Tai-Wai Chin

Esophageal Atresia with Tracheoesophageal Fistula: Ten Years of Experience in an Institute

Background: Esophageal atresia (EA), tracheoesophageal fistula (TEF), or both is a complicated problem. The purpose of this study was to evaluate the outcomes and postoperative complications in patients with EA/TEF who were admitted to our hospital. Methods: In total, 15 patients were enrolled from 1994 to 2003, including 8 males and 7 females. Patient demographics, associated anomalies, and outcomes were analyzed. Results: The most common variant was EA with a distal TEF (type C), which occurred in 12 patients (80%). The latter had associated congenital anomalies, and cardiac anomalies were the most frequent, occurring in 8 patients (53.3%). Of the 6 cases who had life‐threatening anomalies, 4 (66.7%) died, and of the 9 cases who had no life‐threatening anomalies, 2 (22.2%) died. Tracheomalacia and/or stenosis were diagnosed in 8 patients (66.7%) postoperatively. Though 3 of the 4 cases who suffered from dying spell received intratracheal stent implantation, 2 cases still died. Conclusion: The survival rate of the patients with EA/TEF is influenced mainly by associated life‐threatening anomalies. TMS combined with a history of dying spell may be the major fatal complication.

A longitudinal cohort study of incidence rates of inguinal hernia repair in 0- to 6-year-old children.

BACKGROUND/PURPOSE This study provides epidemiologic data on the incidence of inguinal hernia repair in preschool children using the Taiwan National Health Insurance Research Database. We believe that the data on hernia repair in said database provide a close approximation of the true incidence of inguinal hernia in young children. METHOD A cohort of 1,073,891 deidentified individuals was randomly selected from an insured population of 23 million. Subjects born during the period 1997-2004 were followed from birth to 6 years. The chi-square test and logistic regression modeling were used for statistical analyses. RESULT A total of 92,308 individuals were born during the study period. Of these individuals, 3881 underwent hernia repairs. The cumulative incidence of hernia repair in children aged 0 to 6 years was 4.20%/7 years. The boy/girl ratio was 4.27:1 and the unilateral/bilateral ratio was 3.77:1. The incidence of hernia repair among boys was highest during the first year of life, but then decreased with age. In contrast, the incidence among girls remained stable during the first 6 years of life. Boys younger than 1 year had more bilateral repairs than boys in other age groups (p<0.0001) and girls had significantly more bilateral repairs than boys (p<0.0001). Subjects with a history of preterm birth also had a higher incidence of hernia repair than subjects who were born at full term (odds ratio=2.34, p<0.0001). CONCLUSION Yearly incidence of hernia repair was obtained from a nationwide database. Some of the observations have not been reported elsewhere.

Surgical treatment of chylothorax caused by cardiothoracic surgery in children

Four pediatric cases of chylothorax after cardiothoracic surgery, which were managed surgically, are reviewed retrospectively. All patients underwent right thoracotomy and mass ligation of the right thoracic duct without detecting the true site of leakage. Although 1 patient died from heart failure the day after operation, the other 3 recovered quickly without sequelae. Based on our limited experience, we suggest that right thoracotomy with mass ligation of the right thoracic duct can successfully cure chylothorax on either side, particularly if identification of the site of leakage is considered too risky because of severe adhesion from previous cardiothoracic surgery.

OUTCOME AND RISK FACTORS FOR MORTALITY IN PEDIATRIC PERITONEAL DIALYSIS

♦ Background: The mortality rate among children requiring renal replacement therapy is higher than in children without end-stage renal disease (ESRD). Some factors, such as hypoalbuminemia, high peritoneal transport rate, age, malnutrition, cardiovascular disease, and recurrent peritonitis, appear to be associated with lower survival in adult peritoneal dialysis patients. Data regarding risk factors of mortality in children with continuous ambulatory peritoneal dialysis (CAPD) are limited. The aims of this study were to analyze the clinical characteristics of patients and investigate if routinely used laboratory and clinical variables are independent risk factors for mortality in children on CAPD. ♦ Methods: We performed a retrospective chart analysis of pediatric ESRD patients on CAPD between January 1997 and September 2008. 29 patients undergoing CAPD for more than 3 months were enrolled. An analysis was performed on clinical and biochemical variables for survivors and nonsurvivors to identify potential risk factors for mortality. ♦ Results: Mean age was 12.18 ± 4.57 years. During the follow-up period, 8 patients transferred to hemodialysis and 13 patients received deceased donor renal transplantation. By the end of the study, 5 patients had died. Actuarial survival rate at 2 and 5 years was 96.55% and 91.19% respectively. The major complication during therapy was peritonitis (1 episode/57.79 patient-months). In the univariate analysis, younger age at initiation of dialysis, presence of comorbid disease, higher peritoneal transport rate, increased protein losses through peritoneal dialysis, high total daily protein loss, hypoalbuminemia, and hypophosphatemia were variables associated with mortality in pediatric CAPD patients. However, in the multivariate analysis, only low serum albumin (b = –2.089, p = 0.006; hazard ratio 8.06, 95% confidence interval 0.028 – 0.546) was independently associated with mortality. ♦ Conclusion: Mortality was low in our pediatric patients receiving CAPD. Hypoalbuminemia showed a significant association with death in CAPD patients.

Prepubertal testicular germ cell tumors: 25-year experience in Taipei Veterans General Hospital.

Background: Due to the rarity of testicular tumors in the prepubertal population, adequate information about their biological course is difficult to document well in a single institution. The purpose of this study was to focus on prepubertal males in an attempt to evaluate clinical features and optimal management among various testicular germ cell tumors with long‐term follow‐up. Methods: We retrospectively reviewed the records of children younger than 12 years of age with primary testicular germ cell tumors between February 1981 and December 2005 at Taipei Veterans General Hospital. Thirty‐four children were diagnosed with adequate clinical and pathologic data. The stage of the disease was determined according to the staging system used by the Childrens Oncology Group. Mean follow‐up time was 139 months (range, 2–283 months). Results: All of the 34 prepubertal patients were diagnosed initially with a painless scrotal mass. The mean age of the patients at diagnosis ranged from 6 months to 84 months (mean, 20.5 months). All patients underwent radical orchiectomy as an initial treatment. Twenty‐nine (85.3%) patients had yolk sac tumors, and 5 (14.7%) had mature teratomas. Of the 29 patients with yolk sac tumor, 26 (89.7%) were diagnosed as stage I, 1 (3.4%) as stage III, and 2 (7.0%) as stage IV. Five (19.2%) of the 26 stage I yolk sac tumors progressed to metastasis after radical orchiectomy, and all of these 5 patients later received chemotherapy. One patient initially with stage III yolk sac tumor and 2 patients with stage IV yolk sac tumor were also treated with chemotherapy. Eventually, 1 patient with stage IV yolk sac tumor died due to tumor pro‐gression; the remaining 28 patients with yolk sac tumor all survived without tumor relapse after appropriate treatment. In the 5 patients with teratomas, there was no tumor relapse after radical orchiectomy with a mean follow‐up time of 139.1 months. The 5‐year survival rates for yolk sac tumor and teratomas were 96.5% and 100%, respectively. Conclusion: The most common prepubertal malignant testicular tumor is yolk sac tumor, and the most common benign testicular tumor is teratoma. Children with testicular germ cell tumors have excellent long‐term survival rates after appropriate treatment.

Renal Cell Carcinoma in Children and Young Adults

Renal cell carcinoma (RCC) is a relatively uncommon tumor in childhood. Its biologic behavior and prognostic factors have rarely been documented. We report treatment and survival of 4 children (aged 8, 9, 11, and 14 years) who had RCC, along with a review of the literature to analyze the frequency of major symptoms, clinical stage, and prognostic factors based on 130 published cases of RCC in individuals younger than 20 years of age. Two of our cases had renal tumors detected by ultrasound screening, and all 4 cases were followed for a considerable length of time and were alive and free of disease after treatment. An analysis of these 130 published cases of pediatric RCC showed tumor staging and cell type to be the factors that affected patient survival. Tumors composed of granular cells or mixed cells, or at advanced stages, had a poor prognosis. Age, sex, tumor size, symptom duration, and cellular pattern were not related to patient prognosis. Children older than 10 years of age, who have an abdominal mass, flank pain, and/or hematuria should alert clinicians to consider the possibility of RCC. The importance of early diagnosis of renal tumors, using ultrasound as a tool of screening, is emphasized, since surgical treatment leads to a favorable prognosis only in the early stage of RCC.

Second hernia repairs in children—a nationwide study

BACKGROUND Second inguinal hernia repairs may be needed either owing to contralateral metachronous hernia (MH) or ipsilateral recurrent hernia (RH). In this study, we estimated the incidence rates of MH and RH from a large nationwide database. METHODS The information was obtained from the National Health Insurance Database (with 23 million insurants). Subjects with hernia repairs were identified, and information such as age, gender, unilateral/bilateral procedures in the first and second hernia repairs were analyzed. RESULTS Among the 92,308 newborns observed from their births to the end of 6th year, 3881 had first hernia repairs. Among the 3068 subjects with first unilateral repairs, 307 had second repairs, and among the 813 with first bilateral repairs, 15 had second repairs. The incidence of second repairs was 10.85% (13.71% if <1year old) after first unilateral repairs and was 1.23% (0.63% if <1year old) after first bilateral repairs. CONCLUSIONS The incidence of RH (estimated from second hernia repairs after first bilateral repairs) was 1.23%. The incidence of MH (from second repairs after first unilateral repairs) was 9.62%. These incidence rates are consistent with other published reports.

Surgical outcomes of total colonic aganglionosis in children: A 26-year experience in a single institute

Background: There is a lack of consensus regarding the treatment of total colonic aganglionosis (TCA) with respect to perioperative morbidity, mortality, complications, and functional outcomes. The aim of this study was to review the results of surgical TCA treatment over a 26‐year period and characterize the outcomes. Methods: We retrospectively reviewed the clinical characteristics, surgical courses, and outcomes of TCA patients who underwent definitive pull‐through operations from 1986 to 2012. Follow‐up data were collected by chart reviews and telephone interviews using a standardized questionnaire. Results: We identified nine infants with TCA (8.6%) from among 105 infants with Hirschsprungs disease treated during the 26‐year period. Neither sex predominated (male/female ratio = 4:5). All infants underwent laparotomies and simultaneous enterostomies. All patients eventually underwent modified Duhamel pull‐through procedures at a mean age of 179 days (range, 47–352 days). Two infants died of complications after surgery including heart failure and sepsis. The remaining infants recovered smoothly with antilaxative medications, and all but one was weaned off these medications. Although the surviving patients did not catch up on growth, they and their families were satisfied with the surgical results. Conclusion: Infants with TCA had satisfactory outcomes after the modified Duhamel pull‐through operation. Based on our experience, we suggest that the pull‐through operation could be performed earlier, even when there are loose stools from the enterostomy.

Amelioration of paraquat-induced pulmonary injury by mesenchymal stem cells.

Acute paraquat (PQ) poisoning induces redox cycle and leads to fatal injury of lung. Clinical management is supportive in nature due to lack of effective antidote, and the mortality is very high. Mesenchymal stem cells (MSCs) process the properties of immunomodulation, anti-inflammatory, and antifibrotic effects and oxidative stress resistance. MSC transplantation may theoretically serve as an antidote in PQ intoxication. In this study, we examined the potential therapeutic effects of MSCs in PQ-induced lung injury. The degree of PQ toxicity in the rat type II pneumocyte cell line, L2, and MSCs was evaluated by examining cell viability, ultrastructural changes, and gene expression. L2 cells treated with 0.5 mM PQ were cocultured in the absence or presence of MSCs. For the in vivo study, adult male SD rats were administered an intraperitoneal injection of PQ (24 mg/kg body weight) and were divided into three groups: group I, control; group II, cyclophosphamide and methylprednisolone; group III, MSC transplantation 6 h after PQ exposure. MSCs were relatively resistant to PQ toxicity. Coculture with MSCs significantly inhibited PQ accumulation in L2 cells and upregulated the expression of antioxidative heme oxygenase 1 and metallothionein 1a genes, reversed epithelial-to-mesenchymal transition, and increased the viability of PQ-exposed L2 cells. Treatment with MSCs resulted in a significant reduction in severity of liver and renal function deterioration, alleviated lung injury, and prolonged the life span of rats. Altogether, our results suggest that MSCs possess antidote-like effect through multifactorial protection mechanism. The results of this preclinical study demonstrate that transplantation of MSCs may be a promising therapy and should be further validated clinically.

Totally implantable venous access ports via the external jugular vein: safety and effectiveness for young pediatric patients.

Background and Aims Various venous approaches are possible during implanting a totally venous access port. The veins, which are commonly used in pediatric patients are internal and external jugular veins. Comparison of different venous approaches has been discussed in a few reports only. The present study reviews the complication rate, operation time of implanting the port via different veins in children. Patients and Methods From January 2003 to December 2005, 94 venous access ports were implanted in 88 consecutive patients in the Pediatric Surgical section of the Taipei Veterans General Hospital. The patients were classified according to the vein used. Group A (n=45), the external jugular vein access group; and group B (n=43), the internal jugular vein access group. Results The operation time in group A and B were 38.4±11.1 and 57.6±20.3 min, respectively. The mean operation time of group A was significantly shorter than that of group B (P<0.001). The overall complication rates in group A and B were 8.5%, and 19.1%, respectively. These differences, however, were not significant (P>0.05). Conclusions The external jugular vein approach has a shorter operation time and a lower complication rate than the internal jugular vein approach. This approach may be a method of choice in selected pediatric patients.