W Cheng

Foreign-body ingestion in children: Experience with 1,265 cases

BACKGROUND/PURPOSE This study aims to elucidate the clinical presentation, the effectiveness of investigations, and treatment of foreign body ingestion in children and to formulate an algorithm of management. METHODS The records of children admitted to a single institution who had a history of foreign body ingestion over 33 years were reviewed. Symptoms, radiological findings, and endoscopic findings were assessed. RESULTS Foreign bodies were detected in 552 (43%) of the 1,265 children admitted. The age of the children ranged from 6 months to 16 years (mean, 5.2 years). The preschool toddlers (mean age, 3.8 years) were most prone to ingest inanimate objects. The most common objects were coins (49%) and nonmetallic sharp objects (NMSO; 31%). Although x-rays could detect all the metallic objects and 86% of glass objects, the sensitivity of fish bone detection is only 26%. Absence of symptoms was common (50% in metallic group and 29% in NMSO group). Forty-one percent of coins and 95% of NMSO were lodged at sites suitable for removal by direct laryngoscopy alone with success rates of 86% and 77%, respectively. There were 3 disease-related complications and 1 mortality. Two of these children were mentally retarded and presented late. CONCLUSIONS Efforts for prevention of ingestion of inanimate foreign body should focus on the preschool toddler group. Particular attention should be paid to mentally retarded children with vague gastrointestinal symptoms. Absence of symptoms does not preclude presence of foreign body in children. Children with history of NMSO ingestion should undergo direct laryngoscopy despite negative radiological finding, both as a screening procedure or treatment.

Sustained elevation of Epstein-Barr virus antibody levels preceding clinical onset of nasopharyngeal carcinoma

We have monitored Epstein–Barr virus (EBV) IgA antibody levels of 39 nasopharyngeal carcinoma (NPC) cases for up to 15 years before clinical onset of NPC, and assessed preclinical serologic status of another 68 cases. Our results identify a serologic window preceding diagnosis when antibody levels are raised and sustained. This window can persist for as long as 10 years, with a mean duration estimated to as 37±28 months. Ninety-seven of these 107 NPC cases exhibited such a window. Cases that did not may reflect individual antibody response to EBV. Serologic screening at enrollment identified those cases who had already entered the window and became clinically manifested earlier (median=28 months) than those who entered the window after enrollment (median=90 months). The former account for 19 of 21 cases diagnosed within 2 years of screening. Nasopharyngeal carcinoma risk levels among seropositive subjects were also highest during this period. Both prediction rates and risk levels declined thereafter; cases detected at later times were composed of increasing proportions of individuals who entered the serological window after screening. Our findings establish EBV antibody as an early marker of NPC and suggest that repeated screening to monitor cases as they enter this window has considerable predictive value, with practical consequences for cancer treatment.

Early and late results of excision of choledochal cysts

BACKGROUND/PURPOSE Reports on the late results of choledochal cyst excision with hepaticojejunostomy in children are relatively few. METHODS Of the 84 patients who had choledochal cyst who came under our care, 79 have had definitive surgery, three are awaiting surgery, one is being observed with Carolis disease, and the parents of one child have refused surgery. Thirty-eight patients treated decades ago had internal drainage procedures. Since 1972, 41 patients have had cyst excision with hepaticojejunostomy using a 40-cm Roux loop without an antireflux procedure. Early complications in those who underwent cyst excision with hepaticojejunostomy included anastomotic leak in three patients who required reoperation, cholangitis in two, and fluid collection in the gall-bladder bed that required no intervention in one. RESULTS During a follow-up period ranging from 4 months to 17 years (mean, 8.5 years), anastomotic stricture, cholangitis, and intrahepatic stone formation developed in two children after being well for 8 years and over 11 years. These children required additional surgical procedures to overcome their problems. Asymptomatic intrahepatic stones 2 years after cyst excision with hepaticojejunostomy developed in a third child. There was no mortality in the entire group that underwent cyst excision and they are all enjoying a good quality of life. CONCLUSIONS Careful, long-term follow-up is important in children who have choledochal cyst excision with hepaticojejunostomy.

Abnormal enteric nerve morphology in atretic esophagus of fetal rats with adriamycin-induced esophageal atresia

Abstract Gastroesophageal reflux is common in children after successful repair of esophageal atresia (EA), and may be related to a congenital neuronal abnormality of the esophagus. This study employed a fetal rat model of adriamycin-induced EA to investigate whether the innervation of the esophagus is abnormal in EA. The fetal rats were divided into four groups: (1) normal controls; (2) a saline-injected controls; (3) adriamycin administered but without the development of EA; and (4) adriamycin-induced EA. The distal esophageal segments were immunostained with a general neural marker, protein gene product 9.5 (PGP). Immunoreactivity per cross-sectional area (/xsa) was measured with an image analyzer. The extent of the esophageal circumference encircled by PGP-stained nerve tissue was assessed. While there was no significant difference in PGP immunoreactivity/xsa between the groups, the near-complete ring of nerve tissue along the plane of the myenteric plexus was replaced by clusters of nerve tissue in the atretic group (normal vs EA, P = 0.001, Mann-Whitney U test). The abnormal distribution of nerve tissue in the atretic esophagus may be contributing factor in the esophageal dysmotility seen in EA.

Childhood Intussusception: Ultrasound-Guided Hartmann's Solution Hydrostatic Reduction or Barium Enema Reduction?

A comparison was made of the efficacy of ultrasound guided Hartmanns solution hydrostatic reduction on 23 patients (US group) with the same number of consecutive patients in whom hydrostatic reduction was done by barium enema (BE group) under fluoroscopy for childhood intussusception. The US group was diagnosed by ultrasound scan and reduction was attempted under the guidance of ultrasonography with Hartmanns solution at 100 mm Hg pressure. Excluded were patients older than 12 years, patients in shock, patients with peritonitis, bowel perforation, and gross abdominal distension as well as recurrent intussusception of more than three episodes. There were three patients excluded in this group. The diagnosis of intussusception and complete reduction were confirmed by gastrografin enema. This US group had three recurrences (3 of 26, 11.5%), one lead point (1 of 23, 4.4%), and 19 successful reductions (19 of 26, 73%). Incidentally, there were also three patients excluded in this period of barium enema reduction. There was only one recurrence (1 of 24, 4.2%), one leadpoint (1 of 23, 4.4%), and 12 successful reductions (12 of 24, 50%) in these 23 BE patients. The success rates for the ileo-colic intussusceptions with Hartmanns solution reduction and barium enema reduction were 91% (19 of 21) and 55% (12 of 22), respectively (P = .00865). There was no complication in either group, and the accuracy of diagnosing a complete reduction was 100% in both forms of reduction. Hence, ultrasound-guided hydrostatic reduction for childhood ileocolic intussusception is preferred because it is safe, accurate, has a higher success rate, and can avoid radiation exposure risk.

Solid-cystic papillary tumor of the pancreas in children.

Abstract. Solid-cystic papillary tumor (SCPT) of the pancreas is a rare neoplasm in children. The current study attempted to estimate the incidence and possible pathological origin of the tumor. Clinicopathologic features of the children under the age of 16 years with pancreatic tumors managed in a single institution between January 1993 and November 1999 were reviewed. Representative blocks of SCPT specimens were immunostained for neuron-specific enolase (NSE) chromogrannin, synaptophysin, insulin, glucagon, somatostatin, and gastrin. There were three SCPTs, two pancreatic endocrine tumors, and one acinar cell carcinoma during the study period. The estimated yearly incidence in the referral area of 2 million population is about 0.01 pediatric SCPT per year per 100,000 population. The children underwent surgical removal of the tumors. Postoperatively, they were followed up for 6 months to 4 years and were well. Immunostaining for NSE, chromogranin, synaptophysin, insulin, somatostatin, and gastrin was negative in all cases. SCPT may thus be the most common pancreatic tumor in the Asian pediatric population. The pathological origin of the tumor remains unclear and requires further investigations.

A prospective randomized study of wound approximation with tissue glue in circumcision in children

Objective: Bleeding and wound infection are the most common complications of circumcision. Cyanoacrylate tissue glue has been claimed to have the advantage of being haemostatic, bacteriostatic and easy to use. The purpose of this study is to assess the feasibility of using the tissue glue in approximation of circumcision wound in children.

Surgical intervention in necrotizing enterocolitis in neonates with symptomatic congenital heart disease

Abstract The commonly accepted indication for surgical intervention in necrotizing enterocolitis (NEC) is perforation of the bowel. In this study, the indication and role of surgery was assessed in neonates born with symptomatic congenital heart disease (CHD). Records of neonates admitted to a single institution in Hong Kong between January 1981 and December 1997 with symptomatic CHD who subsequently developed NEC were reviewed. The patients were categorized into cyanotic and acyanotic groups. Of 850 neonates with CHD admitted during the period, 30 developed NEC (3.5%); 17 had cyanotic and 13 had acyanotic heart disease. The average Apgar scores at 1 and 5 min were 7.5 and 8.6, respectively. The mean gestational age was 37.7 weeks and the mean birth weight was 2.5 kg. The mean age at which NEC developed was 16 days. The overall mortality in the proven cases of NEC was 57%. After excluding the suspected NEC cases (stage I), it was found that surgery in the proven NEC cases without perforation, i.e., stages II and IIIA, resulted in higher survival than in those managed medically (75% vs 44%). The cyanotic patients had higher mortality than the acyanotic group (71% vs 39%). Neonates with CHD who develop NEC belong to a unique group of mature babies with reasonable birth weights and Apgar scores, unlike the common NEC patient population. The mortality of these patients is extremely high, and a modified management approach is required. Surgical intervention may be indicated at a much earlier stage of proven NEC before gut perforation occurs.

The Involvement of Two or More Systems and the Severity of Associated Anomalies Significantly Influence Mortality in Esophageal Atresia

PURPOSE The aim of this study was to examine the influence of associated anomalies in babies born with esophageal atresia (EA). METHODS A retrospective review of the records of 41 consecutive cases of esophageal atresia managed over an 11-year period was undertaken. RESULTS A higher incidence of associated anomalies was seen in those babies with lower birth weights. Although all five (100%) babies with EA who weighed less than 1,800 g had associated anomalies, those who weighed 1,800 to 2,500 g and more than 2,500 g were associated with 67% (10 of 15) and 43% (9 of 21) anomalies, respectively. The most common system in which anomalies occurred was the cardiovascular system (37%) followed by gastrointestinal (24%), musculoskeletal (17%), genitourinary (7%), chromosomal (5%), and others (12%). All 17 (41%) babies with no associated anomalies survived. Four of the 10 babies who had two or more systems involvement died, whereas only one of 31 babies with less than two systems involvement died; the difference between these two groups was highly significant (Fishers Exact test, P = .009). The overall mortality rate was 12%. Three of the deaths were associated with severe anomalies that were incompatible with life such as bilateral renal agenesis, trisomy 18, and complex cardiac anomalies. CONCLUSION The association of two or more system anomalies and the severity of associated anomalies influence mortality in esophageal atresia.

Abnormalities of neuropeptides and neural markers in the esophagus of fetal rats with Adriamycin-induced esophageal atresia

BACKGROUND/PURPOSE To investigate the distribution of neural markers and neuropeptides in esophageal atresia (EA). METHODS A fetal rat model with Adriamycin-induced EA was used. The animals were divided into four groups: (1) control group, (2) saline-injected group, (3) Adriamycin administered but without the development of EA, and (4) Adriamycin-induced EA group. Specimens of the distal esophagus from each group were immunostained using antibodies to S100, protein gene product 9.5 (PGP), somatostatin, vasoactive intestine peptide (VIP), bombesin, galanin, substance P, neuropeptide Y (NPY), calcitonin gene-related product (CGRP), met-encephalin, nitric oxide synthase, and tyrosine hydroxylase. RESULTS The total cross-sectional area of the distal atretic esophagus was significantly smaller than controls (P = .01), the submucosa being the component most affected (0.0465 v 0.0234 mm). Immunoreactivity for S100 and galanin were significantly elevated in the atresia group (0.0288 v 0.0079 and .001 v 0.000). In addition, there was also an increase in CGRP and Substance P in the atretic group. CONCLUSION The elevated levels of S100 and galanin could explain the disordered motility observed in patients who had esophageal atresia.