Jeffrey R. Horwitz

Complications after surgical intervention for necrotizing enterocolitis: A multicenter review

Necrotizing enterocolitis (NEC) is a serious condition affecting predominantly the premature infant. The purpose of this study is to report a multicenter experience of complications in 252 infants requiring surgical therapy for NEC. Data from eight institutions for the years 1980 through 1990 were collected and analyzed for infants undergoing surgical therapy for NEC. Records were reviewed for gestational age, birth weight, age at operation, indications for operation, degree of intestinal involvement, operation(s) performed, complications, and 30-day mortality rates. A total of 264 infants underwent surgical intervention for NEC during the study period. Complete information was available for 252 patients. The mean gestational age was 31 +/- 5 weeks and the mean birth weight was 1,552 +/- 823 g. The mean age at operation was 18 +/- 35 days. Pneumoperitoneum was the most common indication for operation (42%). The 30-day survival rate was 72%. Eighty-one percent of patients underwent primary laparotomy, whereas peritoneal drainage was performed in 48 (19%) patients. Postoperative complications were identified in 119 (47%) patients. The most common postoperative complications were sepsis (9%), intestinal strictures (9%), and short gut (9%). Wound infections occurred in 6%, and the incidence of intraabdominal abscess formation was only 2.3%. Gestational age < 27 weeks (P < .005) and birth weight < 1,000 g (P < .005) were associated with significantly increased mortality but no increase in postoperative morbidity. The incidence of complications was similar in the very low birth weight (< 1,000 g) infants (51%) compared with infants > or = 1,000 g (46%).(ABSTRACT TRUNCATED AT 250 WORDS)

Importance of diarrhea as a presenting symptom of appendicitis in very young children

BACKGROUND Appendicitis is an uncommon diagnosis in very young children. It is frequently complicated by delays in diagnosis, perforation, and lengthy hospital stays. OBJECTIVES To review our recent experience with appendicitis among children younger than 3 years old, and to identify the independent predictors of a prolonged hospital stay. METHODS A retrospective case series review was performed on all children under age 3 who had an appendectomy for appendicitis between January 1983 and February 1994. Multiple regression analysis was used to identify the independent predictors of a prolonged hospital stay. RESULTS Sixty-three children were identified. Mean age was 2.2 years (range 11 to 35 months). The mean delay from onset of symptoms to presentation was 4.3 days. Fifty-seven percent were initially misdiagnosed. Diarrhea was reported in 33%. Perforation and/or gangrene were found in 84%. Perforation and/or gangrene at laparotomy and a history of diarrhea at presentation were independent predictors of a prolonged hospital stay. CONCLUSIONS Appendicitis in children under 3 years old is characterized by delays in diagnosis and perforation. A history of diarrhea is an important factor that confuses the diagnosis, prolongs the observation period, and delays appropriate therapy.

Pediatric wound infections: a prospective multicenter study.

OBJECTIVE Surgical wound infections remain a significant source of postoperative morbidity. This study was undertaken to determine prospectively the incidence of postoperative wound infections in children in a multi-institutional fashion and to identify the risk factors associated with the development of a wound infection in this population. SUMMARY BACKGROUND DATA Despite a large body of literature in adults, there have been only two reports from North America concerning postoperative wound infections in children. METHODS All infants and children undergoing operation on the pediatric surgical services of three institutions during a 17-month period were prospectively followed for 30 days after surgery for the development of a wound infection. RESULTS A total of 846 of 1021 patients were followed for 30 days. The overall incidence of wound infection was 4.4%. Factors found to be significantly associated with a postoperative wound infection were the amount of contamination at operation (p = 0.006) and the duration of the operation (p = 0.03). Comparing children who developed a wound infection with those who did not, there were no significant differences in age, sex, American Society of Anesthesiologists (ASA) preoperative assessment score, length of preoperative hospitalization, location of operation (intensive care unit vs. operating room), presence of a coexisting disease or remote infection, or the use of perioperative antibiotics. CONCLUSIONS Our results suggest that wound infections in children are related more to the factors at operation than to the overall physiologic status. Procedures can be performed in the intensive care unit without any increase in the incidence of wound infection.

A multicenter trial of 6-aminocaproic acid (Amicar) in the prevention of bleeding in infants on ECMO

BACKGROUND/PURPOSE Intracranial hemorrhage (ICH), is a major source of morbidity and the leading cause of death in neonates treated with extracorporeal membrane oxygenation (ECMO). Anecdotal reports have suggested that epsilon-aminocaproic acid (EACA) can decrease the risk of ICH. The purpose of this study was to evaluate, in a multiinstitutional, prospective, randomized, blinded fashion, the effect of EACA on the incidence of hemorrhagic complications in neonates receiving ECMO. METHODS All neonates (except congenital diaphragmatic hernia) who met criteria for ECMO at three institutions were eligible for enrollment. EACA (100 mg/kg) or placebo was given at the time of cannulation followed by 25 mg/kg/h for 72 hours. Bleeding complications, transfusion requirements, and thrombotic complications were recorded. Post-ECMO imaging included head ultrasound scan computed tomography (CT) scan, and duplex ultrasound scan of the inferior vena cava and renal vessels. RESULTS Twenty-nine neonates were enrolled (EACA, 13 and placebo, 16). Five (17.2%) patients had a significant (grade 3 or larger) ICH. There was no statistical difference in the incidence of significant ICH in patients who received EACA (23%) versus placebo (12.5%). Septic patients accounted for all of the ICH in the EACA group. Thrombotic complications (aortic thrombus and SVC syndrome) developed in two patients from the placebo group. There was no difference in thrombotic circuit complications between groups. CONCLUSIONS Our results suggest that the use of EACA in neonates receiving ECMO is safe but may not decrease the overall incidence of hemorrhagic complications.

Malignant solid tumors in neonates: A 40-year review

To evaluate the outcome of neonatal malignant solid tumors, we reviewed the records of 222 infants under the age of 1 year with malignant disease who were treated at the University of Texas M.D. Anderson Cancer Center over a 40-year period. Forty-five cases of neonatal (< 30 days old at the time of presentation) malignancies were found. Thirty-two infants had solid tumors and form the basis of this report. Diagnoses included soft tissue sarcoma (13), brain tumor (5), neuroblastoma (6), retinoblastoma (3), malignant melanoma (2), hemangiopericytoma (2), and nephroblastoma (1). The mean age at which initial signs and symptoms were noted was 9 days of life. Fifty-nine percent (19) presented within the first week of life, and 47% (15) presented at birth. The mean age at histological diagnosis was 54 days. The head and neck region was the most common site (18), followed by trunk (9), and extremities (5). Thirty-one patients underwent surgical resection of the primary tumor. Thirteen of those neonates received no additional chemotherapy and/or radiation therapy, whereas 18 received some combination of surgery plus perioperative chemotherapy and/or radiation therapy. Overall survival was 78% (25 of 32) with an average follow-up of 8 years (range, 2 months to 29 years). There were no survivors among those patients with distant metastatic disease at the time of diagnosis. Despite delays, prognosis is excellent in the absence of distant metastatic disease, particularly for extracranial tumors.

Venovenous bypass as an adjunct for the management of a retrohepatic venous injury in a child

We report the successful utilization of venovenous bypass in the case of an 8-year-old-boy who suffered a major hepatic injury with a retrohepatic venous injury after a kick by a horse. Initial nonoperative management was successful, but a delayed hemorrhage required operation. Vascular access was obtained via the peripheral circulation, and venovenous bypass was performed without systemic heparinization. Venovenous bypass improved vascular control and allowed the repairs to be performed in a relatively bloodless field, while not compromising venous return.

Bronchogenic and Esophageal Duplication Cyst in a Single Mediastinal Mass in a Child

We report an unusual case of a mediastinal foregut malformation consisting of complete components of both a bronchogenic and an esophageal duplication cyst in a child. The lesion was identified as an incidental finding during evaluation of a clavicular fracture. Thoracotomy was performed for excision of the mass. A discussion of the pathological findings and the diagnosis and management of foregut malformations is presented.

Traumatic rupture of a wandering spleen in a child: case report and literature review.

A case of traumatic rupture of a wandering spleen in a 5-year-old girl is presented. To our knowledge, this is the first reported case of such injury in a child. The splenic injury was managed nonoperatively. The etiology and management of wandering spleen is discussed.

Use of extracorporeal membrane oxygenation in the septic neonate

Extracorporeal membrane oxygenation (ECMO) is widely used for cardiopulmonary support in neonates with cardiopulmonary failure secondary to overwhelming sepsis. The purpose of this study was to examine the effects of culture status on the eventual outcome of septic neonates requiring ECMO support. Data from the Extracorporeal Life Support Organization (ELSO) for the tears 1990 through 1992 inclusive were collected and analyzed for all neonates with a primary diagnosis of sepsis. Records were reviewed for gestational age, birth weight, culture status and isolated organism, last arterial blood gas before beginning ECMO, hemorrhagic complications during bypass, and overall survival. Gram-positive sepsis accounted for 85% of positive cultures. Group B streptococcus (GBS) and Escherichia coli were the most commonly isolated organisms (GBS: 95% of all gram-positive sepsis; E coli: 76% of all gram-negative sepsis) from culture-positive patients. Culture-negative patients were found to have a significantly lower mortality rate compared with culture positive patients (16.6% versus 26.9%, P < .001). The incidence of intracranial hemorrhage (ICH) was greater in culture-positive neonates when compared with culture negative (27.6% versus 20.1%, P < .05). There was no difference in the incidence of ICH or eventual outcome between gram-positive and gram-negative sepsis. The culture-positive, septic neonate who requires ECMO support appears to be at an increased risk for intracranial hemorrhage and death. Intracranial hemorrhage appears to be the primary factor affecting survival in these patients. The etiologic organism does not affect the incidence of ICH or outcome. Frequent head ultrasounds and strict control of coagulation parameters are recommended in this patient population.

Supraumbilical skin-fold incision for pyloromyotomy

We describe our experience with a supraumbilical skin-fold incision for pyloromyotomy in infants. Our technique uses a vertical fascial incision. This approach provides excellent exposure to the pylorus, allows greater operative flexibility, and results in a superior cosmetic outcome compared to the traditional right upper-quadrant incision.