Richard J. Hendrickson

Recurrent inflammatory pseudotumors in children

BACKGROUND/PURPOSE pulmonary (PPT) and extrapulmonary pseudotumors (EPPT) are uncommon benign tumors, which, in general, do not recur after complete resection. Recurrence rates for both types of pseudotumors are undocumented in a large population of children, and the salient features of potential recurrences are unspecified. METHODS This is a report of 15 children with PPT and EPPT; 3 children had a recurrence. These pseudotumors recurred despite adequate primary resection of all gross disease at first presentation. The literature was reviewed to determine rate of recurrence for PPT and EPPT and also to document features common to recurrent pseudotumors. RESULTS Overall recurrence rate for pseudotumors was 14%. PPT and EPPT, which were not confined to a single organ, had a high chance of recurrence (46% and 30%, respectively) compared with PPT and EPPT, which were confined to a single organ (1.5% and 8%, respectively). Recurrences have appeared between 3 months and 7 years. Intraabdominal EPPT accounts for more than 75% of the EPPT recurrences. CONCLUSIONS PPT and EPPT recur more frequently than anticipated. All pseudotumors, which on initial presentation extend beyond the confines of a single organ, have a high chance of recurrence despite what appears to be adequate resection. Children with pseudotumors that extend beyond a single organ, require frequent postoperative evaluation for recurrence and may be candidates for chemotherapy or radiotherapy at the time of initial resection.

Ethanol inhibits mitogen activated protein kinase activity and growth of vascular smooth muscle cells in vitro.

The aim of this study was to determine the effect of ethanol on vascular smooth muscle cell proliferation and mitogen activated protein kinase (MAPK) signaling. Rat aortic smooth muscle cell growth in vitro was determined by measuring cell counts and [3H]thymidine incorporation. MAPK signaling was determined by assessing MEK (also referred to as MAPK kinase) activity by measuring phosphorylated extracellular signal-regulated kinase (pp44ERK - 1 and pp42ERK - 2) expression, and ERK activity by measuring ERK-2-dependent phosphorylation of myelin basic protein (MBP). In quiesced smooth muscle cells, ethanol treatment (24 h) inhibited serum-stimulated mitogenesis in a dose-dependent manner, (IC50 = 60 mM), in the absence of any effect on smooth muscle cell viability. In addition, ethanol treatment caused a significant shift to the right in the smooth muscle cell growth curve, extending the population doubling time from approximately 48 h (control) to approximately 70 h (ethanol). Acute (15 min) ethanol treatment reduced serum-stimulated pp44ERK - 1 and pp42ERK - 2 expression in a dose dependent fashion; 24.5+/-1.5% and 77.6+/-3.2% inhibition for 20 mM and 160 mM ethanol, respectively. Furthermore, there was a significant dose-dependent decrease in ERK2 activity in ethanol treated smooth muscle cells as compared to control smooth muscle cells. These data demonstrate an inhibitory effect of ethanol on smooth muscle cell proliferation and MAPK signalling in vitro. It is tempting to speculate that these actions of ethanol may contribute to its cardiovascular effects in vivo.

Blunt diaphragmatic rupture in children.

BACKGROUND Although several series of blunt diaphragmatic rupture in adults have been published, this injury remains largely uncharacterized in the pediatric population. METHODS We queried our trauma registry for all children admitted with blunt diaphragmatic rupture over a 10-year period at a Level I pediatric trauma center. RESULTS Six children (aged 2-15 years; mean, 7 years) were identified with blunt diaphragmatic rupture (three right, two left, one bilateral), representing 0.4% of admissions. All of the children had associated injuries (4.5 per child), with a mean Injury Severity Score of 32. Four diaphragmatic injuries were identified during the initial evaluation. The two missed injuries were diagnosed at postinjury days 5 and 8. There were no deaths and all children were eventually discharged without sequelae. CONCLUSION Blunt diaphragmatic rupture occurs in children with a frequency and severity commensurate with that observed in adults. Our data suggest improved survival compared with adults with this injury.

Management of giant omphalocele in a premature low-birth-weight neonate utilizing a bedside sequential clamping technique without prosthesis

Management of giant omphalocele in a full-term neonate is a challenging clinical situation. Even more challenging is giant omphalocele in a premature low-birth-weight infant. The authors describe a successful staged noninvasive technique for the management of giant omphalocele in a premature, low-birth-weight neonate without the use of prosthetic material until delayed primary closure could be attempted.

Positioning for the Nuss procedure: avoiding brachial plexus injury.

Background:  In 1987, Nuss developed a minimally invasive technique for the treatment of pectus excavatum. The procedure has had excellent results with minimal complications. Anesthetic concerns include risks of cardiothoracic injuries, dysrythmias, pneumothorax, pleural effusions, and hemorrhage. In addition, we identified a risk of brachial plexus injury that can occur secondary to patient positioning. We report our experience with the Nuss procedure and modified patient positioning.

Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access?

PURPOSE The aim of this study was to determine in a pediatric population whether a routine chest x-ray after central venous access is necessary when the central venous catheter is placed with intraoperative fluoroscopy. METHODS This was a retrospective review of the charts of all patients at Childrens Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, sex, primary reason for access, access site, number of venipuncture attempts, type of catheter, intraoperative fluoroscopy results, chest x-ray results, location of the tip of the catheter, and complications were analyzed. RESULTS There were 1,039 central venous catheters placed in 824 patients, 92.6% in the subclavian vein and 7.4% in the internal jugular vein. There were 604 (58.1%) children who had both fluoroscopy and a postprocedure chest x-ray, there were 308 (29.6%) who had only fluoroscopy, there were 117 (11.3%) who had only a postprocedure chest x-ray, and there were 10 (1.0%) who had neither fluoroscopy nor chest x-ray. On completion of the procedure, there were 12 (1.1%) children with misplaced central venous catheters, only 1 (0.1%) when intraoperative fluoroscopy was used. There were 17 (1.6%) complications; 9 (0.9%) were pulmonary (pneumothorax, hemothorax, or an effusion). All children with pulmonary complications experienced clinical signs and symptoms suggestive of the complication after their central venous catheter insertion but before their postprocedure chest x-ray. CONCLUSIONS The number of complications encountered in children who had central venous access of the subclavian vein or internal jugular central vein with intraoperative fluoroscopy was infrequent, the number of misplaced catheters was minimized with intraoperative fluoroscopy, and all children with pulmonary complications showed clinical signs suggestive of pulmonary complications before postoperative chest x-ray. Therefore, children who have had central venous access of the subclavian and internal jugular vein with intraoperative fluoroscopy do not appear to require a routine chest x-ray after catheter placement unless clinical suspicion of a complication exists.

IL-1β induces an exaggerated pro- and anti-inflammatory response in peritoneal macrophages of children compared with adults

Children have a lower incidence of acute lung injury (ALI) compared with adults. Because ALI appears to be the end result of systemic hyperinflammation, children may either have 1) an attenuated pro-inflammatory response or 2) an augmented anti-inflammatory response compared with adults. The purpose of this study was to determine the IL-1-induced pro- and anti-inflammatory response of pediatric vs. adult peritoneal macrophages (PMs). We hypothesized that pediatric PMs would have an enhanced anti-inflammatory response compared with adult PMs. Human PMs were collected during elective laparoscopic procedures, cultured, and stimulated with IL-1β. IL-6, IL-8, IL-10, and TNFα production were determined by ELISA. Statistical analyses were by ANOVA; a P <0.05 was significant. Our results showed that IL-1β induced an 11-fold increase in IL-10 production in pediatric PMs (659±103 vs. 60±25 control, P <0.05). There was no IL-10 production in IL-1β-stimulated adult PMs. IL-1β-induced TNF production was greater in children compared with adults (2152±166 vs. 592±188, P <0.05). Similarly, IL-1β-induced IL-6 production was greater in pediatric PMs compared with adults (532±3 vs. 444±52, P <0.05). There was no difference in IL-1β-induced IL-8 production in children compared with adults. The IL-10:TNFα ratio after IL-1β stimulation was 0.306±0.056 in pediatric macrophages and 0.020±0.015 in adult macrophages ( P <0.01). In conclusion, IL-1β-induced IL-6 and TNFα production were greater in pediatric than adult PMs. Furthermore, pediatric PMs had an 11-fold increase in IL-1β-induced IL-10 production, while adult PMs did not produce IL-10. Therefore, IL-1β induces both a pro- and an anti-inflammatory response in pediatric PMs, whereas adult PMs produce only pro-inflammatory cytokines in response to IL-1β. The exaggerated anti-inflammatory IL-10 response in children may be an important factor in the observed differences in ALI between children and adults.

Adult right lobe live donor liver transplantation without reconstruction of the middle hepatic vein: a single-center study of 109 cases.

We report our experience in adult-to-adult right hepatic lobe living donor liver transplantation (ALDLT) using extension of the hepatectomy transection line medially to incorporate the right middle hepatic vein branches into the donor graft. One hundred and nine ALDLT were performed at the University of Colorado from August 1997 to December 2005. Donors were screened preoperatively for hepatic venous anatomy compatible with this technique. Of the 109 ALDLT, the first 10 did not include the right middle hepatic vein branches in the graft. As such, three patients required retransplantation, two from graft loss because of venous congestion. Of the next 99 transplants, only 11 required retransplantation and none because of venous congestion. This approach allows adequate venous outflow through the right hepatic vein more than 1 cm, which is demonstrated by the absence of graft loss from venous congestion and superior graft survival.

Pediatric liver transplantation.

Purpose of review Pediatric liver transplantation is a challenging and exciting field for all healthcare providers involved with children who have end-stage liver disease. Graft and patient survival continue to improve due to improvements in medical, surgical, and anesthetic management, organ availability, immunosuppression, and identification and treatment of postoperative complications. This review will describe recent advances in pediatric liver transplantation. Recent findings Although pediatric cases only represent approximately 10% of the total patients on the waiting list, the number of deaths on the waiting list increased from 196 to 1753 between 1988 and 1999. Recently, a new pediatric liver allocation policy was instituted. The utilization of cut down “reduced” livers, split liver grafts, and living-related donors has provided more organs for pediatric patients. Newer immunosuppression regimens, including induction therapy, continue to have a significant impact on graft and patient survival. Excellence in peri-operative management and identification and treatment of complications or infections also has had an impact on graft and patient survival. Finally, investigation and analysis of the postoperative quality of life, for both the patient and parents, is being conducted. Summary Pediatric liver transplantation is a challenging and rewarding field with continued improvements in patient and graft survival. A multidisciplinary team approach coupled with improvements in organ availability, immunosuppression, and peri-operative management has had a dramatic impact on survival.

Renovascular injury: An argument for renal preservation

BACKGROUND Renovascular injury is uncommon among children. This study hypothesized that preservation of the severely injured kidney can be achieved safely without renal insufficiency, postinjury hypertension, or the need for hemodialysis. METHODS Retrospective chart review of renal injuries seen between 1997 and 2001 at a level 1 pediatric trauma center was conducted. Severity of injury was graded by the American Association for the Surgery of Trauma Organ Injury Severity Scale. The outcome variables included the need for hemodialysis, impaired renal function (creatinine), and postinjury hypertension. RESULTS In this study, 34 children presented with grade 1, 2, or 3 injury (74%), whereas 13 children presented with grade 4 or 5 renovascular injury (28%). The children with unilateral renovascular injury who underwent either nephrectomy or renal preservation had comparable outcomes with no hypertension, hemodialysis, or renal insufficiency in either group. CONCLUSIONS The treatment outcomes were not different between the patients who underwent renal preservation and those who had immediate nephrectomy. The authors conclude that renal preservation should be attempted for all children with grade 4 or 5 renovascular injury.