Prophylactic gastropexy in the asplenia syndrome

Torsed wandering spleen as a cause of recurrent abdominal pain in a child

Wandering spleen is an uncommon cause of acute abdomen in children. Diagnosis of this condition is challenging due to its non-specific symptoms, varying intensity and protracted history of presentation. Radiographs and ultrasound imaging provide rapid and reliable means to diagnose this condition without exposure to excessive radiation. We present a case of a torsed wandering spleen in a child with recurrent abdominal pain. We highlight the role of imaging in identifying salient radiographic and sonographic signs for diagnosis.

Pre natal evaluation of heterotaxy syndrome by fetal echocardiography and correlating with autopsy

Introduction

Heterotaxy syndrome/ isomerism is characterized by an abnormal symmetry of the viscera that are normally dissimilar due to abnormal lateralization of thoracic and abdominal viscera and is frequently associated with complex cardiac anomalies. Isomerism may be of right or left.

Materials and methods

This article describes the morphological characteristics of heterotaxy and suggests an approach in evaluating the spectrum of abnormalities associated with this syndrome. This study is based on 12 cases diagnosed on antenatal ultrasound as heterotaxy syndrome. Results of the examinations were re-evaluated and compared by fetal autopsy.

Result

Based on the following echocardiographic criteria, a diagnosis of left isomerism was made if there was viscerocardiac heterotaxy associated with an interruption of inferior vena cava or with bilateral finger-like atrial appendages or if it was associated with heart block. If there was evidence of viscerocardiac heterotaxy with complex cardiac anomalies then it was diagnosed as right atrial isomerism or visceral heterotaxy syndrome. We diagnosed 6/12 as left isomerism and rest of the cases as right isomerism/visceral heterotaxy syndrome. In Autopsy we evaluated visceral situs and morphology of the lungs and the main bronchi, the state of the liver, spleen, bowel, and the precise anatomy of the heart and confirmed 4/12 as left isomerism 4/12 as right isomerism and two cases as visceral heterotaxy syndrome (VHS). Rest of the two cases were included in the study despite missing autopsy data, as the combination of abnormal situs with interrupted inferior vena cava, and cardiac malformation allowed a diagnosis of left isomerism with high probability.

Conclusion

In this study, we aimed to find common features of heterotaxy syndrome on prenatal ultrasound as well as on fetal autopsy. This syndrome should be accurately diagnosed in the prenatal period in order to allow appropriate counseling of parents.

Evaluation of splenectomy as a risk factor for gastric dilatation-volvulus

OBJECTIVE

To evaluate whether dogs undergoing splenectomy had an increased risk of gastric dilatation-volvulus (GDV), compared with a control group of dogs undergoing enterotomy.

DESIGN

Retrospective case-control study.

ANIMALS

219 dogs that underwent splenectomy for reasons other than splenic torsion (splenectomy group; n = 172) or enterotomy (control group; 47) without concurrent gastropexy.

PROCEDURES

Medical records were reviewed for information on signalment, date of surgery, durations of surgery and anesthesia, reason for splenectomy, histopathologic findings (if applicable), whether gastropexy was performed, duration of follow-up, and date of death (if applicable). Follow-up information, including occurrence of GDV, was obtained via medical records review and a written client questionnaire.

RESULTS

Reasons for splenectomy included splenic neoplasia, nonneoplastic masses, infarction, traumatic injury, and adhesions to a gossypiboma. Incidence of GDV following surgery was not significantly different between dogs of the splenectomy (14/172 [8.1 %]) and control (3/47 [6.4%]) groups. Median time to GDV for the 17 affected dogs was 352 days (range, 12 to 2,368 days) after surgery. Among dogs that underwent splenectomy, sexually intact males had a significantly higher incidence of GDV (4/16) than did castrated males and sexually intact or spayed females (10/156). Incidence of GDV among sexually intact male dogs did not differ between groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Results did not support a recommendation for routine use of prophylactic gastropexy in dogs at the time of splenectomy. Other patient-specific risk factors should be assessed prior to recommending this procedure.

Congenital hemidiaphragmatic agenesis presenting as reversible mesenteroaxial gastric volvulus and diaphragmatic hernia: a case report

A 70-yr-old woman complained of left sided chest pain and non-bilious vomiting for four days after taking a gastric bloating agent for an upper gastrointestinal study. The chest radiography revealed gastric air-fluid levels and bowel loops in the left thoracic cavity. An emergency thoracotomy was performed. The abdominal organs (stomach, spleen, splenic flexure of the colon) were in the left thorax and the entire left hemidiaphragm was absent. There were no diaphragmatic remnants visible for reconstruction of the left diaphragm. We provided warm saline irrigation and performed a left lower lobe adhesiotomy. Thirteen days after surgery, the chest radiography showed improvement in the herniation but mild haziness remained at the left lower lung field. Here we present the oldest case of congenital diaphragmatic agenesis presenting with transient gastric volvulus and diaphragmatic hernia.

[Multiple anatomical malformations in 25-year old patient with heterotaxy--case report]

INTRODUCTION

Heterotaxy or situs ambiguus is a rare congenital disorder, characterized by abnormal situs with either left or right isomerism that usually coincides with A complex malformation. The classic left isomerism or bilateral left-sidedness or heterotaxy syndrome with polysplenia implies that patients have bilateral bilobed lungs, bilateral pulmonary atria, a centrally located liver, a stomach in indeterminate position, and multiple spleens, occasionally associated with interruption of the inferior cava with azygos or hemiazygos continuation.

CASE REPORT

We present a case of situs ambiguus associated with severe heart and vascular abnormalities in a 25-year-old male patient. On the admittance to our clinic the patient had history of biliary colic, moderate jaundice of the conjunctive and sclerae, and severe central cyanosis. The echocardiography revealed a large atrial septal defect, complete absence of the interventricular septum resulting in the single ventricle and the inversion of atria. The angiography obtained the hypoplastic inferior vena cava continuing with azygos vein that flowed into the left superior vena cava. The computerized tomography scans showed three splenuli in the right upper quadrant of the abdomen, and a single gallstone appeared in the left-positioned gallbladder. The contrast radiography showed complete transposition of the guts and stomach.

DISCUSSION AND CONCLUSION

To our knowledge, our patient with described severity of the anomalies had the longest life span in this part of Europe, although the longer survivors have been described in the other parts of the world. Furthermore, clinical characteristics of both left and right isomerism have been obtained in the patients with anatomically pronounced left isomerism.

Laparoscopy-assisted gastropexy for gastric volvulus in a child with situs inversus, asplenia, and major cardiac anomaly

AIM

The aim of this study was to report on laparoscopy-assisted gastropexy in a child with situs inversus, asplenia, and major cardiac anomaly.

CASE

A 15-month-old boy presented with a sudden onset of epigastralgia, nonbilious vomiting, and severe abdominal distention. After a nasogastric tube decompression of the stomach, symptoms resolved and an upper gastrointestinal contrast study confirmed situs inversus and asplenia. Computed tomography showed hepatic symmetry. Major cardiac anomalies (e.g., single atrium, single ventricle, common atrioventricular valve, and pulmonary atresia) were also present and had been treated elsewhere by a Blalock-Taussig shunt operation, the Glenn procedure, and pulmonary artery plasty. To prevent recurrent gastric volvulus, an anterior gastropexy procedure was performed laparoscopically. The patient's weight at the time of surgery was 8.1 kg, and the operating time was 65 minutes. Cardiopulmonary status was stable during insufflation and throughout the laparoscopic procedure. Postoperative recovery was uneventful, and the patient was allowed oral fluids 1 day after surgery and an unrestricted diet on day 2. A Fontan procedure was performed 18 months later, and our patient is now 6 years old and well--with no recurrence of gastrointestinal symptoms.

CONCLUSION

This is the first report about the successful application of laparoscopy for performing a gastropexy procedure in a child with gastric volvulus, situs inversus, major cardiac anomaly, and asplenia.

Situs anomalies and gastrointestinal abnormalities

BACKGROUND/PURPOSE

The aim of the study was to review the gastrointestinal abnormalities occurring in association with situs anomalies.

METHODS

Patients with situs anomalies were identified from the medical records of pediatric patients of Seoul National University Children's Hospital from January 1980 to July 2004. Retrospective study was undertaken. Diagnosis was made on the basis of the information obtained from a combination of echocardiography, angiography, abdominal ultrasonography, liver scan, upper gastrointestinal study, or abdominal computed tomography.

RESULTS

A total 67 patients diagnosed as having situs anomalies were identified. There were 40 males and 26 females (1.54:1). Of these 67 patients, 45 patients (67%) were diagnosed as having situs inversus, 16 patients (24%) as having right isomerism, and 6 patients (9%) as having left isomerism. Of 45 patients with situs inversus, there were 26 patients (58%) who had intraabdominal abnormalities. These were duodenal atresia, biliary atresia, gastroschisis with malrotation, congenital hepatic fibrosis, tracheoesophageal fistula (type C), Currarino's triad, and pheochromocytoma. Of 16 patients with right isomerism, there were 14 patients (88%) who had intraabdominal abnormalities. These were hiatal hernia and diaphragmatic hernia. Of 6 patients with left isomerism, there were 4 patients (67%) who had intraabdominal abnormalities. These were malrotation and biliary atresia.

CONCLUSION

When a patient is noted to have congenital heart disease as part of situs anomalies, or if an atypical position of organs is noted at imaging evaluation, we recommend that the patient undergo chest radiography, abdominal ultrasonography, upper gastrointestinal study, and abdominal computed tomography.

Fetal echocardiographic evaluation of atrial morphology and the prediction of laterality in cases of heterotaxy syndromes

OBJECTIVE

To evaluate whether abnormal atrial morphology, which is well recognized in autopsy series, is detectable by fetal echocardiographic examination of the four-chamber view, and can therefore be utilized to differentiate left from right isomerism in heterotaxy syndromes.

METHODS

This study was a retrospective review of 30 cases with prenatally diagnosed heterotaxy syndromes. Ultrasound video recordings and still images were reviewed with respect to atrial morphology in the four-chamber view. In 25 cases the morphology of both atria was sufficiently well visualized on the recordings to be evaluated and only these were included in the study.

RESULTS

Two types of atrial morphology were distinguished in our cohort: a sickle-shape with the tip pointing laterally and apically, and a blunt shape resembling the usual atrial appearance in the four-chamber view. Nineteen out of the 25 cases (76%) presented with isomerism of the atria in the four-chamber view. Thirteen had bilateral sickle-shaped atrial morphology, all associated with left isomerism. Six had bilateral blunt-shaped atrial morphology, all associated with right isomerism. The atria of the remaining six cases were not isomeric, the right atrium being sickle-shaped and the left blunt-shaped. Five of the latter cases were associated with left and one with right isomerism.

CONCLUSIONS

The majority of prenatally diagnosed heterotaxy syndromes seem to present with isomeric atrial morphology in the four-chamber view. In these cases a differentiation between left and right isomerism can be based on the two distinct types of atrial morphology. This may further enhance the prenatal differentiation of these syndromes.

Clinical implication of hiatal hernia in patients with right isomerism

OBJECTIVE

Despite a reported association between hiatal hernia in patients with heterotaxy syndrome, the clinical significance has remained unclear. Based on large patient cohorts, this study specifically aimed at defining the implication of hiatal hernia in patients with right isomerism.

METHODS

From 1994 to 2002, 143 patients were identified as having right isomerism. Among them, 119 received ultrafast computed tomography (CT) to determine the presence of hiatal hernia as well as any cardiovascular anomalies.

RESULTS

Hiatal hernia was found in 17 patients (seven females and 10 males, 14.3%). The upper gastrointestinal (GI) series in six patients confirmed the diagnosis of hiatal hernia in all and revealed severe gastro-oesophageal reflux in four. The most common symptom of hiatal hernia was vomiting (47%), followed by recurrent bronchiolitis or pneumonia (41.2%) and upper gastrointestinal bleeding (11.8%). Three patients with hiatal hernia underwent fundoplication for medically refractory vomiting. Seven patients were found to have midgut malrotation (5.9%), and four of these had both hiatal hernia and malrotation. Pulmonary atresia was closely associated with the presence of hiatal hernia (p=0.02). One patient with hiatal hernia died suddenly at 6 mo. However, overall mortality was similar between those patients with hiatal hernia and those without.

CONCLUSIONS

The incidence of hiatal hernia was considerably high in patients with right isomerism, especially in those with pulmonary atresia, and it is this that may have led to vomiting and recurrent airway infections. While an association between sudden death and hiatal hernia may well exist, this does require further clarification.

Acute mesenteroaxial gastric volvulus and congenital diaphragmatic hernia

The current report describes the case of an 11-year-old girl with Down syndrome who was admitted because of sudden abdominal pain and vomiting. Her symptoms were secondary to severe gastric volvulus associated with congenital diaphragmatic hernia.

Wandering spleen: a rare cause of mesenteroaxial gastric volvulus

Gastric volvulus is a rare cause of acute abdomen in children. Usually it is associated with defects such as diaphragmatic hernia, hiatal hernia, eventration, and paralysis of the diaphragm. We report an extremely rare case presenting with acute intractable vomiting and abdominal distention. Passage of a nasogastric tube relieved the symptoms. A history of the ingestion of a large bolus of chewing gum and a suboptimal contrast study were misleading, and there was a delay in diagnosis of 3 days. Later, repeat upper GI fluoroscopy with contrast medium identified mesenteroaxial volvulus of the stomach. Exploratory laparotomy additionally revealed a wandering spleen. Derotation of the stomach with anterior gastropexy was performed. To our knowledge, wandering spleen in association with gastric volvulus has been mentioned only three times before in the literature.

Prenatal diagnosis of cardiosplenic syndromes: a 10-year experience

OBJECTIVE

To assess the accuracy of fetal echocardiography in the prenatal diagnosis of cardiosplenic syndromes and the spectrum of associated anomalies.

METHODS

This was a retrospective survey of fetuses in our databases over a period of 10 years with postnatally confirmed prenatal diagnosis of cardiosplenic syndromes.

RESULTS

In 32 of 35 fetuses the prenatal diagnosis of cardiosplenic syndromes was confirmed postpartum. Twenty-two fetuses had left isomerism. Their main prenatal ultrasound features were interrupted inferior vena cava (n = 21), complete atrioventricular septal defect (n = 15), viscerocardiac heterotaxy (n = 15), persistent bradyarrhythmia (n = 12) and fetal hydrops or nuchal edema (n = 12). Twelve pregnancies were terminated, two fetuses were stillborn and eight infants survived. Ten fetuses had right isomerism. Their main sonographic features were juxtaposition of the descending aorta and inferior vena cava (n = 7), complete atrioventricular septal defect (n = 7), left persistent superior vena cava (n = 6) and viscerocardiac heterotaxy (n = 6). In this group there was one stillbirth, five infant deaths and four survivors. The overall survival rate and spectrum of other cardiac malformations were similar between the two groups. Prenatal diagnosis of other visceral features of cardiosplenic syndromes was inconsistent.

CONCLUSION

Cardiosplenic syndromes can be diagnosed with high accuracy by prenatal sonography. A diagnosis of left isomerism should be strongly suggested in the presence of a combination of at least two of the following: (1) complete atrioventricular septal defect or other structural heart disease; (2) interruption of inferior vena cava with azygos continuation; (3) early fetal heart block; (4) viscerocardiac heterotaxy. Right isomerism should be suspected in the presence of a combination of at least two of the following: (1) structural heart disease, namely complete atrioventricular septal defect; (2) juxtaposition of inferior vena cava and descending aorta; (3) viscerocardiac heterotaxy.

An easy method for laparoscopic-assisted percutaneous anterior gastropexy

Laparoscopic antireflux surgery is becoming a standard procedure in pediatric surgery. Anterior gastropexy is often performed in antireflux procedures, as well as in children with recurrent and intermittent volvulus of the stomach. We present a simple and secure technique for anterior laparoscopic-assisted gastropexy.

Gastric volvulus associated with wandering spleen in a child

Wandering spleen is an uncommon entity in childhood and has been described only rarely in association with gastric volvulus. Wandering spleen and gastric volvulus were diagnosed in a 5-year-old boy who presented with acute abdominal pain and distension. Intraoperatively, normal ligamentous connections between the stomach, spleen, and posterior abdominal wall were absent. Developmental anomalies that result in wandering spleen may lead to hypermobility of the stomach and a predisposition to gastric volvulus. In such patients, prophylactic gastropexy should be considered.

A radiochemical assay for beta-ureidopropionase using radiolabeled N-carbamyl-beta-alanine obtained via hydrolysis of [2-(14)C]5, 6-dihydrouracil

A radiochemical assay was developed to measure the activity of beta-ureidopropionase in human liver homogenates which is based on the detection of the reaction product (14)CO(2) by liquid scintillation counting. Radiolabeled N-carbamyl-beta-alanine was prepared within 15 min by a simple hydrolysis of [2-(14)C]5, 6-dihydrouracil under alkaline conditions at 37 degrees C. The enzymatic reaction proved to be linear with time up to at least 3.5 h and protein concentrations up to at least 1 mg/ml. Human beta-ureidopropionase obeyed Michaelis-Menten kinetics with an apparent Km for N-carbamyl-beta-alanine of 15.5 +/- 1.9 microM. The assay proved to be very accurate and sensitive with an intraassay coefficient of variation of 2% and a detection limit of 28 pmol for the product CO(2).