Renal Artery Stenosis Due to Entrapment ()

BACKGROUND

Common etiologies of renovascular occlusive disease include atherosclerosis disease, developmental fibrotic conditions such as fibromuscular dysplasia (FMD), vasculitis. Extrinsic compression of the renal artery is a rarely reported phenomenon but can lead to similar clinical manifestations.

METHODS

We report recent experience with two patients who presented with extrinsic renal artery compression due to entrapment. Diagnosis was made with a constellation of findings on computed tomography angiography, dynamic duplex sonography, and catheter angiography. Both patients had hypertension and one had downstream subsegmental renal infarcts. The patients, both with right sided renal artery entrapment, were treated with open surgical decompression. Exposure was achieved via extended Kocher maneuver followed by mobilization of the right kidney and, in one patient, detachment of the right lobe of liver to allow circumferential exposure of the proximal right renal artery to the aorta. All entrapping tissue was circumferentially released.

RESULTS

Both operations were uncomplicated. Intraoperative sonography was used to confirm luminal patency of the released segments. Follow-up renal artery duplex in both patients demonstrated resolution of dynamic compression. Renal artery peak systolic velocity and accelerations indices were all within normal limits. In both patients, improvement in blood pressure control was noted and discontinuation of anticoagulation was possible in the patient who had recurrent episodes of renal infarct.

CONCLUSION

Extrinsic compression of renal artery by diaphragmatic crura is rare but should be considered in younger patients or otherwise any patients with no vascular risk factors when renovascular hypertension workup yields no demonstrable intrinsic disease. A high index of suspicion should be raised when an anomalously high origin of the renal artery or proximity to the diaphragmatic crura are seen on cross sectional imaging. Work-up should include dynamic imaging to assess compression of renal arteries during expiration. Open surgical or laparoscopic decompression of the involved renal arteries can be curative.

Comparative Effectiveness of Parent-Based Interventions to Support Injured Children

OBJECTIVES

A comparative effectiveness trial tested 2 parent-based interventions in improving the psychosocial recovery of hospitalized injured children: (1) Link for Injured Kids (Link), a program of psychological first aid in which parents are taught motivational interviewing and stress-screening skills, and (2) Trauma Education, based on an informational booklet about trauma and its impacts and resources.

METHODS

A randomized controlled trial was conducted in 4 children's hospitals in the Midwestern United States. Children aged 10 to 17 years admitted for an unintentional injury and a parent were recruited and randomly assigned to Link or Trauma Education. Parents and children completed questionnaires at baseline, 6 weeks, 3 months, and 6 months posthospitalization. Using an intent-to-treat analysis, changes in child-reported posttraumatic stress symptoms, depression, quality of life, and child behaviors were compared between intervention groups.

RESULTS

Of 795 injured children, 314 children and their parents were enrolled into the study (40%). Link and Trauma Education was associated with improved symptoms of posttraumatic stress, depression, and pediatric quality of life at similar rates over time. However, unlike those in Trauma Education, children in the Link group had notable improvement of child emotional behaviors and mild improvement of conduct and peer behaviors. Compared with Trauma Education, Link was also associated with improved peer behaviors in rural children.

CONCLUSION

Although children in both programs had reduced posttrauma symptoms over time, Link children, whose parents were trained in communication and referral skills, exhibited a greater reduction in problem behaviors.

Bronchial Compression and Tracheosophageal Fistula Secondary to Prolonged Esophageal Foreign Body

INTRODUCTION

Foreign body ingestion is a common pediatric problem that can have a delayed presentation, as presented herein.

CASE REPORT

We present the case of a 15-year-old female who developed bronchial compression and an acquired tracheoesophageal fistula secondary to a longstanding esophageal foreign body.

DISCUSSION

There are several challenges in diagnosis and management of this unusual situation. We review the literature regarding prolonged retention of foreign bodies and the challenges in diagnosis in the developmentally disabled child.

CONCLUSION

Providers must have a high suspicion for foreign bodies in the case of unusual symptoms present in children with neurodevelopmental delays.

The Thoracic Inlet Index in patients with tracheal obstruction caused by chest wall deformity: Validation in patients and age-matched controls

AIM

We present a novel index for evaluating severity of airway-threatening thoracic inlet compromise in childhood. Two indices were validated in three cases and sixty asymptomatic controls.

METHODS

We developed an index to determine severity of thoracic inlet narrowing. Two different measurement methods were evaluated: Thoracic Inlet Index (TII) was determined at the site of greatest airway compromise at the level of the innominate artery crossing the anterior trachea and TII (anatomic) using purely skeletal measurements, both determined from thoracic CT scan. We sought to validate both indices to determine which was more predictive of the risk of airway compromise. Three patients who presented with life threatening airway compromise were compared to sixty age matched asymptomatic controls obtained from the trauma registry.

RESULTS

The mean TII in controls was 3.89. The TII was consistent at various ages. In patients, mean TII was 12.16 (range of 11.31-12.95). For TII the difference between controls and symptomatic patients was highly significant (P=0.0012). The mean TII (anatomic) in controls was 3.5. The TII (anatomic) was less consistent when evaluated in different age groups. In patients mean TII (anatomic) was 6.32 (range 5.38-7.59). For TII (anatomic), the difference between controls and symptomatic patients was also significant (P=0.0474) but did not discriminate as well as the functional index.

CONCLUSIONS

The TII measured at the level of the innominate artery crossing on thoracic CT scan appears to be the most useful. A level of greater than 10 was highly predictive of airway compromise in our patient group.

Patient education and recall regarding postsplenectomy immunizations

BACKGROUND

The purpose of this study was to determine the rates of initial vaccinations after splenectomy for trauma, assess the effectiveness of patient education on reimmunizations, and evaluate patients' utilization of their knowledge regarding immunization after discharge.

METHODS

From June 1996-December 2011, 144 patients underwent splenectomy after traumatic injury. A telephone survey was completed in 100 of 144 splenectomized patients (69%) at a mean of 7.9 y after their splenectomy. Questions were directed to determine the quality of patients' recall of the implications of splenectomy, the need for vaccinations, and the quality of the health information administered. Research electronic data capture tool was used for collecting data, and data were analyzed with Stata 11.2.

RESULTS

Only 27% of participants recall receiving education on postsplenectomy vaccination and 41% of those patients rated their education as poor or minimal. Ninety-one percent of patients indicated that they would like more information in the form of a brochure. Our overall initial vaccination rates among patients who had splenectomy from 1996-2011 were 76%, 75%, and 68% for Streptococcus pneumoniae, Neisseria meningitidis, and Hemophilus influenza type b, respectively. Since 2004, 95% of those who had splenectomy between 2004 and 2007 received all three vaccines. Since 2008, our institution has maintained 100% initial vaccination rates for all three vaccines. The revaccination rates in this group of patients (from 1996-2007) were 39% and 15% for pneumococcal and meningococcal vaccines, respectively.

CONCLUSIONS

Patients had poor recall of the information provided during hospitalization for splenectomy. There were low revaccination rates in our patient cohort. Specific educational and vaccination surveillance strategies are required to improve vaccination rates.

Segmental resection for the treatment of congenital pulmonary malformations

PURPOSE

The purpose of this study was to compare clinical outcomes of segmental resection to lobectomy as increasing antenatal diagnosis of congenital pulmonary malformations has led to a shift in surgical management.

METHODS

A retrospective institutional review for patients undergoing surgical excision of congenital pulmonary malformations was performed.

RESULTS

Sixty-two patients with congenital pulmonary malformations were reviewed between 2001 and 2012. Forty-five were included for analysis. Malformations were subdivided into two groups, including congenital lobar emphysema (CLE) (n=11, 24%) and intrapulmonary (IP) lesions (n=34, 76%). Nineteen (56%) IP patients underwent segmental resection, and 15 (79%) were performed thoracoscopically without conversion to thoracotomy. None of these patients had recurrent disease. Lobectomy was performed in 11 (100%) CLE and 15 (44%) IP patients, and the majority were by thoracotomy. Median hospital stay was longer for the lobectomy group at 7days when compared to the segmentectomy group at 2days (p<0.001). There was not a difference in complication rate (21% vs. 19%, p=1.000) or in median number of chest tube days (2 vs. 3days, p=0.079) for segmentectomy versus lobectomy patients.

CONCLUSIONS

Segmental resections of congenital pulmonary malformations can be performed safely while conserving healthy lung tissue.

Outcome of antegrade continent enema (ACE) procedures in children and young adults

OBJECTIVE

Intractable incontinence affects a large number of children and young adults in the US. The goal of this study is to evaluate the long-term outcomes of surgical access for administration of antegrade continence enemas (ACE) in affected children and young adults.

METHODS

Patients who underwent surgical procedure to enable administration of ACE from 1994 to 2011 were retrospectively reviewed. Data collected included patient demographics, primary diagnosis, surgical technique, conduit used, complications, follow-up duration, and social continence.

RESULTS

Sixty eighty patients underwent surgery to enable ACE; mean follow up was 61 months. Enteral conduit (EC) was performed in 19 patients, tube cecostomy catheters (CC) in 49. Meningomyelocele was diagnosed in 60% of patients. Mean age was 11 (1.67-53) years. Complications included tube dislodgement (43%), granulation tissue (46%), site infection (13%), leakage (32%), break in the tube (6%) and tract stenosis (6%). Complete social continence was achieved in 68%, partial continence was achieved in 29%, and no benefit was achieved in 3% of patients. The rate of complications and incontinence resolution following CC was 78% and 66%, and following EC 89% and 74%. The differences were not statistically significant. CC patients developed granulation tissue more frequently (53%) and leaks of fecal material less frequently (20%) compared to EC patients (26% and 53%) (p < 0.05 and < 0.01). Although children 7 years or younger developed more overall complications (94%) than older patients (69%; p < 0.05), there was not a significant difference in the frequency of any one complication or in the rate of continence, between the two groups. Multivariate analysis showed that EC is three times more likely to be complicated by fecal leakage. CC patients are at greater risk to develop granulation tissue (p < 0.05).

CONCLUSIONS

Most patients achieved social continence and improved hygiene with the aid of ACE. Younger children also benefited greatly from institution of ACE. CC was associated with fewer major complications such as leak of fecal contents than EC but required regular tube changes.

Gender assignment surgery on children with disorders of sex development: a case report and discussion from South Africa

This case report highlights the dilemma faced by staff with regard to the timing of surgery on a child with a disorder of sex development living in a large, lower socio-economic class, South African, urban township. In this community, children with disorders of sex development can sometimes become an object of interest and ridicule or are thought to be bewitched. Many parents of children with such disorders find it difficult to protect their offspring from the marginalization and rejection that is the consequence of such curiosity and transparency. Current research and theory pertaining to the biological and social bases of gender identity and behaviour are reviewed and their capacity to guide decisions is explored. The absence of a support group to assist these children and their parents, and the paucity of information available in the public domain, compounds an already challenging problem.

Experience and outcomes of nephroblastoma in Johannesburg, 1998 - 2003

INTRODUCTION

Outcomes for children with cancer in the developing world are compromised by the difficulties for patients in accessing health services and by competition for resources between oncological services and the myriad other health problems of emerging nations. The purpose of this study is to document and analyse our experience and the outcomes of children with nephroblastoma over recent years.

METHODS

This is a retrospective review of all patients who underwent combined oncological and surgical treatment for nephroblastoma in the Paediatric Oncology Unit between 1998 and 2003.

RESULTS

Sixty-three patients were treated for Wilms' tumour; the mean age was 3 years 8 months (range 4 months to 11 years). The majority of children presented with an abdominal swelling or mass. Preoperative chemotherapy was given in forty-six cases (73 %). The tumour stage distribution was 11/63 stage I (17 %), 11/63 stage II (17 %), 21/63 stage III (33 %), 16/63 stage IV (25 %) and 4/63 stage V (6 %). Postoperative chemotherapy and radiotherapy was given according to the SIOP protocol. During the study period, thirteen patients (21 %) died (7 cancer-specific, 2 postoperative, 4 sepsis related), thirteen (21 %) were lost to follow-up and thirty-seven (59 %) are free of disease with a mean follow-up period of 3.67 years. Children with stage I and stage II had a disease-free survival at 4 years of 89 %. However, those with stage III, IV and V disease had 4-year survival of 66.75 % (p = 0.07). Overall, four-year post-nephrectomy survival was 76 %.

CONCLUSION

Outcomes for children with cancer have improved dramatically over recent years; however, in the developing world, the scarcity of hospital resources and the overwhelming burden of non-cancer diseases can mean that oncological treatment is extremely challenging. In our society, children tend to present with nephroblastoma at an advanced stage; however, treatment by dedicated, multidisciplinary teams can achieve good results.

Surgeons are failing to recognize children with HIV infection

AIM OF THE STUDY

Despite much clinical experience, there are few published accounts of the surgical manifestations of HIV/AIDS in children and still fewer guidelines for the best or most appropriate treatment. Our primary objective was to document the incidence of HIV infection in children who presented with a surgical emergency to a major pediatric surgical unit in South Africa. If possible, we aimed to provide a description of the impact of the disease in a surgical pediatric population and to raise awareness of the mode of presentation of HIV to the pediatric surgeon in a developing nation, now that specific antiretroviral therapies are available.

METHODS

This was a prospective observational study of consecutive surgical emergency admissions to the Division of Paediatric Surgery at the University of the Witwatersrand, Johannesburg, South Africa, between April 1 and May 31, 2005. Consent for inclusion in the study was sought in all cases. The clinical profile of children presenting during the study period was recorded. If relevant, permission was sought from the parent/guardian to undertake HIV status testing if this were not already known.

MAIN RESULTS

Three hundred ninety-one children were admitted as emergency cases during the study period. Thirty-seven (9.5%) of 391 were excluded, because consent could not be obtained, leaving 354 children. Ages ranged between 1 day and 17 years, with a median age of 3 years. The diagnosis in most was trauma/burns (42%) and abdominal emergencies (27%). Infections occurred in 13% of these patients. Human immunodeficiency virus status was already known in 10 (3%) of 354 patients, and only 18 (5%) of 344 children were tested; of these, 10 (55%) were positive. As expected, the predominant surgical presentation of HIV positive children was sepsis. The prevalence of HIV/AIDS in those children not tested is unknown.

CONCLUSION

It is likely that the incidence of HIV/AIDS infection is higher than the 4% identified in our study group. The surgical manifestations in these HIV-positive children are dominated by sepsis, often severe in nature and with opportunistic pathogens. Despite increased knowledge about the disease and widening therapeutic opportunities, our results suggest that many children with HIV infection are not being recognized, despite entry into the healthcare system. Prompt recognition and surgical management of the complications of pediatric HIV infection can sometimes result in a good outcome. Further studies are therefore required to define the true incidence of HIV/AIDS infection in children presenting as a surgical emergency case. These patients may benefit from early antiretroviral therapy. Surgeons are well placed to identify children who are HIV positive and should do more to ensure HIV testing and enrollment into antiretroviral treatment programs.

Brown tides and mariculture in Saldanha Bay, South Africa

In 1997, the brown tide organism, Aureococcus anophageffens, was detected for the first time in Saldanha Bay, South Africa. Its presence was limited to an isolated, tidal dam that was similarly impacted during the late summer of the following two years but not in 2000. Bloom concentrations are typically of the order of 10(-9) cells l-1. This is one of the few reported occurrences of these nuisance blooms outside the north-eastern United States. A small oyster grow-out facility based in the dam has been severely affected by the reduced growth of oysters during these blooms. Reduced flushing of this culture site is a possible explanation for bloom initiation and persistence. However, Aureococcus blooms can be considerably more extensive as was evident during 1998 when the whole of the bay system, including Langebaan Lagoon, was affected for 6-8 weeks during late summer.

Fiber-endoscopic thoracoscopy for diaphragmatic injury in children

Diagnosis of a diaphragmatic injury is important to prevent late sequelae of herniation of abdominal viscera and intestinal gangrene. A safe, simple, reliable and inexpensive method of assessing the diaphragm was devised for use in the emergency department. A standard fiberoptic upper gastrointestinal endoscope was used as a thoracoscope to visualize the diaphragm, using the thoracostomy tube incision as the portal of entry to the thoracic cavity. Two cases in which this technique was used are presented. The procedure was well tolerated and allowed for an adequate view of the diaphragm and prompt decision making.