Oliver S. Soldes

Chylopericardium and chylothorax: Unusual mechanical complications of central venous catheters

Obstruction and thrombosis of major systemic veins can occur due to indwelling central venous catheters. If obstruction of the innominate vein or superior vena cava occurs, lymphatic drainage can be impaired due to an increase in pressure in the thoracic duct and lymphatics. We describe a case where superior vena cava syndrome, chylopericardium and chylothorax occurred in a 16‐year‐old girl due to an indwelling central venous catheter. This was successfully treated with removal of the line, anticoagulation and angioplasty of the innominate vein and superior vena cava.

Robotic Surgery may Not “Make the Cut” in Pediatrics

Since the introduction of robotic surgery in children in 2001, it has been employed by select pediatric laparoscopic surgeons, but not to the degree of adult surgical specialists. It has been suggested that the technical capabilities of the robot may be ideal for complex pediatric surgical cases that require intricate dissection. However, due to the size constraints of the robot for small pediatric patients, the tight financial margins that pediatric hospitals face, and the lack of high level data displaying patient benefit when compared to conventional laparoscopic surgery, it may be some time before the robotic surgical platform is widely embraced in pediatric surgical practice.

Metastatic osteosarcoma to the stomach and ascending colon in a pediatric patient causing gastrointestinal hemorrhage

Osteosarcoma metastasis to the gastrointestinal tract is a rare phenomenon (Horiuchi A, Watanabe Y, Yoshida M, et al.: Metastatic osteosarcoma in the jejunum with intussusception: report of a case. Surg Today 2007;37:440-2). Gastrointestinal metastases may cause intussusception, bowel obstruction, or hemorrhage (Horiuchi A, Watanabe Y, Yoshida M, et al.: Metastatic osteosarcoma in the jejunum with intussusception: report of a case. Surg Today 2007;37:440-2; Chondramohan K, Somanathan T, Kusamakumary P: Metastatic osteosarcoma causing intussusception. J Pediatr Surg 2003;38(E44):1-3; Hung GY, Chiou TJ, Hsieh YL, et al.: Intestinal metastasis causing intussusception in a patient treated for osteosarcoma with history of multiple metastases: a case report. Jpn J Clin Oncol 2001;31:165-167). We report a case of a 17 year old male with osteosarcoma metastatic to the stomach and ascending colon, causing significant chronic gastrointestinal hemorrhage. Surgical resection was performed due to persistent, symptomatic anemia. The patient is free of recurrent hemorrhage at 24months after metastectomy. Resection of gastrointestinal metastases of osteosarcoma offers good palliation of chronic hemorrhage related to these lesions.

NASPGHAN Clinical Report on Postoperative Recurrence in Pediatric Crohn Disease

ABSTRACT Pediatric Crohn disease is characterized by clinical and endoscopic relapses. The inflammatory process is considered to be progressive and may lead to strictures, fistulas, and penetrating disease that may require surgery. In addition, medically refractory disease may be treated by surgical resection of inflamed bowel in an effort to reverse growth failure. The need for surgery in childhood suggests severe disease and these patients have an increased risk for recurrent disease and potentially more surgery. Data show that up to 55% of patients had clinical recurrence in the first 2 years after initial surgery. The current clinical report on postoperative recurrence in pediatric Crohn disease reviews the risk factors for early surgery and postoperative recurrence, operative risk factors for recurrence, and prevention and monitoring strategies for postoperative recurrence. We also propose an algorithm for postoperative management in pediatric Crohn disease.

Bronchoscopy and Tracheobronchial Disorders

Tracheobronchial disorders refer to a wide variety of both congenital and acquired diseases involving the lower airway. Rigid and flexible bronchoscopy plays a role in both the diagnosis and treatment of many of these disorders. Foreign body aspiration is the most commonly encountered entity. This chapter provides an overview of many of the tracheobronchial disorders, as well as equipment and technique.

Prospective observational study to assess the need for postoperative antibiotics following surgical incision and drainage of skin and soft tissue abscess in pediatric patients

BACKGROUND Post-operative antibiotics are often utilized for skin and soft tissue infection (SSTI) requiring surgical incision and drainage (I&D). We propose that antibiotics are unnecessary following I&D. METHODS Patients aged 3months to 6years with SSTI of the buttocks, groin, thigh, and/or labia requiring I&D were prospectively enrolled. The primary outcome was the proportion of patients requiring re-drainage and/or antibiotics for SSTI recurrence, within 30days. Follow-up consisted of a 30-day phone call, with optional 2-week office visit, combined with chart review for patients lost to follow-up. A one-sample binomial proportion with 95% confidence interval (CI) was used to examine non-inferiority for rate of treatment success, using previously published success rates for patients receiving antibiotics post-operatively (95.9%, with a 7% margin of equivalence). RESULTS A total of 92 patients were enrolled. All patients received pre-operative antibiotics. There was one treatment failure (success rate 0.989, CI 0.941-0.999). The recurrence rate was noninferior to previously-published data for patients receiving postoperative antibiotics (p<0.001). Subgroup analysis of patients who completed 30-day follow-up yielded a success rate of 0.973, CI 0.858-0.999 and evidence of non-inferiority (p=0.04). CONCLUSIONS Post-operative management excluding antibiotics should be considered for patients who undergo I&D for SSTI. LEVEL OF EVIDENCE Level II (prospective cohort study with <80% follow-up).

Intra-abdominal (Type IV) sacrococcygeal teratoma presenting with buttock hemangioma

Sacrococcygeal teratoma is the most common type of extragonadal germ cell tumor in infants and young children. Sacrococcygeal teratomas can uncommonly present in an intra-abdominal fashion, with minimal clinical findings. Dermatologic lesions overlying the vertebrae or buttocks are often associated with sacrococcygeal teratoma and may be the only clue to their presence. Here, we report a case of an intra-abdominal sacrococcygeal teratoma presenting with an anatomically separate buttock hemangioma.

Unilateral Coexisting Intralobar and Extralobar Pulmonary Sequestrations

Pulmonary sequestration is a focal area of nonfunctioning, dysplastic lung parenchyma that lacks communication with the normal tracheobronchial tree. It is supplied by the systemic arterial circulation and has two types, intralobar and extralobar, that can be differentiated from each other by the pleural covering and the venous drainage. Their coexistence is extremely rare. We report the imaging findings of a patient who had coexisting but completely separate intralobar and extralobar sequestrations at the left lower lung. We elucidated the complex vascular anatomy using three dimensional volume rendering and multiplanar reconstructions from a 64-detector helical CT scanner.