Peter Chait

Percutaneous cecostomy : A new technique in the management of fecal incontinence

A pilot study on the percutaneous introduction of a cecostomy tube for colonic irrigations in the treatment of children with fecal incontinence is described. The results were good, and the technique is recommended for certain patients.

Efficacy and safety of radiologically placed gastrostomy tubes in paediatric haematology/oncology patients

BACKGROUND The treatment of malnutrition, which is of great concern in paediatric haematology/oncology patients, is fraught with problems. The goals of our study were to document the complications and assess the weight gain with gastrostomy tubes (G-tubes) in this population. PROCEDURE Patient data were acquired by retrospective review of all haematology, oncology, and bone marrow transplant (BMT) patients (n = 44) who received radiologically placed G-tubes at our institution over a 4-year period. RESULTS Forty-four G-tubes were placed (59% peri-BMT). At tube placement, 55% of patients were malnourished and 45% were nourished. Seventy-five percent of patients had the procedure without general anaesthetic. Localized G-tube-site infection was the most common complication (41%). Major complications occurred in 3 patients; 2 patients experienced localized peritonitis, and 1 patient developed a localized collection of pus in the abdominal wall. There were no G-tube-related deaths. At 1 month after the tube insertion, 39% of patients had gained, 54% maintained, and 7% lost weight. At 3 months, 69% had gained, 28% maintained, and 3% lost weight. There was a statistically significant weight gain from the time of the G-tube placement to both 1 month (P < 0.018) and 3 months (P < 0.0001) after G-tube placement. Patients in all diagnosis categories showed improvement from 1 to 3 months. CONCLUSIONS We conclude that retrograde tube placement is safe and can frequently be done without general anaesthetic and that G-tube feeding effectively reverses malnutrition and prevents weight loss in this patient population.

Sonographically Guided Percutaneous Liver Biopsy in Infants: A Retrospective Review

OBJECTIVE The purpose of our study was to assess the technical success and complication rate of sonographically guided percutaneous liver biopsies performed in infants under 1 year old at a tertiary pediatric center. MATERIALS AND METHODS Retrospective analysis of 65 biopsies performed in 61 infants between January 1999 and December 2003 was conducted. Data collected included patient demographics; details of the biopsy procedure including indication, needle type and size, number of passes, and samples; pathology results; and procedure-related complications. RESULTS The 61 infants studied included 37 males and 24 females with a mean age of 119 days (age range, 7-348 days; median age, 83 days) and a mean weight of 4.5 kg (1.9-8.3 kg). A total of 65 biopsies were performed in these 61 infants. General anesthesia was used in 66.1% of procedures. An 18-gauge needle was used in 47 (72.3%) procedures. Coaxial technique was used in seven procedures, and five biopsy tracts were embolized. In 63 of 65 procedures, the mean number of passes was 1.8. In two procedures, using a coaxial technique, 11 and 12 passes were made. One biopsy was considered technically unsuccessful, and 64 of 65 (98.5%) of the biopsies provided adequate tissue for pathologic analysis. There were three (4.6%) major complications related to bleeding: one requiring a blood transfusion, one requiring surgery, and one arteriobiliary fistula requiring transarterial embolization. Three (4.6%) minor complications also occurred. There were no deaths. CONCLUSION Sonographically guided percutaneous liver biopsy in infants is a good and effective diagnostic tool. The complication rate, however, even when performed by an experienced physician, is not insignificant in this age group of patients.

Non-operative management of traumatic pancreatic pseudocysts associated with pancreatic duct laceration in children

Objective. To assess the successful non-operative management in traumatic pancreatic pseudocysts (TPP) associated with duct laceration in children. Surgical therapy (cystogastrostomy or distal pancreatectomy with splenic salvage) has been classically considered the treatment of choice for those pseudocysts. Materials and methods. This report presents the clinical and imaging findings in two children with TPP and pancreatic duct disruption observed either on endoscopic retrograde cholangiopancreatography or injection via catheter drainage. Results. Both children responded to long-term cyst drainage. Conclusion. Although the experience is limited, the authors suggest that pancreatic injury associated with duct laceration can respond to non-operative management.

Fluoroscopic landmark for SVC-RA junction for central venous catheter placement in children.

Background. Vascular access devices are commonly placed under image guidance. The usual aim is to place the tip at the superior vena cava-right atrial juntion (SVC-RA).¶Objective. To identify a radiographic landmark for the SVC-RA junction that would be useful for accurate central venous catheter tip placement in children.¶Materials and methods. Images from 56 children undergoing contrast studies of their upper limb venous systems were examined for location of the SVC-RA in relation to a radiographic landmark.¶Results. Most patients (92.5 %) showed the SVC-RA junction to lie at the sixth thoracic vertebral level or the interspace above or below. The SVC-RA junction lay lower than the right main bronchus and the notch on the right cardiomediastinal contour.¶Conclusion. The vertebral body provides a useful and radiographically visible landmark for accurate central catheter tip placement.

Retrograde percutaneous gastrostomy: a prospective study in 57 children.

We prospectively studied Retrograde Percutaneous Gastrostomy (RPG) in 57 children (age 3 weeks-17 years, 1.7–48 kg) as the feasibility and complications of this technique have not been reported in a large series of children. We used IV sedation (42), oral sedation (4 neonates), general anaesthesia [6] or lcoal anaesthesia only [5]. The retrograde approach for gastrostomy or gastrojejunostomy catheter placement is described. Catheter placement was unsuccessful in only one child, due to the presence of marked hepatosplenomegaly. Catheters were successfully placed in all the other 56 children. In one of these, catheter misplacement occurred due to retraction of the stomach from the anterior abdominal wall during its insertion. This was recognized during the procedure. The catheter was removed and reinserted on the same occasion. One catheter was accidentally pulled out after six days and was subsequently replaced. Two children had mild, local abdominal tenderness and fever for up to 48 hours but post procedure septicemia or significant infection were not encountered. All children benefitted from gastrostomy feeding and gained weight.

Gastrostomy and Gastrojejunostomy Tube Placements: Outcomes in Children with Gastroschisis, Omphalocele, and Congenital Diaphragmatic Hernia

PURPOSE To retrospectively evaluate the technical success, safety, and outcomes of radiologically guided retrograde percutaneous gastrostomy and gastrojejunostomy tube placements in terms of weight gain and growth in children with gastroschisis, omphalocele, and/or congenital diaphragmatic hernia (CDH). MATERIALS AND METHODS Research ethics board approval, with waived informed patient consent, was obtained for review of the data of 37 children (17 male, 20 female; age range, 1-20 months; mean age, 4.3 months) in whom gastrostomy or gastrojejunostomy tubes were inserted between 1995 and 2004. Twenty-two patients had CDH, eight had gastroschisis, five had omphalocele, and two had both CDH and omphalocele. The technical success and complications of the procedures were recorded. Tube maintenance problems were analyzed separately from postprocedural complications. Initial and final patient growth percentiles were compared by using a one-sided paired Student t test. RESULTS Thirty-six of the 38 procedures performed in the 37 patients were successful. There were three intraprocedural complications (two cases of access difficulty, one case of bleeding) and three major complications (one skin and prosthetic material infection, one track loss during tube replacement, one delayed gastrostomy track closure necessitating surgery). Sixteen patients had at least one minor complication (cellulitis, feeding intolerance, skin-site bleeding, intussusception). Twenty-two patients had at least one tube maintenance problem. All patients gained weight (mean weight gain, 4.7 kg) after the procedure, with a significant increase in growth percentile (average increase, 6.5%; P = .029). CONCLUSION Radiologically guided percutaneous gastrostomy and gastrojejunostomy tube placements in children with gastroschisis, omphalocele, and/or CDH are associated with high success rates and low major complication rates. Although tube maintenance problems and minor complications are common, use of gastrostomy and gastrojejunostomy tubes effectively improves nutritional support.

Image-guided therapy and minimally invasive surgery in children: a merging future

Minimally invasive image-guided therapy for children, also known as pediatric interventional radiology (PIR), is a new and exciting field of medicine. Two key elements that helped the rapid evolution and dissemination of this specialty were the creation of devices appropriate for the pediatric population and the development of more cost-effective and minimally invasive techniques. Despite its clear advantages to children, many questions are raised regarding who should be performing these procedures. Unfortunately, this is a gray zone with no clear answer. Surgeons fear that interventional radiologists will take over additional aspects of the surgical/procedural spectrum. Interventional radiologists, on the other hand, struggle to avoid becoming highly specialized technicians rather than physicians who are responsible for complete care of their patients. In this article, we briefly discuss some of the current aspects of minimally invasive image-guided therapy in children and innovations that are expected to be incorporated into clinical practice in the near future. Then, we approach the current interspecialty battles over the control of this field and suggest some solutions to these issues. Finally, we propose the development of a generation of physicians with both surgical and imaging skills.

Ectopic drainage of the common bile duct into the lesser curvature of the gastric antrum in a newborn with pyloric atresia, annular pancreas and congenital short bowel syndrome

We report a newborn with bilious vomiting and the rare combination of pyloric atresia, annular pancreas and ectopic drainage of the common bile duct into the lesser curvature of the gastric antrum. Radiologic, sonographic and percutaneous transhepatic transcholecystic cholangiographic (PTTC) findings, with surgical correlation, are presented.