Walter Pegoli

Immune Response: Effects of Operative Stress in a Pediatric Model

PURPOSE The purpose of this study is to delineate the effect of different operative procedures on the cell-mediated immune response in a pediatric animal model using the delayed type hypersensitivity (DTH) skin test. METHODS Sprague Dawley rats (1 week old) were sensitized against keyhole limpet hemocyanin (KLH). Animals were challenged 2 weeks later by an intradermal injection of KLH (0.3 mg) in sterile saline. Rats with positive DTH skin reactions at 24 and 48 hours after challenge (baseline) were divided randomly into five groups (n = 10 each): group I, unmanipulated control; group II, anesthesia; group III, anesthesia and midline extraperitoneal incision; Group IV, anesthesia and laparoscopy (pneumoperitoneum with carbon dioxide); Group V, anesthesia and midline laparotomy. Before each procedure (day 0) and on postoperative days 3 and 6, animals were again challenged intradermally with KLH (0.3 mg). DTH skin reaction was evaluated 24 and 48 hours later. RESULTS A statistically significant difference (P < .05) in DTH skin reaction at 24 and 48 hours was observed between postoperative days 1 to 5 in the extraperitoneal and laparotomy groups with respect to baseline and the control group. Statistically significant differences were found in postoperative days 1, 4, and 5 between laparoscopy and laparotomy. The laparoscopy group showed a statistically significant decrease in DTH skin induration on postoperative day 2 when compared with the control group. At postoperative day 7 and 8 there was no statistical difference in DTH skin response comparing baseline values or between groups. CONCLUSIONS These results suggest that in a pediatric animal model, abdominal surgical procedures accompanied by extensive tissue dissection produce a cellular immunosuppression, lasting up to 7 days, which is not observed in less invasive procedures. Observations concerning lesser immunosuppressive effects of laparoscopy when compared with laparotomy in adult models, as previously described by our laboratory, were also found in this pediatric model.

Disease severity, not operative approach, drives organ space infection after pediatric appendectomy.

Objective:This study examines patient and operative factors associated with organ space infection (OSI) in children after appendectomy, specifically focusing on the role of operative approach. Background:Although controversy exists regarding the risk of increased postoperative intra-abdominal infections after laparoscopic appendectomy, this approach has been largely adopted in the treatment of pediatric acute appendicitis. Methods:Children aged 2 to 18 years undergoing open or laparoscopic appendectomy for acute appendicitis were selected from the 2012 American College of Surgeons Pediatric National Surgical Quality Improvement Program database. Univariate analysis compared patient and operative characteristics with 30-day OSI and incisional complication rates. Factors with a P value of less than 0.1 and clinical importance were included in the multivariable logistic regression models. A P value less than 0.05 was considered significant. Results:For 5097 children undergoing appendectomy, 4514 surgical procedures (88.6%) were performed laparoscopically. OSI occurred in 155 children (3%), with half of these infections developing postdischarge. Significant predictors for OSI included complicated appendicitis, preoperative sepsis, wound class III/IV, and longer operative time. Although 5.2% of patients undergoing open surgery developed OSI (odds ratio = 1.82; 95% confidence interval, 1.21–2.76; P = 0.004), operative approach was not associated with increased relative odds of OSI (odds ratio = 0.99; confidence interval, 0.64–1.55; P = 0.970) after adjustment for other risk factors. Overall, the model had excellent predictive ability (c-statistic = 0.837). Conclusions:This model suggests that disease severity, not operative approach, as previously suggested, drives OSI development in children. Although 88% of appendectomies in this population were performed laparoscopically, these findings support utilization of the surgeons preferred surgical technique and may help guide postoperative counsel in high-risk children.

Endovascular treatment of renal artery thrombosis caused by umbilical artery catheterization

Renal arterial thrombosis, usually in association with aortic thrombosis, has been reported as a result of prolonged neonatal umbilical artery catheterization. A case of renal artery thrombosis attributable to umbilical artery catheterization, resulting in malignant renovascular hypertension, in a 15-day-old neonate, treated by catheter-directed thrombolysis through the involuting umbilical artery, was studied. Resolution of systemic hypertension and partial return of right renal function followed rapid thrombus dissolution.

Rupture of the right diaphragm following blunt trauma in an infant: Case report

Traumatic diaphragmatic rupture is a rare childhood injury and is often difficult to diagnose. This is particularly true in infants. We present the case of a 3-month-old infant with traumatic rupture of the right diaphragm that became clinically apparent only after extubation. The diagnosis can often be made on the basis of chest radiography and clinical signs. Surgical treatment is required. Some phrenic nerve injuries can be anticipated and late sequelae may result.

Transluminal migration of ingested foreign body without peritonitis.

The authors present 2 cases of transluminal migration of an ingested foreign body into the peritoneal cavity without causing peritonitis. Clinical and radiologic features and surgical approach are described, focusing on the absence of an acute abdomen in transluminal migration and the use of laparoscopy in achieving extraction of the foreign object.

Mesenchymal hamartoma of the chest wall

A 33-week gestational male infant with mild respiratory distress after triplet birth was found on physical examination to have a firm, fixed 2-cm mass arising from the lateral right chest wall. Chest x-ray confirmed a spherical soft tissue mass distorting the right fourth and fifth ribs (A). Fine needle biopsy was consistent with a benign chest wall hamartoma (mesenchymoma). The child was treated expectantly until four months of age, when rapid enlargement of the lesion prompted CT examination. CT evaluation revealed progressive destruction of the right third, fourth, and fifth ribs with leftward mediastinal displacement by the mass (B). Heterogeneous areas within the lesion were consistent with hemorrhage and likely accounted for the rapid expansion of the mass seen clinically. The infant had primary resection of the lesion with Gore-Tex (WL Gore & Assoc, Flagstaff, AZ) patch reconstruction of the chest wall. The recovery period was uneventful. Histologic examination showed a benign mesenchymoma with no evidence for malignancy. The characteristic elements of this benign tumor are primitiveappearing mesenchymal cells, stromal elements, and cartilage. Hypercellular cartilage with enchondral ossification at its periphery is present (C1). Woven bone with a suggestion of osteoblastic rimming appears to arise from the primitive mesenchymal cells (C2). In the upper left corner and center of the slide is a dense cellular mixture of primitive mesenchymal cells, osteoclasts, and vascular spaces. At 1-year followup, the child is asymptomatic with a normal chest CT.

Temporary occlusion of the gastroesophageal junction: a modified technique for stabilization of the neonate with esophageal atresia and tracheoesophageal fistula requiring mechanical ventilation

Management of newborn infants with esophageal atresia and tracheoesophageal fistula that require mechanical ventilation is challenging. Without rapid control of the fistula, these patients develop profound respiratory failure and massive distention of the gastrointestinal tract. We present the case of a newborn who upon intubation exhibited respiratory failure and cardiovascular collapse, and in whom traditional intra-operative techniques to gain control of the tracheoesophageal fistula were unsuccessful. We describe a technique that temporarily occludes the gastroesophageal junction, and allows for stabilization of the neonate and definitive repair of the tracheoesophageal fistula.

Ectopic calcitonin in adrenocortical carcinoma: A new tumor marker

Ectopic calcitonin has never before been described in association with pediatric malignancy. This is the first report of ectopic calcitonin in a child with adrenocortical carcinoma. It may prove to be a useful tumor marker in this, as well as other childhood malignancies.

Prenatal Presentation of Inguinoscrotal Hernia

Prenatal diagnosis of inguinal hernia is rare and easily confused with other entities, including masses of the scrotum, abdominal wall, and perineum. Pathologic processes of the scrotum rarely result in enlargement beyond 7 cm. Peristalsis can help to indentify bowel within the mass, suggestive of hernia or omphalocele rather than hydroceles or tumors that contain no bowel. Torsions have a double-ring appearance with no testicular blood flow, whereas hydroceles have visible testicles within a fluid-filled scrotum. Doppler evaluation may be helpful, as hernias typically have minimal vascularity, unlike tumors and teratomas, which are vascular with a widely variable appearance. The authors present the sonographic features of a late-presenting fetal mass that was clinically indistinguishable from omphalocele other than its skin thickness and was larger than typically reported for hernias. Skin thickness and subcapsular fluid are useful adjuncts in distinguishing inguinoscrotal hernia from omphalocele in late gestation.