What is the chance that asymptomatic GB stones in kids will cause problems in the future?

As I prepared to see a kiddo in the office for asymptomatic gall stones, I decided to do a quick review of the literature to see what's new.

Not surprisingly, couldn't find any good studies that looked at the outcome of this patient population.  The best paper I found was by Bogue et al, who retrospectively reviewed charts of 382 patients with GB stones and identified a group of patients who were incidentally found to have cholelithiasis (asymptomatic).  Of the 382 patients, 50% were asymptomatic.  Their mean age was 8 YO, and they had their u/s for unrelated causes, manly other abdominal pathology.

The authors reported that follow up for these asymptomatic kids was "an annual clinical and ultrasound assessment for 1 to 2 years" unless they had other pathology that necessitated longer follow up.  With this strategy, their mean follow up for this patient group was 3+/- 1.7 years.  During this follow up period, only 4.6% of the patients developed complications related to their stones (pancreatitis, choledocholithiasis, cholecystitis). Interestingly, they noted that 19% of GB stones eventually resolved, as demonstrated by follow up ultrasounds (when they were done).

So what does this mean?  Not much when it comes to counseling parents.  At best I can suggest to them that there is very little chance the stones will cause problems in the near future, but that we can not predict their behavior (or even their persistent existence) over the long run.

Reference:
Bogue C O et al.  Risk factors, complications, and outcomes of gallstones in children: a single-center review. Journal of Pediatric Gastroenterology and Nutrition (2010) 50:p303

What is the fate of abnormal looking bowel seen on prenatal ultrasound?

While reviewing the literature on prenatal imaging and their prognostic implications, I came across this relevant article by Ruiz et al from Morgan Stanley Children's Hospital.

The authors looked to study the relationship between abnormal prenatal ultrasound findings in the bowel and the presence of an actual bowel abnormality at birth.  They divided patients into two groups, those with hyperechogenic bowel and those with dilated bowel.

Of the fetuses with a finding of hyperechogenic bowel, the authors noted a 20% rate of prenatal demise.  Otherwise, only 10% of those patients were born with abnormal bowel (usually from meconium disease).  During follow up prenatal ultrasound studies, 65% of the findings resolved in that group of patients.

The group with the dilated bowel on u/s had a higher chance of having a true bowel abnormality when born.  Although the rate of prenatal demise in that group was lower (10%), fetuses with dilated loops of bowel on prenatal u/s had a 53% chance of being born with abnormal bowel (usually from intestinal atresia).  On follow up prenatal ultrasound studies, only 20% of the findings resolved in that group of patients.

This data sheds some light on the significance of bowel abnormalities found on prenatal ultrasounds, and thus helps better counsel parents on what to expect.

Reference:

Ruiz JR et al.  Neonatal outcomes associated with intestinal abnormalities diagnosed by fetal ultrasound.  Journal of Pediatric Surgery (2009) 44,71

What is the most common type of vascular rings in children?

The basic back bones of the development of the vascular system are the dorsal aortae and ventral roots, and 6 aortic arches that join the two, on the right and left.

Regression of some of the arches in central to the normal development of the vascular system.
Only the 3rd, 4th, and part of the 6th arches should persist to contribute to the carotid arteries, right subclavian/aortic arch, and the pulmonary arteries, respectively (figure).

The most common vascular ring (1% of population) results from a right subclavian artery that takes off from the arch of the aorta on the left, due to abnormal regression of the right 4th arch. The subclavian artery passes behind the esophagus.  This type of incomplete vascular ring rarely causes symptoms in children, and surgical therapy, if needed, consists of division of the vessel through a left thoracotomy.

Reference:
Pediatric Surgery.  Coran A. 7th edition

Staging ovarian masses intra op... what are we responsible for as pediatric surgeons?

Managing ovarian masses in children can be quite challenging. This is more of a decision making challenge than a technical one.

The fact that we usually have little information preop that is useful in helping to risk stratify a lesion and answer the question 'is this malignant or not' makes many of the decisions we make difficult: Laparoscopic or open resection? shall we try to save any remnant ovarian tissue or do a complete oopherectomy?...

Occasionally some intraoperative findings guide that decision, but more frequently we are faced with an ovarian mass, normal preop AFP/BHCG (whatever the diagnostic implications of those are), and no evidence of local or distant spread.

Regardless of different approaches to that scenario, one thing we are responsible to do as surgeons is clearly document intraoperative findings (including pertinent negatives) so that the information is available if the mass does turn out to be malignant.

Per COG recommendations, intraoperative documentation of the following should be made (including pertinent negatives)

1. Collection of ascites or washings on entering the peritoneum

2. Examination of peritoneal surface with biopsy of any nodules

3. Examination and palpation of retroperitoneal LN's and biopsy of firm or enlarged ones

4. Inspection and palpation of the omentum with excision of any abnormal or adherent areas

5. Inspection and palpation of the contralateral ovary and biopsy any abnormal areas

6. Complete resection of the tumor and ovary with sparing of the fallopian tubes if not involved.

Clearly, if a totally laparoscopic approach is used, palpation of the peritoneal lining and omental lesions is not possible, which makes it impossible to perform the complete staging mentioned. In some situations, however, the contralateral ovary and retroperitoneal lymph nodes may still be palpated if a small Pfannenstiel incision is used to extract the ovarian mass.

Reference:
Oltmann S et al. Pediatric ovarian malignancies: how efficacious are current staging practices? JPS(2010)45,1096-1102

Do we need to administer antibiotics before enema reduction of intussusception?

When reading the chapter on intussusception in Grosfeld's Pediatric Surgery, I noticed that the authors recommended that antibiotics be administered to patients before attempts at air enema reduction. No good explanation was given for this practice, which we do not follow where I train. Patients go for their enema reduction, and if that fails, get preoperative antibiotics at the time of surgery, just like everyone else.

 

An article the May issue of JPS attempted to answer the question of the benefit of pre-contrast enema reduction antibiotics. The authors performed a retrospective, cohort study comparing outcome of patients form two different institutions; one that routinely gives pre-reduction antibiotics and one that does not.

 

The main end-points of this study were the incidence of post-reduction fever (as a marker of bacteremia) as well as adverse reactions to antibiotic administration. The authors noted no significant difference in either, suggesting (despite the usual shortcomings of a retrospective study) that antibiotics are not necessary.

 

Although it would take a prospective randomized study to better answer this question, it does not seem to make sense to give antibiotics before enema reduction.

 

Reference: Al-Tokhais et al. Antibiotics administration before enema reduction of intussusception: is it necessary? JPS (2012);47:928

Collection of videos of pediatric surgical procedures.

Below is a collection of videos of pediatric surgical procedures. Most are from WebSurg (requires registration-free). I will update the list as I find more. Enjoy!

VATS Left lower lobectomy on an 11 month old infant for a congenital lung lesion. From WebSurg with Dr Rothenberg

VATS left upper lobectomy on a 3 year old for a congenital lung lesion.  From WebSurg with Dr Barcelo.

Lap Nissen fundoplication in 18 month old. From WebSurg with Dr Rothenberg

PSARP for recto-urethral fistula. From WebSurg with Dr Peña.

Meltzer III slip knot. Laparoscopic extracorporeal slip knot.

Lap Heller myotomy for achalasia from WebSurg with Dr MacKinlay

Lap Kasai portoenterostomy with Dr Dutta; Lucile Packard Children's Hostpial, Stanford

Lap choledocal cyst excision with Dr Hollands; LSU Health Sciences Center


Lap Duodenal atresia (and malrotation) repair with Dr Rothenberg.

VATS thoracic sympathectomy 

Left lap adrenalectomy WebSurg

Sketchnotes: VV ECMO

Sketchnotes: Differential diagnosis of mediastinal masses

Lung metastectomy in osteosarcoma: thoracotomy or VATS?

Osteosarcoma, which presents with metastatic lung disease in 15-20% of cases, is one of the few malignancies (along with non-rhabdo soft tissue sarcoma and hepatoblastoma) where resection of metastatic disease to the lung can improve survival.

Although lung metastectomy has been shown to be beneficial in this group, the optimal modality of resection, whether by open thoracotomy or VATS, is not clear. The argument for the use of an open thoracotomy in the management of lung mets has to do with the ability to palpate lesions, whereas VATS relies on imaging for detection of lung nodules. Studies have shown that a CT scan that detects a nodule(s) in the lung can miss additional palpable ones in 50% of patients, approximately half of which contain viable malignant tissue. So, in essence, VATS would likely miss additional malignant nodules, and thus leave behind otherwise palpable malignant lesions, in 25% of patients.

So it seems obvious that an open thoracotomy is the way to go, except that we don’t really know if a VATS followed by close monitoring to detect the 25% of patients with missed nodules that can be salvaged by a second VATS (and thus spare a number of kids a thoracotomy) changes the outcome in terms of long term survival when compared to primary resection of all the palpable nodules with an open thoracotomy.

Reference:
1. St Jude Oncology Review Course
2. Kayton ML et al. Computed tomographic scan of the chest underestimates
the number of metastatic lesions in osteosarcoma (2006);41:200

Why should kids with short gut syndrome be on proton pump inhibitors?

During rounds today, I noticed that someone had changed an order for a proton pump inhibitor to an H2 blocker on one of our patients with short gut syndrome. The reason was some form of shortage, so they decided it was OK to switch.

So it was time for that discussion again.

Patients with intestinal failure secondary to substantial small bowel loss need proton pump inhibitors because they are in a state of hypergastrinemia, as gastrin is primarily metabolized in the small bowel.

Elevated gastrin levels cause an increase in the volume and acidity of gastric secretions, which results in an acidic environment in the small bowel. The increase in volume worsens the fluid and electrolyte balance which is already tenuous in patients with short gut. Additionally, the acidic environment in the small bowel exacerbates malabsorption by causing bile acids to precipitate (sabotage micelle formation) and by inactivating pancreatic enzymes.

He's back on his proton pump inhibitors.

Reference:
Kocoshis SA. Medical management of pediatric intestinal failure. Seminars in Pediatric Surgery (2010);19:20

Is a bowel prep necessary before colostomy reversal?

Another paper that supports omitting bowel preps before pediatric bowel operations came out in this month’s issue of JPS. In this study, the authors conducted a retrospective, multi-institution study and compared the outcome of 272 children who underwent colostomy reversal with and without (187 vs. 85) a polyethylene glycol bowel prep.

The authors noted a significantly higher rate of wound infection (14.4% vs. 5.8%), as well as a longer hospital stay (5.6% vs. 4.4%) in the group who underwent a bowel prep. Additionally, they noted that the risk for other complications such as abdominal abscess formation (~1%) and ansastomotic leak (~1%) was the same whether a bowel prep was used or not.

Reasons given for the potential deleterious effects of the bowel prep included the characteristics of liquid stool (bowel prep) that make it more difficult to contain, the fact that the bacterial load in prep’d stool is not necessarily lower than unprepped stool (papers sited), and the potential harmful effect of the bowel prep on the integrity of the bowel mucosa.

As with all retrospective studies, the authors acknowledged the limitations of their results, but stressed that, except for intra-pelvic rectal surgery, a bowel prep is likely unnecessary for colonic surgery in children.

Reference:
Serrurier K et al. A multicenter evaluation of the role of mechanical bowel preparation in pediatric colostomy takedown. JPS (2012);47:190-193