Vinci S. Jones

Post-liver transplant mycotic aneurysm of the hepatic artery

BACKGROUND Mycotic aneurysm of the hepatic artery is a rare complication of liver transplantation, occurring in 0% to 3% of patients and having a mortality of around 30%. We present a unique report of mycotic aneurysms of the hepatic artery following liver transplantation in children. METHODS AND RESULTS A chart review of the 194 patients who underwent a liver transplantation over a 21-year period revealed 2 patients who developed a mycotic aneurysm of the hepatic artery. The first patient died due to rupture prior to diagnosis. The second patient was treated successfully using radiological coil embolization, followed by surgical excision with hepatic artery ligation and antibiotic therapy. CONCLUSIONS Early diagnosis and prompt multidisciplinary treatment is crucial to optimize treatment in this condition.

Atypical congenital mesoblastic nephroma presenting in the perinatal period

Congenital mesoblastic nephroma (CMN) is a rare tumour of infancy having an overall good prognosis. The less common, atypical CMNs have cellular elements in them and tend to have an unpredictable course. Occurrence in the perinatal period may further change the outcome. By reporting three patients presenting in the perinatal period with atypical CMN, an attempt is made in this paper to characterize the clinical behaviour of these variant tumours. Though one of our patients had an uneventful course, the other two had several complications including polyhydramnios, prematurity, hypertension, haemodynamic instability and tumour spillage. The course was complicated by recurrence in the latter two and refractoriness to chemotherapy and death in one. That the atypical subset of CMNs occurring in the perinatal period can have a stormy course is well illustrated by this report. Possible prognostic factors are evaluated and the sparse reports of similar cases in the literature are reviewed and compared.

Navigating the thoracic inlet in children

Though various approaches to the thoracic inlet have been described in adults, currently no guidelines exist in children. Reports in the literature of resection of thoracic inlet tumours in children are only anecdotal. Literature was reviewed to assess the various described approaches with reference to suitability in children. Experience with a 3.5-year-old boy having a thoracic inlet ganglioneuroma, using the anterior cervico-thoracic trap door incision demonstrated excellent access and minimal morbidity. We recommend the trap door incision as the preferable route for exploring thoracic inlet tumours in children.

Reverse portal flow after liver transplantation–ominous or acceptable?

Jones VS, McCall JL, Thomas G, Stormon M, Shun A. Reverse portal flow after liver transplantation‐ominous or acceptable?
Pediatr Transplantation 2010: 14:E34–E37.

An optimum animal model for neonatal thoracoscopy.

PURPOSE This study attempted to define an optimum animal model for neonatal thoracoscopy. MATERIALS AND METHODS Seven rabbits and three 5-7-kg piglets were subjected to thoracoscopy by three pediatric surgeons. The outcome for the successful completion of esophageal anastomosis and additional procedures, including diaphragmatic plication and lung biopsy, were noted. RESULTS Whereas esophageal anastomosis could be accomplished in all piglets, it could be achieved in only 1 rabbit. Additional procedures were possible in 2 piglets and no rabbits. Anesthetic complications were seen in 4 rabbits and 1 piglet. CONCLUSION Our findings suggest that the piglet may be the optimum animal model for replicating neonatal thoracoscopy. The fragility of the rabbit, coupled with a limited intrathoracic working space, limits its use for thoracoscopy.

What causes intrathoracic gastric dilatation in a late-presenting diaphragmatic hernia?

A 13-year-old previously asymptomatic patient presented with abdominal pain and vomiting. Chest radiogram revealed a left intrathoracic stomach. Laparotomy confirmed a dilated, hypertrophic stomach herniating through a left Bochdalek hernia. The patient recovered after a period of prolonged gastric paresis. While highlighting the importance of considering this condition in the differential diagnosis of a cystic lesion in the chest, this article also postulates a mechanism for the hypertrophic gastric dilatation in a late presentation of a congenital diaphragmatic hernia.

The ping-pong ball as a surgical aid in liver transplantation

BACKGROUND Liver transplantation using split adult segmental grafts in infants can be a technical challenge because the small abdominal cavity cannot comfortably accommodate the graft, leading to compression. This size mismatch can be a particularly difficult problem when the anteroposterior diameter of the graft is greater than the infants available anteroposterior peritoneal space. We describe a simple and novel technique that may prevent this complication. METHODS AND RESULTS Two infants with biliary atresia weighing 5 kg each and aged 6 and 5 months, received split adult liver left lateral segment transplants from deceased donors weighing 55 and 65 kg, respectively. Congestion of the graft and inadequate perfusion were prevented by placing a sterilized ping-pong ball in the retrohepatic space to elevate the graft off the native hepatic fossa. The bilateral subcostal incision was required to be extended vertically in the midline up to the xiphisternum in both patients to enlarge the abdominal cavity. Delayed closure of the wound was performed after 5 days using Surgisis (porcine small intestine submucosa, Cook Surgical Inc, Bloomington, IN) when it was possible to remove the ping-pong ball in one of the patients. Both patients have recovered well from the transplant. A follow-up of 1 year in the patient with the in situ ping-pong ball shows it to be well anchored and causing no symptoms. CONCLUSIONS In children undergoing large-for-size split liver grafts, delaying the closure of the abdominal wound along with elevation of the graft using a ping-pong ball can be a useful and simple adjunct to prevent the complications of graft compression.

Impact of Minimally Invasive Surgery on the Pediatric Surgical Profession

We conducted a survey among pediatric surgeons to examine the impact of the advent of minimally invasive surgery (MIS) on the pediatric surgical profession with respect to job satisfaction and training challenges. An invitation to participate in a web-based questionnaire was sent out to 306 pediatric surgeons. Apart from demographic details and training recommendations, parameters relevant to job satisfaction, including patient interaction, peer pressure, ethical considerations, academic progress, ability to train residents, and financial remuneration, were studied. The response rate was 38.2%. Working in a unit performing MIS was identified by 71% of respondents as the most effective and feasible modality of training in MIS. Inability to get away from a busy practice was the most common reason cited for inability to acquire MIS training. The overall responses to the job satisfaction parameters showed a positive trend in the current MIS era for patient interaction, ethical considerations, academic progress, and training residents, with a negative trend for peer pressure and financial remuneration. The enthusiastic minimally invasive surgeons (EMIS) were defined as those having more than 5 years of MIS experience and also performing more than 10% of their work using MIS. Of the 113 responses analyzed, 67 belonged to the EMIS category. Those belonging to the EMIS group were less likely to feel inadequate in training their residents, in meeting the felt needs of the patients, or to complain about peer pressure. They were more likely to consider MIS to be as relevant and beneficial in children as in adults. Embracing MIS, as represented by the EMIS group, correlated with an overall greater job satisfaction.