present study supports early ERCP as an essential part of the initial patient evaluation when pancreatic transection is highly suspected.

Management of Primary Spontaneous Pneumothorax in Children

Objective. To examine the role of CT scans and early surgical intervention in the management of pediatric patients with primary spontaneous pneumothorax (PSP). Methods . Retrospective cohort study. Results. The authors identified 46 cases with 70 episodes of pneumothorax. The recurrence rate among conservatively treated patients was 50% both after the first and the subsequent episode. Recurrence rate in cases with and without blebs on CT was comparable. Initial episodes were treated with supplemental oxygen (n = 18) and chest tube drainage (n = 18), and 10 patients underwent video-assisted thoracoscopic surgery (VATS). The recurrence rate was significantly lower following surgical intervention compared with other therapy, and morbidity was comparable with that in patients who needed chest tube drainage. Conclusions. Recurrence after the first episode of PSP in children is frequent and is difficult to predict by CT findings. VATS is safe and effective in preventing recurrences. Surgical intervention may be an attractive alternative in patients who require chest tube drainage for the first episode of PSP.

Adnexal torsion involving hydatids of Morgagni: a rare cause of acute abdominal pain in adolescents.

OBJECTIVE: Hydatids of Morgagni are common embryonal remnants of the müllerian duct and among the infrequent causes of adnexal torsion. The purpose of this study was to investigate the occurrence of adnexal torsion involving hydatids of Morgagni, as well as its possible mechanisms. METHODS: A database search was conducted for cases of adnexal torsion treated in our institution from January 2002 to July 2005. These cases were analyzed, focusing on a subgroup of adolescents with adnexal torsion involving the hydatids of Morgagni. RESULTS: There were 76 patients with adnexal torsion. The rate of hydatid of Morgagni torsion was 26% (4 of 15 cases, 95% confidence interval [CI] 0.15–0.51) in the adolescent subgroup (10–19 years old), compared with 0% (0 of 61 cases, 95% CI 0–0.048) in the adult subgroup. The difference between the hydatid torsion rates in the two subgroups was statistically significant (P = .01, 95% CI 0.001–0.532). The four patients with hydatid torsion (postmenarchal girls, aged 13–18 years) were managed with laparoscopic adnexal detorsion and cystectomy of the affected hydatid of Morgagni. At surgery, we noted three different mechanisms of hydatid torsion: torsion of the adnexa together with torsion of the hydatid of Morgagni, torsion of the hydatid of Morgagni with intact adnexa (n = 2), and entanglement of the hydatids pedicle around the distal fallopian tube. The hydatids of Morgagni were observed on the preoperative transabdominal ultrasonogram in only one patient and appeared as a simple cyst. CONCLUSION: Adnexal torsion involving the hydatids of Morgagni appears to be more common in adolescents than previously thought. LEVEL OF EVIDENCE: III

Bicycle-related injuries in children: Disturbing profile of a growing problem

CONTEXT We observed a changing pattern of bicycle-related injuries in children, with the focus changing from head trauma to thoracic and abdominal injuries, and a trend to increasingly severe injuries. OBJECTIVE To assess the changing injury pattern, and investigate the development of preventive measures to improve safety. DESIGN, SETTING, AND PARTICIPANTS Retrospective record review of 142 paediatric patients admitted to our Department of Paediatric Surgery between 1996 and 2005 following bicycle-related injuries. Clinical, laboratory, diagnostic, and therapeutic aspects were analysed. Additional information concerning childrens bicycle-related injuries in Israel was obtained from the Gertner Institute (Israel National Center for Trauma and Emergency Medicine Research) and from Beterem (The National Center for Childrens Safety & Health, the Safe Kids Israeli Chapter) National Report on Child Injuries in Israel 2006. MAIN OUTCOME MEASURES The nature and severity of injuries were reviewed, and two 5-year periods compared-from 1996 to 2000 (53 children-Group 1), and from 2001 to 2005 (89 children-Group 2). RESULTS Head trauma was more common in the Group 1 patients (52.6% vs. 45.2%), but skull fractures and intracranial haemorrhage occurred more frequently in Group 2 (28.5% vs. 16.7%; 21.3% vs. 8.3%, respectively). Injury to the stomach or duodenum, kidneys and liver were all more common in Group 2. Splenic injury occurred with equal frequency in both groups, but more severe injuries were seen in Group 2. More children in Group 2 required intensive care (31% vs. 19.3%). CONCLUSIONS There is a changing pattern of bicycle-related injuries in children, with chest and abdominal injuries dominating, and an increasing incidence of more severe injury. These findings are important in decision-making regarding preventive measures.

Familial wandering spleen: a first instance

We report on 2 sisters presenting with acute torsion of a wandering spleen within a 3-year interval. The diagnosis was made preoperatively by computed tomography (CT) in both cases. A high index of suspicion because of our experience with the first patient, who underwent splenectomy, enabled a correct early diagnosis in the sibling. On urgent surgery, reversible ischemic changes were found, and detorsion and splenopexy resulted in preservation of the spleen.

Superior mesenteric artery syndrome after scoliosis repair surgery: a case study and reassessment of the syndromeʼs pathogenesis

We carried out a retrospective analysis to investigate the prevalence of superior mesentery artery syndrome (SMAS) in children who underwent scoliosis surgical repair at our hospital between 1998 and 2006 and to reassess the syndromes pathogenesis. Among 133 consecutive pediatric patients, two cases were identified, both 13-year-old girls with idiopathic scoliosis, undergoing surgery using third-generation instrumentation systems. Conservative management achieved resolution of the symptoms without recurrence. SMAS prevalence in our series was 1.6%. SMAS might occur after derotation and translation forces application, and even with nonextreme corrections. Low BMI and significant weight loss at presentation are not mandatory.

The contribution of intraoperative transinguinal laparoscopic examination of the contralateral side to the repair of inguinal hernias in children

BackgroundBilateral inguinal hernias are relatively common in children. This fact has led to a controversy of more than 50 years concerning the necessity of bilateral surgical exploration during the repair of unilateral inguinal hernias in children. The advent of transinguinal laparoscopic visualization of the contralateral side is a turning point and a major contribution to the subject, offering the opportunity to reassess the systematic bilateral exploration and the “wait and see” policies currently in use at most services of pediatric surgery.Data sourcesThe current information concerning intraoperative transinguinal laparoscopic evaluation of inguinal hernias in children was summarized in a didactic way. A MEDLINE search (PubMed) from 1995 to the present days was conducted.ResultsA patent processus vaginalis (PPV) is not equal to a future symptomatic hernia. There is still no definitive evidence on which PPVs will become a hernia (5.8% to 11.6%) and which remain clinically insignificant. Diagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side is today the most simple and accurate way to reduce the incidence of negative explorations.ConclusionDiagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side during pediatric inguinal hernia repair is a simple, accurate, fast, and effective method to assess the contralateral processus vaginalis, improving decision-making, reducing the number of negative explorations, and sparing the surgeon the embarrassment associated with the appearance of a metachronous hernia at a later date. It is easily learned and should be part of every pediatric surgeon’s practice.

Fibrous hamartoma of infancy

Fibrous hamartoma of infancy is a rare benign soft tissue tumor that usually occurs within the first 2 years of life. We report 3 cases of fibrous hamartoma of infancy seen over a 10-year period. Treatment is curative by local excision with a low local recurrence rate. Fibrous hamartoma of infancy should be considered in the differential diagnosis of soft tissue masses in children because it is always benign and subject to nonaggressive treatment.

Diagnosis and treatment of pediatric vaginal and genital tract abnormalities by small diameter hysteroscope

The vaginal speculum can be safely and efficaciously replaced by the less traumatic small diameter continuous flow hysteroscopic vaginoscopy for diagnosis and treatment of genital tract lesion in children and adolescents.

Treatment of epilepsy by stimulation of the vagus nerve from Head-and-Neck surgical point of view

The current article is dedicated to the surgical aspect of the vagus nerve stimulation (VNS) and our efforts to improve the surgical technique. The aim was to reduce the side effect/surgical complication rate as well as the time needed for this surgery.