J. Mark Walton

Hypotonic Versus Isotonic Maintenance Fluids After Surgery for Children: A Randomized Controlled Trial

OBJECTIVE: The objective of this randomized controlled trial was to evaluate the risk of hyponatremia following administration of a isotonic (0.9% saline) compared to a hypotonic (0.45% saline) parenteral maintenance solution (PMS) for 48 hours to postoperative pediatric patients. METHODS: Surgical patients 6 months to 16 years of age with an expected postoperative stay of >24 hours were eligible. Patients with an uncorrected baseline plasma sodium level abnormality, hemodynamic instability, chronic diuretic use, previous enrollment, and those for whom either hypotonic PMS or isotonic PMS was considered contraindicated or necessary, were excluded. A fully blinded randomized controlled trial was performed. The primary outcome was acute hyponatremia. Secondary outcomes included severe hyponatremia, hypernatremia, adverse events attributable to acute plasma sodium level changes, and antidiuretic hormone levels. RESULTS: A total of 258 patients were enrolled and assigned randomly to receive hypotonic PMS (N = 130) or isotonic PMS (N = 128). Baseline characteristics were similar for the 2 groups. Hypotonic PMS significantly increased the risk of hyponatremia, compared with isotonic PMS (40.8% vs 22.7%; relative risk: 1.82 [95% confidence interval: 1.21–2.74]; P = .004). Admission to the pediatric critical care unit was not an independent risk factor for the development of hyponatremia. Isotonic PMS did not increase the risk of hypernatremia (relative risk: 1.30 [95% confidence interval: 0.30–5.59]; P = .722). Antidiuretic hormone levels and adverse events were not significantly different between the groups. CONCLUSION: Isotonic PMS is significantly safer than hypotonic PMS in protecting against acute postoperative hyponatremia in children.

Sclerotherapy for lymphatic malformations in children: a scoping review

PURPOSE This scoping review assesses the literature and summarizes the current evidence on sclerotherapy for the treatment of lymphatic malformations in pediatric patients. METHODS A comprehensive search of published and unpublished literature was conducted using multiple databases. Title, abstract, and full-text screening was conducted by 2 independent clinicians. All discrepancies were resolved during consensus meetings. RESULTS A total of 182 articles were retrieved. Forty-four articles were removed as duplicates, and 11 articles were added after reviewing prominent studies. After full-text abstraction, 44 articles and 2 conference proceedings (N = 882 patients) were included in the final results. Twelve articles were classified as level II and 34 articles as level IV evidence. Picibanil (OK-432) was the primary agent used in most included studies. Postinjection symptoms with OK-432 were primarily fever, swelling, and erythema at the site. Life-threatening complications were uncommon and involved postinjection swelling of cervical lesions causing airway compromise. CONCLUSIONS The literature regarding sclerotherapy for lymphatic malformations is of a low level of evidence and suffers from a lack of standardization. Randomized clinical trials focused on OK-432, bleomycin, or alcoholic solution of zein; standardized dosing protocols; and consistent and reliable outcome reporting will be necessary for further development of treatment guidelines.

Mucoepidermoid Carcinoma of the Parotid Gland: A Rare Presentation in a Young Child

Although mucoepidermoid carcinoma (MEC) is the most common malignant salivary gland neoplasm in childhood and adolescence, it is rarely found in children under the age of 10. A 6-year-old girl had an asymptomatic neck mass for 5 months. Clinical examination findings showed a 1.5-cm smooth and firm but mobile nontender mass located in the upper left anterior cervical triangle, clinically separate from the parotid gland. Ultrasound examination findings showed a vascular mass, with a cystic component, possibly within the tail of the parotid gland. An excisional biopsy was performed and frozen section showed a low-grade MEC. A left superficial parotidectomy was then performed. Final histopathologic examination showed one positive resection margin. Subsequently, reexcision of the surgical site and an upper modified neck dissection was undertaken. This unusual presentation of MEC as a neck mass in one of the youngest reported patients illustrates that the anatomic region for parotid tumors is large. Possibly some of these tumors may arise from heterotopic or accessory parotid tissue.

Parent health literacy and satisfaction with plain language education materials in a pediatric surgery outpatient clinic: a pilot study

BACKGROUND Although significant, the issue of health literacy (HL) among parents attending pediatric surgery outpatient clinics has received little attention. PURPOSE The objectives of this study are to determine the HL skills of parents attending the pediatric surgery outpatient clinic at McMaster Childrens Hospital and to describe parent satisfaction with plain language materials. METHODS This cross-sectional study was conducted at the pediatric surgery outpatient clinic at McMaster Childrens Hospital. Using convenience sampling for 4 months, parents were recruited and interviewed regarding their demographic status. The Newest Vital Sign tool was used to assess HL. Feedback on the plain language education material was received. RESULTS Seventy-nine individuals were recruited, with a recruitment rate of 62%. Seventy-one percent had adequate HL. English as a first language and Canada as the place of birth were significantly correlated with adequate HL (r = 0.367, P < .001; r = 0.259, P < .05). Parents reported satisfaction with the plain language material, regardless of their HL level. CONCLUSION Twenty-nine percent of parents showed inadequate HL, likely an underestimate owing to study limitations. Parents expressed satisfaction with the plain language material, emphasizing the need for clear, effective communication with patients and families. Future directions include evaluating staff knowledge of a universal precautions approach to health communication and the accessibility of plain language materials.

Fundoplication and gastrostomy versus percutaneous gastrojejunostomy for gastroesophageal reflux in children with neurologic impairment: A systematic review and meta-analysis.

BACKGROUND Children with neurologic impairment often fail medical management of gastroesophageal reflux and proceed to fundoplication and gastrostomy (FG) or percutaneous gastrojejunostomy (GJ). Current guidelines do not recommend one treatment over the other, and there is ongoing uncertainty regarding clinical management. METHODS We conducted a structured search of Medline, Embase, trial registries, and the gray literature. We included studies that compared outcomes for FG and GJ in children with neurologic impairment. RESULTS We identified 556 children from three retrospective studies who underwent FG (n=431) or GJ (n=125). There were no differences in rates of pneumonia (17% vs 19%, p=0.74) or mortality (13% vs 14%, p=0.76). Few deaths were due to procedural complications (1%) or reflux (2%). There was a trend towards more major complications with FG (29%) compared to GJ (12%) (risk ratio=1.70, 0.85-3.41, p=0.14). Minor complications were more common with GJ (70%) than FG (45%), but this difference was also not statistically significant (risk ratio=0.38, 0.05-3.07, p=0.36). No studies reported quality of life using validated measures. CONCLUSIONS The quality of the evidence for outcomes of FG versus GJ is very low. Large comparative studies are needed to determine which approach is associated with the best quality-of-life outcomes.

Spindle epithelial tumor with thymus-like elements of the thyroid: a multi-institutional case series and review of the literature

BACKGROUND/PURPOSE Spindle epithelial tumor with thymus-like elements (SETTLE) is a rare tumor of the thyroid observed in children and adolescents. We present a case series of 3 patients with SETTLE, focusing on the clinical and pathologic features of this rare tumor. METHODS Three male patients presented at ages 4.5, 6.5, and 7 years with a right thyroid mass. All were treated by standard hemithyroidectomy. None had evidence of distant metastases at presentation. The diagnosis of SETTLE was confirmed at the time of the initial operation in 2 of the 3 patients. RESULTS All patients had uneventful postoperative courses. Two patients remain disease-free 4 and 7 years postresection, respectively. One patient presented 10 years after resection with shortness of breath and hemoptysis secondary to multiple bilateral parenchymal lung metastases. This patient received chemotherapy against the epithelial components of the tumor with a 25% response based on imaging studies. CONCLUSION Spindle epithelial tumor with thymus-like elements is rare tumor that should be suspected if spindle elements are observed in the resected thyroid specimen. Because these patients may present with delayed metastases, follow-up is recommended. However, chemotherapy against specific tumor elements is only marginally effective.

Inflicted esophageal perforation

Esophageal perforation in children is uncommon. A 2 1/2-year-old girl presented with multiple soft tissue injuries of various chronological ages. Initial lateral cervical spine films showed the presence of a prevertebral air collection with soft tissue swelling. Enhanced computerized tomography confirmed the presence of proximal esophageal rupture and a retropharyngeal abscess. External drainage of the abscess and intravenous antibiotics led to resolution of the perforation in 13 days. Discrepancies in the history and the constellation of injuries pointed to an inflicted etiology (through child abuse). Since 1984, 21 case studies have described inflicted esophageal perforation. Common mechanisms of injury include foreign body ingestion and blunt or penetrating external trauma. Early diagnosis of these injuries reduces both acute and long-term morbidity and mortality. Pediatric surgeons must be aware of inflicted injury as an etiology of esophageal and hypopharyngeal perforation.

Gastrostomy matters—The impact of pediatric surgery on caregiver quality of life

INTRODUCTION While pediatric surgeons consider gastrostomy to be routine treatment for children with feeding difficulties, the impact on the family is not fully understood. This study focuses on Quality of Life (QoL) of parents of children who require a gastrostomy tube. METHODS A prospective repeated measures cohort study was conducted between November 2009 and March 2012. Demographic, surgical, and QoL data were collected at Baseline, 2 weeks, 3, 6, 9, and 12 months after surgery. At each time-point parents completed three QoL measures: Short Form 36v2 (SF-36), Caregiver Strain Index (CSI), and Parent Experience of Childhood Illness (PECI). RESULTS A total of 31 caregivers were recruited with a mean age of 32.6 years (SD=7.0). Overall, a 38% increased risk of depression was seen in the SF-36 when compared to population norms, and a moderate effect was seen in mental health at 12 months (ES=0.56). The CSI demonstrated a decrease in caregiver burden (8.72 to 7.05, p=0.007, 95% CI (0.57-3.18)), while the PECI revealed a decrease in frequency of feelings of guilt, worry, sorrow, anger, and long term uncertainty over 12 months. CONCLUSION Gastrostomy not only improves the childs physical health, but also improves the mental health of the childs caregivers, especially at (or after) one year.

Are some children with empyema at risk for treatment failure with fibrinolytics? A multicenter cohort study

BACKGROUND Guidelines recommend that children with empyema be treated initially with chest tube insertion and intrapleural fibrinolytics. Some patients have poor outcomes with this approach, and it is unclear which factors are associated with treatment failure. METHODS Possible risk factors were identified through a review of the literature. Treatment failure was defined as need for repeat pleural drainage and/or total length of stay greater than 2weeks. RESULTS We retrospectively identified 314 children with empyema treated with fibrinolytics at The Hospital for Sick Children (2000-2013, n=195), Childrens Hospital, London Health Sciences Centre (2009-2013, n=39), and McMaster Childrens Hospital (2007-2014, n=80). Median length of stay was 11days (range 5-69days). Thirteen percent of children required repeat drainage procedures, and 34% experienced treatment failure. There were no deaths. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, albumin, urea to creatinine ratio, and signs of necrosis on initial chest x-ray were not associated with treatment failure. Multivariable logistic regression demonstrated increased risk with positive blood culture (odds ratio=2.7), immediate admission to intensive care (odds ratio=2.6), and absence of complex septations on baseline ultrasound (odds ratio=2.1). Male gender and platelet count were associated with treatment failure in the univariate analysis but not in the multivariable model. CONCLUSIONS Predicting which children with empyema are at risk for treatment failure with fibrinolytics remains challenging. Risk factors include positive blood culture, immediate admission to intensive care, and absence of complex septations on ultrasound. Routine blood work and inflammatory markers have little prognostic value.

Abdominal Compartment Syndrome Secondary to Chronic Constipation

Abdominal compartment syndrome (ACS) is defined as an elevated intraabdominal pressure with evidence of organ dysfunction. The majority of published reports of ACS are in neonates with abdominal wall defects and in adults following trauma or burns, but it is poorly described in children. We describe the unusual presentation of an 11-year-old boy with a long history of chronic constipation who developed acute ACS requiring resuscitative measures and emergent disimpaction. He presented with a 2-week history of increasing abdominal pain, nausea, diminished appetite and longstanding encopresis. On exam, he was emaciated with a massively distended abdomen with a palpable fecaloma. Abdominal XR confirmed these findings. Within 24 hours of presentation, he became tachycardic and oliguric with orthostatic hypotension. Following two enemas, he acutely deteriorated with severe hypotension, marked tachycardia, acute respiratory distress, and a declining mental status. Endotracheal intubation, fluid boluses, and vasopressors were commenced, followed by emergent surgical fecal disimpaction. This resulted in rapid improvement in vital signs. He has been thoroughly investigated and no other condition apart from functional constipation has been identified. Although ACS secondary to constipation is extremely unusual, this case illustrates the need to actively treat constipation and what can happen if it is not.