Juan Bass

Blunt Pancreatic Injuries in Children: The Role of Percutaneous External Drainage in the Treatment of Pancreatic Pseudocysts

During the past 10 years, 26 cases of blunt pancreatic trauma were diagnosed in our institution. In 42.3% (11/26) the accident was bicycle-related. Seventy-three percent of patients were seen within 48 hours of injury. The most frequent clinical presentations included abdominal pain, tenderness and vomiting. Diagnosis of pancreatic injury was suggested by hypermylasemia in most cases. Associated trauma was seen in seven patients (26.9%) and it was intraabdominal in four (15.3%). Computerized tomography (CT) scan is the single most useful radiologic investigation in evaluating pancreatic trauma. Ultrasound, although less accurate than CT scan in determining the severity of the initial injury, is useful in the evaluation and treatment of pancreatic pseudocysts. Pancreatic pseudocysts developed in ten patients. Spontaneous resolution occurred in five (50%). In three patients, percutaneous external drainage (PED) was successful in treating pancreatic pseudocysts without complications or recurrence at 11, 19, and 31 months. PED is a suitable form of treatment in selected cases of pancreatic pseudocysts. Results in children are better than in the adult population, probably due to the absence of primary pancreatic pathology. We believe that PED should be considered the primary therapeutic procedure for traumatic pancreatic collections prior to more invasive surgical treatment, when there is no evidence of pancreatic duct transection on CT scan.

Regional anaesthesia for hernia repair in children: local vs caudal anaesthesia.

The purpose of this study was to compare the effect of local anaesthesia (LA) with that of caudal anaesthesia (CA) on postoperative care of children undergoing inguinal hernia repair. This was a randomized, single-blind investigation of 202 children aged 1–13 yr. Anaesthesia was induced with N2O/O2 and halothane or propofol and maintained with N2O/O2/halothane. Local anaesthesia included ilioinguinal and iliohypogastric nerve block plus subcutaneous injection by the surgeon of up to 0.3 ml · kg−1 bupivacaine 0.25% with 5 μg · kg−1 adrenaline. The dose for caudal anaesthesia was 1 ml · kg−1 up to 20 ml bupivacaine 0.2% with 5 μg · kg−1 adrenaline. Postoperative pain was assessed with mCHEOPS in the anaesthesia recovery room, with postoperative usage of opioid and acetaminophen in the hospital, and with parental assessment of pain with a VAS. Vomiting, time to first ambulation and first urination were recorded. The postoperative pain scores and opioid usage were similar; however, the LA-group required more acetaminophen in the Day Care Surgical Unit. The incidence of vomiting and the times to first ambulation and first urination were similar. The LA-patients had a shorter recovery room stay (40 ± 9 vs 45 ± 15 min, P < 0.02). The postoperative stay was prolonged in the CA group (176 ± 32 vs 165 ± 26 min, P = 0.02). We conclude that LA and CA have similar effects on postoperative care with only slight differences.RésuméCette étude vise à comparer les effets de l’anesthésie locale (AL) avec ceux de l’anesthésie caudale (AC) sur le suivi postopératoire d’enfants soumis à une cure de hernie inguinale. Cette étude randomisée et à l’aveugle porte sur 202 enfants âgés de 1 à 13 ans. L’anesthésie est induite au N2O/O2 avec halothane ou au propofol et entretenue avec N2O/O2/halothane. L’anesthésie locale comprend le bloc ilioinguinal et iliohypogastrique avec injection maximale par le chirurgien de 0,3 ml · kg−1 de bupivacaïne 0,25 avec 5 μg · kg−1 d’adrénaline. Pour l’anesthésie caudale, on utilise 1 ml · kg−1 jusqu’à un maximum de 20 ml de bupivacaine 0,2% avec 5 μg · kg−1 d’adrénaline. La douleur postopératoire est évaluée par mCHEOPS à la salle de réveil, par la dose de morphinique et d’acétaminophène durant la séjour hospitalier et par l’évaluation sur l’EVA des parents. Les vomissements, le délai jusqu’à l’ambulation et la première miction sont enregistrés. Les scores sur l’échelle de la douleur et l’utilisation de morphinique sont identiques, mais le groupe AL reçoit plus d’acétaminophène à l’unité de chirurgie d’un jour. L’incidence des vomissements et les délais à l’ambulation et à la première miction ne diffèrent pas. Les patients du groupe AL demeurent moins longtemps à la salle de réveil (40 ± 9 vs 45 ± 15 min, P < 0,02). Le séjour postopératoire est prolongé dans le groupe AC (176 ± 32 vs 165 ± 26 min, P = 0,02). Nous concluons que l’AL et l’AC, à l’exception de minimes différences, ont des effets identiques sur les soins postopératoires.

Reducing pain after inguinal hernia repair in children: caudal anesthesia versus ketorolac tromethamine.

Background The optimal method to achieve analgesia after inguinal hernia repair in children is unknown. This study compared the analgesic efficacy, adverse events, and the costs associated with supplementation of local anesthesia (infiltration of the wound) with either intravenous ketorolac or caudal analgesia in children having inguinal hernia repair. Methods With parental consent and institutional review board approval, children aged 2-6 yr having elective, outpatient inguinal hernia repair were studied in this randomized, single-blinded investigation. Anesthesia was induced by inhalation with nitrous oxide and halothane or intravenously with propofol. Anesthesia was maintained with nitrous oxide and halothane. Patients were randomly assigned to receive caudal analgesia (1 ml/kg 0.20% bupivacaine with 1/200,000 epinephrine) or intravenous ketorolac (1 mg/kg) immediately after induction of anesthesia. Both groups received field blocks with 0.25% bupivacaine administered by the surgeon under direct vision during operation. Patients were assessed for 24 h. In-hospital pain was assessed using a behavior-based pain score. Parents assessed pain with a visual linear analog pain scale with anchors of 0 (no pain) and 100 (worst pain imaginable). Results The authors studied 164 children, with 84 patients in the ketorolac group. The groups had similar demographic data. In-hospital analgesic requirements and pain scores were almost identical in both groups. Pain at home was significantly less in the ketorolac group, with visual linear analog pain scale scores of 10 (0-80) compared with 20 (0-80) (median [range]) for ketorolac versus caudal (P = 0.002 by the Mann-Whitney U test). The ketorolac group also had a lower incidence of vomiting, ambulated more rapidly, and micturated earlier (P < 0.05). Conclusion The use of intravenous ketorolac to supplement local anesthesia infiltrated by the surgeon during pediatric inguinal hernia repair is superior to supplementation with caudal analgesia.

Absolute vs relative improvements in congenital diaphragmatic hernia survival: what happened to “hidden mortality”

PURPOSE The aim of this study is to determine if there has been a true, absolute, or apparent relative increase in congenital diaphragmatic hernia (CDH) survival for the last 2 decades. METHOD All neonatal Bochdalek CDH patients admitted to an Ontario pediatric surgical hospital during the period when significant improvements in CDH survival was reported (from January 1, 1992, to December 31, 1999) were analyzed. Patient characteristics were assessed for CDH population homogeneity and differences between institutional and vital statistics-based population survival outcomes. SAS 9.1 (SAS Institute, Cary, NC) was used for analysis. RESULT Of 198 cohorts, demographic parameters including birth weight, gestational age, Apgar scores, sex, and associated congenital anomalies did not change significantly. Preoperative survival was 149 (75.2%) of 198, whereas postoperative survival was 133 (89.3%) of 149, and overall institutional survival was 133 (67.2%) of 198. Comparison of institution and population-based mortality (n = 65 vs 96) during the period yielded 32% of CDH deaths unaccounted for by institutions. Yearly analysis of hidden mortality consistently showed a significantly lower mortality in institution-based reporting than population. CONCLUSION A hidden mortality exists for institutionally reported CDH survival rates. Careful interpretation of research findings and more comprehensive population-based tools are needed for reliable counseling and evaluation of current and future treatments.

A twenty-year experience with thyroid carcinoma in children

During the past 20 years, 23 patients (7 males, 16 females) were operated on for thyroid carcinoma in our institution. The average age was 13.6 years (range, 22 months to 27 years). Our series includes papillary carcinoma in 11, follicular carcinoma in four, and medullary thyroid carcinoma in eight patients. Follow-up ranged from 8 months to 20.3 years, with an average of 7.5 years for well-differentiated carcinomas and 4.3 years for medullary thyroid carcinomas. All patients are presently alive with no evidence of progressive disease. Patients with papillary and follicular carcinomas underwent partial thyroidectomy; those with medullary carcinoma underwent total thyroidectomy. Serious complications included three permanent hypoparathyroidism and two tracheostomies, all after secondary neck explorations. The overall results observed in our series of patients seem to support the current conservative approach to well-differentiated thyroid carcinoma, reserving total thyroidectomy for medullary cancer of the thyroid. A more aggressive search for familial medullary carcinoma through use of pentagastrin stimulation leads to early detection and more effective therapy.

Intraabdominal Pulmonary Sequestration

A left upper quadrant fetal abdominal mass was detected at 24 weeks gestation. The mass was again confirmed in a postnatal ultrasound. Pathological analysis of the excised mass demonstrated an intraabdominal lung sequestration with Stocker type II congenital cystic adenomatoid malformation (CCAM). The sonographic characteristic of these lesions are those of a homogeneous echogenic mass with variable shape passing through or arising from the diaphragm. Surgical excision is recommended because of the uncertainty of the preoperative diagnosis and the possibility of malignant changes in CCAM.

Thoracoscopic vs open resection of congenital lung lesions: a meta-analysis

BACKGROUND Several comparative studies are published evaluating both the open and the minimally invasive approaches for congenital lung lesions with inconsistent results. Our objective was to compare both procedures using systematic review and meta-analysis methodology. METHODS All publications describing both interventions were reviewed. The statistical analysis was performed using RevMan 5 software (Cochrane library). MAIN RESULTS No randomized trials were identified. Six retrospective studies were identified and were included in this study. There was no significant difference in overall complication rates between both techniques. Lengths of hospital stay as well as days with chest tube in place were longer with the open approach. There was no difference in the duration of surgery. Postoperative pain management was heterogeneous between studies. No study looked at long-term follow-up. Subgroup analysis for congenital cystic adenomatoid malformation of the lung was done. CONCLUSIONS Our results suggest no differences between thoracotomy versus thoracoscopy for congenital lung lesions with respect to overall complications and the duration of surgery. However, length of hospital stay and days with chest tube in place were longer after the open approach. Thoracoscopic resection is a safe and feasible alternative to open resection of congenital lung lesions in experienced hands.

The muscle-sparing thoracotomy in infants and children

Deformities of the chest wall, breast, shoulder girdle, and spine are well-documented sequelae of major thoracotomies that transect muscles, divide major motor nerves, resect ribs, or cause them to fuse. These deformities are probably aggravated by the growth process. This is why we make a plea for the routine use, in infants and children, of a muscle-sparing thoracotomy that will minimize these sequelae without sacrificing exposure. Major (lateral) thoracotomy by this technique involves these steps: (1) creating a transverse incision below the tip of the scapula, or a vertical axillary incision; (2) elevating the skin flaps to expose the muscles; (3) retracting the latissimus dorsi posteriorly; (4) retracting the serratus anterior and scapula superiorly; (5) disinserting the lower origins of the serratus if required only; (6) opening the desired intercostal space; (7) reapproximating the ribs without crowding, using a pericostal suture that is passed along the inferior rib subperiosteally, to avoid any compression on the neurovascular bundle; and (8) allowing the muscles to fall back into place, reattaching the serratus insertions as indicated. Lessened postoperative pain and improved respiratory function are additional benefits.

Testicular fate after incarcerated hernia repair and/or orchiopexy performed in patients under 6 months of age☆

This study assessed testicular viability after 476 inguinal procedures performed in 338 infants under 6 months of age, between 1974 and 1993. One hundred twenty-one elective hernia repairs (contralateral explorations) were compared with 355 hernia repairs complicated by incarceration and/or orchiopexy. Clinical examination of 323 testes in the early postoperative period showed 20 atrophic testes. Since January 1994, 71 of the 338 patients have had testicular measurements obtained through ultrasonography (US). An additional 13 atrophic testes were found during US examination. Of these, nine were believed to be normal during early postoperative examination. Assuming that US examination will confirm atrophy in the 20 atrophic testes noted early in the postoperative clinical evaluation, and that all other testes not yet scanned are found to be normal, the minimal atrophy rate (MAR) would be 9.3% (33 of 355). Neither operative nor early postoperative testicular assessment correlates with ultimate testicular survival. Testicular pathology may become more evident after puberty, and the real incidence of atrophy may increase.

Effect of delivery approach on outcomes in fetuses with gastroschisis.

BACKGROUND/PURPOSE There is considerable controversy regarding optimal mode and timing of delivery for fetuses with gastroschisis. Our objectives were to describe the variation in institutional approach regarding these factors, and to evaluate the effect of timing of delivery on outcomes in fetuses with gastroschesis. METHODS Members of the maternal-fetal medicine community across Canada were surveyed regarding their personal and institutional approach of delivery. Data from the Canadian Pediatric Surgery Network (CAPSnet) were analyzed. RESULTS The survey showed significant variability in delivery approach between institutions, although no center routinely performs cesarean section. Infants delivered vaginally (VD) were categorized into three groups: Group 1, VD <36 weeks (n=114); Group 2, VD 36-37 weeks (n=218); and Group 3, VD ≥38 weeks (n=75). Score of Neonatal Acute Physiology, complication rates, length of time on total parenteral nutrition (TPN), and length of hospital stay (LOS) were higher in Group 1; bowel matting was greater in Group 3. There were no differences between the groups regarding other complications. CONCLUSIONS Our data suggest that preterm delivery was associated with more complications, longer time on TPN, and longer LOS; delivery ≥38 weeks was associated with increased bowel matting. These outcomes should be considered when determining institutional protocol.