Michael E. Höllwarth

Analysis of dog bites in children who are younger than 17 years

OBJECTIVES. This study focuses on the pattern of incidence, mechanisms, and circumstances of accident and injury in a series of pediatric patients who sustained dog bites. METHODS. In our retrospective survey, the medical charts of all children who were younger than 17 years and sought medical attention after a dog bite between 1994 and 2003 were reviewed. To obtain the total number of each dog breed in the administrative district, we analyzed 5873 files from the community dog registers. For establishment of a risk index, the representation of a dog breed among the total canine population was divided by the frequency of dog bites from this breed. RESULTS. A total of 341 children (mean age: 5.9 years) were identified. The annual incidence of dog bites was 0.5 per 1000 children between 0 and 16 years of age. Incidence was highest in 1-year-old patients and decreased with increasing age. The relative risk for a dog attack by a German shepherd or a Doberman was ∼5 times higher than that of a Labrador/retriever or cross-breed. The vast majority (82%) of the dogs were familiar to the children. Most (322; 94%) of the children had injuries to 1 body region; in the remaining 19 (6%) children, up to 3 body regions were injured. Of 357 injuries, the face, head, and neck region was the leading site affected (50%). Inpatient treatment was required in 93 (27%) patients. CONCLUSIONS. Dog bites in children are frequent and influenced by the breed-related behavior of dogs, dog owners, children, and parents. Therefore, prevention strategies should focus on public education and training of dogs and their owners. Children who are younger than 10 years represent the high-risk group for dog attacks.

Multiple trauma in pediatric patients.

Abstract.We analyzed the causes and diagnoses, the treatment, short and long-term outcome of a consecutive series of 70 pediatric polytrauma patients. From 1989 to 1996, 70 children (aged 10 months to 16 years, mean 7.4 years) presented with multiple trauma. A follow-up investigation was performed 4.2 years (mean) after the accident. Traffic accidents (68%) were the leading cause of injuries. Among all injuries (mean ISS 24.6 range 17–57), injuries of the head/neck area were most frequent (87%) followed by extremity fractures (76%) and 135 operations were performed on 55 children, mostly for fracture stabilisation. All multiple injured children survived. At discharge 25 children were still impaired (36% of 70). At follow-up 58 patients were revisited, 11 (19% of 58) presented with impairments, 8 of those (73% of 11) following severe head trauma. This study showed a 10% rate of late impairment due to the severity of the primary head trauma.

Experience with gastro-intestinal duplications in childhood.

Abstract. Background: Intestinal duplications are rare congenital malformations. The different locations and sizes of these duplications require a specific diagnostic and surgical approach. This study reviews our paediatric patients with intestinal duplications in order to analyse the influence of prenatal sonography and laparoscopy on the clinical course. Patients and methods: Thirteen duplications of the alimentary tract in 12 patients have been treated over a 10-year period from 1989 to 1999. Six of our patients were diagnosed prenatally by ultrasound and were free of symptoms until surgery, except for one patient who had meconium-ileus owing to cystic fibrosis. In another five patients, the diagnosis was made on the basis of symptoms with signs of obstruction. In one child, the duplication was found incidentally during an operation for an anorectal malformation. The location of the 13 duplications was the stomach in three cases, the duodenum in one case, the jejunum in two cases, the ileum in six cases and the rectum in one case. Laparotomy was performed in ten patients. Two cases were treated by laparoscopic-assisted resection. Conclusion: Early diagnosis and treatment of uncomplicated intestinal duplications by means of prenatal sonographic screening and laparoscopic-assisted resection, respectively, are desirable in this congenital malformation. Resection of the duplication with or without minimal resection of the adjacent normal intestine should be mandatory.

OK-432 therapy of lymphangiomas in children

Between April 1988 and July 1995, 11 children with a lymphangioma were treated with intralesional OK-432 injection. In 7 patients it was the primary therapy and total shrinkage of the lesion was obtained in 5 of them. Two patients did not respond and the children underwent surgery. Following incomplete surgical removal or recurrence of the lymphangioma, intralesional OK-432 injection was used as secondary therapy in 4 patients. Total regression was observed in 2 cases and marked regression in the 2 others. No serious side-effects except fever lasting for 2–3 days and slight tenderness with swelling of the lymphangioma for 3–4 days after the injection was noted. Local inflammatory reaction did not cause any damage to the overlying skin and did not lead to scar formation. Depending on the size, location, and anatomical relationship to the airway, intralesional injections of the lymphangiomas were performed under general anaesthesia and the children were observed for 24 h. There was no recurrence after follow up periods ranging from 2 months to 7 years.

Sacrococcygeal teratoma: clinical course and prognosis with a special view to long-term functional results

Abstract From 1976 to 1995, 23 children, 4 boys and 19 girls, were treated at our department for sacrococcygeal teratomas (SCT). Their records were analyzed retrospectively, considering age at operation, histopathology, recurrences, and long-term evolution. One died on the 1st day of life following tumor rupture with hemorrhagic shock without surgical intervention. All others were operated upon at a mean age of 4.2 days for those 19 (=82%) who were diagnosed in the neonatal period and whose histology proved benign. In the remaining 3 children, in whom tumor manifestation did not occur before 11 months, 13 months, and 10 years of age, respectively, histopathologic evaluation revealed 2 carcinomas and 1 yolk-sac tumor, and all 3 recurred. Overall, 5 patients died, the 1 mentioned above, 1 due to volvulus after laparotomy, and 1 from multiple associated congenital malformations. Two deaths were related to malignancy, whereby only 1 was a malignant teratoma diagnosed at the original operation. Eight children had recurrences, 2 were benign and 6 malignant, with 3 of the latter having been graded benign on histology of the primary tumor. Of the 18 surviving patients, 17 (93.5%) returned for clinical review following a standardized protocol. The average interval from the primary surgery was 12.3 years (range 3.5–22 years). Four had malignant tumors with a recurrence-free period of from 9 to 14 years; 5 (29.4%) had urinary or anorectal functional impairment. One child with a patulous anus presented with fecal soiling. Two reported nocturnal enuresis, 1 associated with perineal anesthesia. One had a neurogenic bladder with overflow voiding and bilateral third-degree vesicoureteral reflux. Second-degree reflux was found in the last patient. We conclude that follow-up after surgery for SCT should not only search for tumor recurrence but include the diagnosis and treatment of possible secondary urinary and/or fecal incontinence.

The role of transanal endorectal pull-through in the treatment of Hirschsprung's disease - a multicenter experience.

Abstract.The transanal approach (TAA) is a new technique for surgery of Hirschsprungs disease (HD) that was introduced by de la Torre in 1998. The purpose of this multicenter study, including experience from three Austrian and one Italian departments of peadiatric surgery, was to evaluate the role of this approach in HD in 18 children aged 1–72 months. In 14 children the TAA only was performed; in 3 an additional laparoscopy was performed and in 1 conversion to a laparotomy was necessary. One complication (abscess) occurred after laparoscopic-assisted pull-through. The postoperative recovery was rapid, no severe long-term problems were observed. The transanal pull-through technique is generally possible in most classic cases of HD with extension of the disease to the sigmoid colon. If necessary, it can be combined with laparoscopy. Our preliminary results show that the technique is safe, less invasive, and gives excellent cosmetic results, and allows rapid recovery. Long-term results are still pending.

Allopurinol reduces bacterial translocation, intestinal mucosal lipid peroxidation, and neutrophil-derived myeloperoxidase activity in chronic portal hypertensive and common bile duct-ligated growing rats.

Bacterial translocation (BT) from the gastrointestinal tract has been thought to play a role in the pathogenesis of septic complications in patients with chronic portal hypertension (PH) and obstructive jaundice. The purpose of this study was to investigate the incidence of BT and to assess the role of intestinal mucosal malondialdehyde (MDA) levels as an indicator of lipid peroxidation and polymorphonuclear neutrophil-derived myeloperoxidase (MPO) in chronic portal hypertensive and common bile duct-ligated rats. Twenty male rats were subjected to sham laparotomy (SL), 20 rats to calibrated portal vein constriction (PH), 20 rats to common bile duct ligation (CBDL), and 10 rats served as a nonoperated control group (NOP). After 4 wk, 10 animals of each operated group received 50 mg/kg allopurinol intraperitoneally, at 24 h, and again 2 h prior to estimation of BT, intestinal mucosal MDA, and MPO activities. In the NOP and SL groups, BT to the mesenteric lymph nodes (MLN) and spleen was present. In PH and in CBDL rats, BT to liver, portal vein, peritoneum, and caval vein occurred. Allopurinol treatment attenuated the frequence of BT in PH and decreased BT in CBDL rats significantly (p< 0.05). Ileal mucosal MDA levels (nanomoles/g) in untreated rats increased from 45,1 ± 7.9 in SL to 98.2 ± 9.1 in PH and to 102.2 ± 11 in CBDL rats (p < 0.01). In the allopurinol groups the increase of MDA to 49.1 ± 1.3 in PH, and 66.2 ± 2.2 in CBDL was significantly lower (p < 0.01). MPO activity (units/g) in the ileal mucosa increased in untreated rats from 319 ± 129 after SL to 866± 104 after PH and to 1016 ± 104 after CBDL (p < 0.01). Allopurinol significantly attenuated MPO activity to 369 ± 44 in PH, and to 372 ± 60 in CBDL animals (p < 0.01). In PH and CBDL rats significant BT, intestinal mucosal lipid peroxidation, and polymorphonuclear neutrophil-derived MPO activity occurred. Allopurinol reduced BT and improved intestinal mucosal MDA and MPO activities, suggesting that there might be an association between BT and intestinal mucosal lipid peroxidation.

Esophagus tissue engineering: in vitro generation of esophageal epithelial cell sheets and viability on scaffold

PURPOSE Management of long gap esophageal atresia poses challenges. The surgical techniques for esophageal replacement are associated with complications and high morbidity. The aim of this study was to develop protocols to obtain single layer sheets of esophageal epithelial cells (EECs) and to investigate their survival on collagen scaffolds. METHODS Esophageal epithelial cells were sourced from adult Sprague-Dawley rats. Briefly, the esophagus was treated with dispase to separate the epithelial layer and further trypsined to obtained EEC. The esophageal epithelial cells were cultured in vitro and seeded on to new generation of 3-dimensional collagen scaffolds. RESULTS Esophageal epithelial cells organized after 48 hours in culture and formed clusters after 72 to 96 hours. Organization of the EEC was completed after 7 days in culture and characteristic sheets of EEC with the histologic morphology of mature esophageal epithelium were obtained after 14 days of culture. Immunohistochemistry demonstrated pure EEC culture using cytokeratin (CK-14) markers. The esophageal epithelial cells transferred on to collagen polymers demonstrated excellent viability after 8 weeks of in vitro culture. CONCLUSION Successful protocols for EEC isolation and proliferation have been established. The engineering of sheets of EEC and the viability of EEC on collagen scaffolds for 8 weeks in vitro, which are prerequisites for esophagus tissue engineering, was demonstrated.

Nonoperative treatment of tibial spine fractures in children-38 patients with a minimum follow-up of 1 year.

Objectives: The aim of this study was to determine if nonoperative treatment of fractures of the tibial spine (intercondylar eminence) in pediatric patients is the treatment of choice for these injuries. Design/Setting: Retrospective clinical analysis in a single department. Patients: All patients younger than 17 years presenting with a fracture of the intercondylar eminence between January 1, 1995 and December 31, 2004 were included in this retrospective study. Patients with ossification of the growth plate (physis) at the time of accident were excluded by protocol. Intervention: Nonoperative treatment with knee aspiration, reduction, and immobilization in a long leg cast. Main Outcome Measurements: History-taking and follow-up examinations were performed using the Cincinnati Knee Score and International Knee Documentation Committee Guidelines of 2000. In addition, a magnetic resonance imaging scan of the injured knee was offered to all patients. SPSS 12.0 and Microsoft Excel 2000 were used for data processing and statistical analysis. Results: Forty-three patients have been included in the study. Twenty-three were female and 20 male. The mean age at trauma was 11.5 years (6-16 years). Only 1 patient required a change of therapy and needed open reduction. Thirty-eight patients were available for follow-up at an interval of 1-7.5 years after trauma (mean 3.5 years). None of the patients reported pain, swelling, disability or giving-way, or was handicapped in their daily life. Of 26 magnetic resonance imaging examinations, we found a missing anterior cruciate ligament in 1 and a partial rupture in another patient. Conclusion: Based on our results, nonoperative management can still be recommended as the primary treatment for tibial spine fractures in children.

A study of metatarsal fractures in children

BACKGROUND Metatarsal fractures are common in children. The aim of the present study was to analyze a consecutive series of metatarsal fractures in children and to describe the epidemiology of the fractures, the location of the fractures, and the mechanism of injury. METHODS A consecutive series of 125 patients with metatarsal fractures who presented to one pediatric surgery department over a twenty-two-month period was evaluated with use of a questionnaire to define the mechanism of injury. All patients were followed until the fracture was healed. The specific location of the fractures and the mechanism of injury were identified. RESULTS One hundred and twenty-five children (seventy-five boys and fifty girls; average age, 8.6 years [range, one to seventeen years]) presented with 166 metatarsal fractures. Major differences were found between children who were five years of age or less and those who were more than five years of age. In patients who were five years of age or less, the predominant location of the accident that had caused the fracture was inside the house and the primary mechanism was a fall from a height. In patients who were more than five years of age, most accidents occurred at sports facilities and were caused by a fall on a level surface. The most frequently fractured metatarsal in younger children was the first, whereas the most frequently fractured metatarsal in older children was the fifth. CONCLUSIONS The mechanism of injury and clinical presentation of metatarsal fractures in children are age-dependent, with patients five years of age or less and those more than five years of age having different mechanisms of injury and different types of metatarsal fractures.