James S. Donaldson

Clinical application of ultrasonography in the diagnosis of intussusception

Sixty-five consecutive patients seen in a pediatric emergency department, in whom the diagnosis of intussusception was considered, had an ultrasound examination of the abdomen before a barium enema. The mean age of the patients was 1.7 years (range 2 weeks to 5 years). Intussusception was detected by ultrasonography in all 20 cases proved by barium enema. There were three false-positive ultrasound results (sensitivity = 100%, confidence interval (Cl) = 86% to 100%; specificity = 93%, Cl = 86% to 96%). Normal findings on ultrasonography correlated with a negative barium enema results in 42 of 42 cases (negative predictive value = 100%, Cl = 94% to 100%). No intussusception was missed by ultrasonography. To determine which patients would most benefit from ultrasonography, we divided patients into either a high-risk group (81% with intussusception) or a low-risk group (14% with intussusception) on the basis of clinical symptoms (p less than 0.01). If each high-risk child had a barium enema and each low-risk child had an ultrasound study as their initial diagnostic test, 89% of the patients in this study would have undergone only one examination. We conclude that ultrasonography can be used as a rapid, sensitive screening procedure in the diagnosis or exclusion of childhood intussusception. Children considered at low risk of having intussusception on the basis of clinical symptoms should initially have an ultrasound examination; patients at high risk should have an immediate barium enema.

Malrotation of bowel: Variable patterns with different surgical considerations

The records of 53 patients with varied roentgenographic patterns of malrotation were reviewed. The patterns were categorized as A-Infantile (Al), A-Adult (Aa), B, C, and D. The differences in form were obvious and each differed clinically, radiographically, and surgically. The differences allowed the development of prognostic insights simply based on the presence and/or position of the ligament of Treitz and the cecum as shown by barium gastrointestinal examination. The literature was reviewed to find supportive or contradictory case material or other data that complemented or devalued the developed system for determining prognosis of patients with varied bowel patterns. The developed prognostic scheme seems to satisfy the requirements of reliability.

Outcomes and risk factors for failure of radiologic treatment of biliary strictures in pediatric liver transplantation recipients

Posttransplantation biliary strictures occur in 5–34% of the pediatric liver transplant patients and are conventionally managed by interventional radiological techniques. The aim of this manuscript is to assess the outcomes of patients with biliary strictures treated by percutaneous dilatation at our institution. Included in the study were 35 children with posttransplant biliary strictures that were treated with percutaneous dilatation and stenting. Initial dilation and biliary stent placement was accomplished in all patients without complications requiring surgical intervention. Recurrent strictures developed in 23 (66%) of 35 patients. The recurrence rate was 45% for anastomotic strictures, 90% for intrahepatic strictures, and 100% for those with both an anastomotic and intrahepatic component. Seven patients required revision of the choledochojejunostomy, 5 of them with a successful outcome and 2 requiring retransplant. Five patients were treated with retransplantation without surgical revision. Patients with an intrahepatic or a “combined” stricture were less likely to have a successful outcome after radiologic treatment. In conclusion, the radiological treatment of biliary strictures with balloon dilation and stenting can be performed successfully with minimal complications avoiding the need for surgical correction in many cases. Liver Transpl 12:821–826, 2006.

Long-term outcome of patients with intraspinal neuroblastoma

BACKGROUND Chemotherapy, radiotherapy, and surgical decompression with laminectomy are effective therapeutic options in the treatment of cord compression from neuroblastoma (NB). We report the long-term outcome of patients with intraspinal NB treated with or without laminectomy at two large pediatric oncology centers. PROCEDURE We reviewed the medical records and radiographs of 26 children with intraspinal NB treated at Childrens Memorial Hospital in Chicago, Illinois, between 1985 and 1994 or at St. Jude Childrens Research Hospital in Memphis, Tennessee, between 1967 and 1992. RESULTS Twenty-four of the 26 patients are alive and disease-free (follow-up of 2-29 years; median, 10 years 2 months). Fifteen of the 23 patients with neurologic impairment underwent initial laminectomy. Nine of these 15 patients recovered neurologic function, including 3 patients who presented with paraplegia. Eleven of the 15 patients who underwent laminectomy have developed mild to severe spinal deformities. Eight patients with neurologic symptoms consequent to cord compression were treated with initial chemotherapy and/or surgery, but did not undergo laminectomy. Three patients with mild to moderate deficits recovered neurologic function. Four of 11 patients with intraspinal NB who did not undergo laminectomy have mild to severe scoliosis. CONCLUSIONS A low incidence of neurologic recovery was seen in patients with long-standing severe cord compression regardless of treatment modality. For patients with partial neurologic deficits, recovery was seen in most patients following chemotherapy or surgical decompression with laminectomy. A higher incidence of spinal deformities was seen in the patients treated with initial laminectomy.

IMAGING OF DEVELOPMENTAL DYSPLASIA OF THE HIP

Careful clinical examination remains the primary and most important way of diagnosing developmental dysplasia of the hip (DDH) in newborn infants. Repeated examinations during the first year are important to diagnose DDH subsequent to the newborn period. Sonography can detect cases of clinically silent DDH. Targeting high-risk infants for supplemental ultrasound screening at 4 to 6 weeks of age increases diagnosis of DDH and at significantly less expense than widespread screening. When sonography is not available, a pelvis radiograph at 3 months should be obtained in high-risk infants. Sonography also is used to monitor hip position and acetabular development in children undergoing harness treatment. Computed tomography and magnetic resonance imaging are reserved for children with more severe dysplasia, often as preoperative studies to help orthopedic surgeons to select the appropriate procedure.

Ultrasound of the distal pouch in infants with imperforate anus

Optimal surgical management of the newborn with imperforate anus depends on accurate determination of the level of the rectal pouch. Eighteen children with imperforate anus were evaluated with ultrasound. The distance from the end of the pouch to the perineum was measured. Ultrasound correctly predicted the level of the distal pouch in all 12 children who had confirmation of the pouch level by surgery or by distal contrast stomagrams. Six children have not yet had definitive surgery. Five children with a pouch to perineum (P-P) distance of less than or equal to 10 mm and three of six children with a P-P distance of 10 to 15 mm had successful correction by a simple perineal anoplasty. Three of six children with a P-P distance of 10 to 15 mm and all of those (seven) with a P-P distance greater than 15 mm were diverted with colostomies.

Improved neurocognitive function after radiologic closure of congenital portosystemic shunts.

Congenital portosystemic shunts are rare vascular anomalies causing direct shunting of blood from the portal circulation into the central venous circulation (1,2). They are often a consequence of persistence of elements from the fetal circulation, in particular the ductus venosus. Patients with congenital portosystemic shunts often have no signs or symptoms of disease until adulthood, at which time encephalopathy is the leading presenting symptom (3–6). Shunts may be discovered during surgery for other reasons and as incidental findings during sonography or computed tomography. Recent advances in interventional radiology have provided an opportunity to change management strategies from surgical to less invasive interventions (7–9). We report two children with symptomatic portosystemic shunts in whom interventional radiology was used to obliterate the shunts. Clinical symptoms and neurocognitive function improved in both children after the shunts were obliterated and hepatic portal venous perfusion restored.

Splenic microabscesses in the immune-compromised patient

Four immune-compromised children who were receiving antineoplastic chemotherapy (three for leukemia), presented with recurrent episodes of fever and left upper abdominal pain. Blood cultures grew enteric gram-negative organisms in three children. Multiple blood cultures were negative for fungus although three patients had mucocutaneous and urinary candidiasis. All remained febrile and symptomatic despite treatment with broad spectrum antibiotics and antifungal chemotherapy. Computed tomography (CT) scans in all patients showed 2- to 10-mm focal defects in the spleen. The larger defects could be seen by ultrasonography but not on the live-spleen nuclear scan. A splenectomy was performed 2 to 4 weeks after the onset of symptoms in each child, and the cut surface of the spleens showed multiple small abscesses. All operative cultures were negative. A histological examination confirmed Candida infection in two patients and Aspergillus in one. Necrotizing granulomas strongly suggestive of fungus were seen in the fourth child. The patients defervesced and appeared well within three days. Antifungal therapy was continued. One child remains in remission from acute lymphocytic leukemia; one continues on chemotherapy; and one has recurrent widespread tumor. The patient with Aspergillus died following a bone marrow transplantation 6 months after the splenectomy. He had disseminated aspergillosis. An immune-compromised patient with persistent unexplained fever should have a CT scan of the abdomen. The presence of multiple splenic lesions strongly suggests fungal disease. If antifungal therapy does not result in complete resolution of fever and the splenic lesions, a splenectomy is indicated.

Air Embolism during Tunneled Central Catheter Placement Performed without General Anesthesia in Children: A Potentially Serious Complication

Central venous catheters have had an increasingly important role in a variety of patient care situations, including long-term antibiotic therapy, chemotherapy, and nutritional support. The recent past has seen a gradual transition from placement of vascular access catheters by surgeons to placement by interventional radiologists. The interventional radiology service places a majority of the vascular access devices at our childrens hospital, including peripherally inserted central catheters, tunneled central venous catheters, temporary and permanent hemodialysis catheters, and subcutaneous ports. Most procedures performed by our interventional radiology service in children can be successfully completed with use of intravenous (i.v.) sedation, and a few require general anesthesia (GA). Key advantages of GA over i.v. sedation include the ability to have positive pressure ventilation (PPV) or controlled apnea during the procedure. We report our experience of venous air embolism in three small children during placement of tunneled central venous catheters when GA was not used.

Pediatric vascular access.

Pediatric interventional radiologists are ideally suited to provide vascular access services to children because of inherent safety advantages and higher success from using image-guided techniques. The performance of vascular access procedures has become routine at many adult interventional radiology practices, but this service is not as widely developed at pediatric institutions. Although interventional radiologists at some children’s hospitals offer full-service vascular access, there is little or none at others. Developing and maintaining a pediatric vascular access service is a challenge. Interventionalists skilled in performing such procedures are limited at pediatric institutions, and institutional support from clerical staff, nursing staff, and technologists might not be sufficiently available to fulfill the needs of such a service. There must also be a strong commitment by all members of the team to support such a demanding service. There is a slippery slope of expected services that becomes steeper and steeper as the vascular access service grows. This review is intended primarily as general education for pediatric radiologists learning vascular access techniques. Additionally, the pediatric or adult interventional radiologist seeking to expand services might find helpful tips. The article also provides education for the diagnostic radiologist who routinely interprets radiographs containing vascular access devices.