Drainage In Children Research Articles

Efficacy of Endoscopic Ultrasound-Guided Drainage of Pancreatic Pseudocysts in a Pediatric Population

While pancreatitis is uncommon in children, pseudocyst development can be a serious complication. Endoscopic drainage of pseudocysts is well established in adults. However, there are limited data regarding this procedure in a pediatric population. The objective of this study is to determine the safety and efficacy of endoscopic ultrasound-guided pseudocyst drainage in children. The study group included children (age <18 years) who presented for endoscopic drainage of symptomatic pancreatic pseudocysts in whom endoscopic ultrasound (EUS) was performed. In those cases with EUS guidance, a 19-gauge needle was used to access the pseudocyst and place a guidewire under fluoroscopic visualization. Needle-knife diathermy and balloon dilation of the tract were performed with subsequent placement of double pig-tailed stents for drainage. Ten children with mean age of 11.8 years (range 4-17 years) were analyzed for pancreatic pseudocysts due to biliary pancreatitis (n = 4), trauma (n = 2), familial pancreatitis (n = 1), idiopathic pancreatitis (n = 2), and pancreas divisum (n = 1). In eight cases, EUS-guided puncture and stent placement was successful. In the remaining two cases, aspiration of cyst fluid until complete collapse was adequate. As experience increased with EUS examination in children, the therapeutic EUS scope alone was used in 50% of cases for the entire procedure. In all ten cases, successful transgastric endoscopic drainage of pseudocysts was achieved. Endoscopic drainage of symptomatic pancreatic pseudocysts can be achieved safely in children. EUS guidance facilitates optimal site of puncture as well as placement of transmural stents.

Unnecessary Gastric Decompression in Distal Elective Bowel Anastomoses in Children: A Randomized Study

The goal of this study was to investigate the role of nasogastric drainage in preventing postoperative complications in children with distal elective bowel anastomosis. Nasogastric drainage has been used as a routine measure after gastrointestinal surgery in children and adults to hasten bowel function, prevent postoperative complications, and shorten hospital stay. However, there has been no study that shows in a scientific manner the benefit of nasogastric drainage in children. We performed a clinical, controlled, randomized trial comprising 60 children who underwent distal elective bowel anastomoses and compared postoperative complications between a group with nasogastric tube in place (n = 29) and one without it (n = 31). Demographic data and diagnoses were comparable in both groups (P = NS). No anastomotic leaks or enterocutaneous fistulae were found in any patient. There were no significant differences between the two groups with respect to abdominal distension, infection, or hospital stay. Only one patient in the experimental group required placement of the nasogastric tube due to persistent abdominal distension (3.2%). The routine use of nasogastric drainage after distal elective intestinal surgery in children can be eliminated. Its use should depend on the individual patient's situation.

Abstract No. 310: Transrectal abscess drainage in children

To retrospectively evaluate the effectiveness and safety of transrectal(TR) drainage of deep pelvic abscess in children using a combination of ultrasound(US) and fluoroscopic guidance. Both transgluteal(TG) and TR approaches are accepted techniques but vascular complications, catheter related pain and the need for CT-guidance make the TG approach less desirable in the pediatric population.

Long-Term Results of Percutaneous Bilioenteric Anastomotic Stricture Treatment in Liver-Transplanted Children

The purpose of this study was to evaluate the mid- and long-term results of percutaneous transhepatic cholangiography (PTC) and biliary drainage in children with isolated bilioenteric anastomotic stenosis (BAS) after pediatric liver transplantation. Sixty-four children underwent PTC from March 1993 to May 2008. Nineteen cholangiograms were normal; 10 showed intrahepatic biliary stenosis and BAS, and 35 showed isolated BAS. Cadaveric grafts were used in 19 and living donor grafts in 16 patients. Four patients received a whole liver, and 31 patients received a left lobe or left lateral segment. Roux-en-Y hepaticojejunostomy was performed in all patients. Indication for PTC was based on clinical, laboratory, and histopathologic findings. In patients with isolated BAS, dilation and biliary catheter placement, with changes every 2 months, were performed. Patients were separated into 4 groups according to number of treatment sessions required. The drainage catheter was removed if cholangiogram showed no significant residual stenosis and normal biliary emptying time after a minimum of 6 months. The relationship between risk factors (recipient's weight <10 kg, previous exposure to Cytomegalovirus, donor-recipient sex and weight relations, autoimmune disease as indication for transplantion, previous Kasai's surgery, use of reduced liver grafts, chronic or acute rejection occurrence) and treatment was evaluated. Before PTC, fever was observed in 46%, biliary dilation in 23%, increased bilirubin in 57%, and increased gamma-glutamyltransferase (GGT) in 100% of patients. In the group with BAS, 24 of 35 (69%) patients had histopathologic findings of cholestasis as did 9 of 19 (47%) patients in the group with normal PTC. Of the 35 patients, 23 (65.7%) needed 1 (group I), 7 needed 2 (group II), 4 needed 3 (group III), and 1 needed 4 treatment sessions (group IV). The best results were observed after 1 treatment session, and the mean duration of catheter placement and replacement was 10 months. The primary patency rate was 61.2%, and the recurrence rate was 34.3% (group I). Seven patients (7 of 35; 20%) had their stricture treated with a second treatment session (group II). The average drainage time in group II was 24 months. During a period >20 months, 4 patients (4 of 35; 11.4%) required 1 additional treatment session (group III), and 1 patient (1 of 35; 2.9%) had a catheter placed at the end of the study period (group IV). Drainage time in group I was significantly shorter than those in groups II, III, and IV (p < 0.05). There was no statistically significant relation between therapeutic response and the selected risk factors (p > 0.05). The majority of complications, such as catheter displacement and leakage, were classified as minor; however, 2 patients (5.7%) with hemobilia were noted. Complications increased according to the need for reintervention. In conclusion, balloon dilation and percutaneous drainage placement is safe and effective, and it has long-term patency for children with BAS after liver transplantation. Because of prolonged treatment time, reintervention may be necessary, thereby increasing the complication rate. Balloon dilation and percutaneous drainage placement should be considered as the first treatment option because of its minimally invasive nature.

Trocar transrectal abscess drainage in children: a modified technique

We describe our 6-year experience with an US-guided one-step trocar technique for transrectal abscess drainage in a pediatric population. Although transrectal drainage of pelvic abscesses has been proved effective, the technique described here simplifies the procedure into a single step, minimizing potential injury to the operator and patient and eliminating potential fluoroscopic radiation while maintaining an excellent clinical success rate. Additionally, our technique obviates the need for protective techniques for sharp instrumentation while advancing the needle from the anus through the rectum into the abscess.

Comparison of the Efficacies of Antibiotic-Impregnated and Silver-Impregnated Ventricular Catheters on the Prevention of Infections

Background and Objective: Infection of the cerebrospinal fluid is a life-threatening condition which is usually treated with systemic antibiotics and continued ventricular drainage in children. The aim of this study was to analyze the antimicrobial activities of two antimicrobial-agent-impregnated ventricular catheters and to compare their efficacies on the bacterial cultures. Methods: Antibiotic-impregnated (clindamycin and rifampicin), silver-impregnated, and standard ventricular catheters were used in this study. The experiment was performed in 2 steps. In the first step, small pieces of the catheters were cut and incubated. Then, they were washed and placed in agar medium. Finally, the number of colonies was counted. In the second step, the pieces of catheters were placed on agar plates containing Staphylococcus aureus,Staphylococcus epidermidis, and Pseudomonas aeruginosa. The plates were incubated, and then, the inhibition zone for each catheter was measured. Results: An inhibition zone was observed only in the plates for antibiotic-impregnated catheters. In the other plates, no inhibition zone was detected. The number of colonies was lowest in the plate with the silver-impregnated catheter, followed by the antibiotic-impregnated and standard catheters. Conclusion: The antibiotic-impregnated catheter seems more effective for antimicrobial treatment. Although no inhibition zone was found in the plates for silver-impregnated catheters, these catheters allow the lowest bacterial colonization in agar.

Endoscopic insertion of cystostomy button for bladder drainage in children

Aim The aim of this study is to describe a safe and simple minimally invasive technique for insertion of cystostomy buttons for bladder drainage and cycling in children. Material and methods This is part of an ongoing prospective study since 2002 looking at our experience with insertion of cystostomy buttons in children. We recently published the results of the use of cystostomy buttons in 17 children inserted by an open technique reporting minor complications of urinary leakage and wound infection. We have modified our practice in the last 2 years to a percutaneous endoscopic approach. Results Twelve children (four girls, eight boys) with a mean age of 7.1 years underwent endoscopic insertion of a cystostomy button. Mean follow up was 11 months (3–24 months). There were no complications such as leakage in the endoscopically inserted buttons. Conclusions Button cystostomy is a safe and effective form of bladder drainage and gives children a less restricted quality of life. Endoscopic technique allows insertion of buttons under vision with good snug fit and no leakage.

Endoscopic insertion of Cystostomy Button for Bladder Drainage

PURPOSE Our aim is to present our experience with insertion of buttons for bladder drainage and cycling in children. MATERIAL AND METHODS This is an ongoing prospective study for over 5 years from 2002 looking at our experience with endoscopic insertion of cystostomy buttons in children. We initially performed this procedure by an open surgical approach but have now modified our practice to an percutaneous endoscopic technique. This new technique involves insertion of a cystoscope into the bladder which is then punctured with a needle under vision. A guide wire is introduced, needle removedand replaced with a peel away sheath. The outer sheath is then peeled, obturator removed and the appropriate size button device is inserted. The balloon is then inflated with 5 mls of water to allow a snug fit. The button can then be used to drain the bladder intermittently or cycle it with the extension set. RESULTS Twenty-five children (11 girls:14 boys) with a mean age of 8.6 years underwent insertion of a cystostomy button (15 open: 10 endoscopic). Mean follow up was 16 months (2–44). Indications include neuropathic bladder, prune belly syndrome, previous major bladder neck surgery, those unsuitable for mitrofanoff and bladder cycling prior to reconstruction. Complications include 1 wound infection (treated with antibiotics); four children had leakage of urine (all open approach) successfully treated with a change in button size. Twenty buttons remain in situ. Change of button is a straightforward procedure and can be performed in an outpatient setting. The endoscopic insertion allows a snug fit (no leakage with this technique) and is performed in less than 10 minutes. CONCLUSIONS Button cystostomy is a safe and effective form of bladder drainage in children. It is a good alternative to standard suprapubic drainage and it gives children a less restricted quality of life. Endoscopic insertion allows insertion of buttons under vision with good snug fit and no leakage.

Computerized Tomography Findings in Pediatric Renal Trauma—Indications for Early Intervention?

We sought to determine if initial computerized tomography findings in pediatric patients suffering blunt renal trauma with urinary extravasation were predictive of the need for operative intervention. A total of 17 patients with grade IV blunt renal trauma and urinary extravasation were identified between 2000 and 2007. Each computerized tomogram was reviewed to determine location, size and number of sites of extravasation, as well as the presence of contrast material in the ipsilateral ureter. These findings were compared with subsequent ureteral stent placement, percutaneous urinoma drainage, angiographic embolization and nephrectomy. A total of 13 male and 4 female patients (mean age 11.1 years) were identified. Eight patients (47%) required delayed intervention. Conservative treatment was unsuccessful in patients with absence of contrast material in the ipsilateral ureter and large separation of the upper and lower poles, and in 3 of 5 patients with multiple areas of extravasation and 4 of 5 patients with transfusion requirements. The diameter (9.6 vs 9.7 mm, p = 0.96) and location of extravasation were not predictive of subsequent intervention. Two of 5 patients with posterior extravasation required intervention, both for symptomatic urinoma. Early ureteral stent placement may be considered for pediatric patients with blunt renal trauma who demonstrate absence of contrast material in the ipsilateral ureter, since clinical indications for stent placement will likely develop. Further study may show if wide separation of the upper and lower poles, multiple areas of extravasation and transfusion requirement are factors in the decision for early intervention.

Abstract No. 151: Ultrasound and Fluoroscopy Guided Transrectal Pelvic Abscess Drainage in Children: 5 Year Single Center Experience

Abstract No. 151: Ultrasound and Fluoroscopy Guided Transrectal Pelvic Abscess Drainage in Children: 5 Year Single Center Experience

Abstract No. 314: Trocar Transrectal Abscess Drainage in Children: A Modified Technique

Abstract No. 314: Trocar Transrectal Abscess Drainage in Children: A Modified Technique

Inter-observer reproducibility in reporting on renal drainage in children with hydronephrosis: a large collaborative study

The goal of this study was to evaluate the inter-observer reproducibility in reporting on renal drainage obtained during (99m)Tc MAG3 renography in children, when already processed data are offered to the observers. Because web site facilities were used for communication, 57 observers from five continents participated in the study. Twenty-three renograms, including furosemide stimulation and posterect postmicturition views, covering various patterns of drainage, were submitted to the observers. Images, curves and quantitative parameters were provided. Good or almost good drainage, partial drainage and poor or no drainage were the three possible responses for each kidney. An important bias was observed among the observers, some of them more systematically reporting the drainage as being good, while others had a general tendency to consider the drainage as poor. This resulted in rather poor inter-observer reproducibility, as for more than half of the kidneys, less than 80% of the observers agreed on one of the three responses. Analysis of the individual cases identified some obvious causes of discrepancy: the absence of a clear limit between partial and good or almost good drainage, the fact of including or neglecting the effect of micturition and change of patient's position, the underestimation of drainage in the case of a flat renographic curve, and the difficulties of interpretation in the case of a small, not well functioning kidney. There is an urgent need for better standardisation in estimating the quality of drainage.

Cystostomy Button for Bladder Drainage in Children

The "button" enteral feeding systems are widely used as a gastrostomy. We describe our use of this device to facilitate bladder drainage in children. We prospectively reviewed all patients who underwent insertion of a cystostomy button between 2002 and 2005. Indications and complications were analyzed. A total of 17 children (8 female, 9 male) with a mean age of 7.1 years underwent insertion of a cystostomy button during the 4-year period. Mean followup was 16 months (range 2 to 40). Cases selected included those with a neuropathic bladder, prune belly syndrome, previous major bladder neck surgery and those unsuitable for Mitrofanoff stoma formation. Complications included 1 wound infection treated with antibiotics. Four children had leakage from the cystostomy site that was successfully treated with a change in button size, and 14 buttons remain in situ. Button cystostomy is a safe and effective form of bladder drainage in children. It is a good alternative to standard suprapubic drainage and it gives children an improved quality of life.

Endoscopic Cystostomy for Posttraumatic Pseudocyst in Children

Endoscopic Cystostomy for Posttraumatic Pseudocyst in Children

Thorax ultrasound in the management of pediatric pneumonias complicated with empyema

The aim of this work is to prospectively study the value of thoracic ultrasound (US) before pleural drainage in children with parapneumonic effusion (PPE). All children hospitalized for PPE, identified by thoracic radiography, underwent US to assess pleural loculation, echogenicity, and pleural fluid quantity. From August 2001 to July 2003, 52 children were examined. US was performed on 48 of these children, of whom 35 received chest tube drainage and 13 only received clinical treatment. US identified 38 patients with free flowing and 10 with loculated pleural fluid. About 25 of the free flowing (65.8%) and 10 (100%) of the loculated patients received chest tube drainage. Echogenicity was anechoic in 13, echoic without septations in 17 and echoic with septations in 18. Chest tube drainage was required in 6 anechoic (46.15%), 14 echoic without septations (82.35%), and 15 echoic with septations (83.33%). Quantity of fluid estimated by US varied from 20 to 860 ml. Effusion volume was higher in patients that were echoic with septations and loculated effusions. Pleural glucose and pH were lower, and LDH was higher in loculated PPE patients. In conclusion, US is an auxiliary exam for determining whether thoracic drainage is needed in parapneumonic effusion; loculated or echoic effusion should be drained, and free anechoic fluid needs further investigation.

Is retrograde stenting more reliable than antegrade stenting for pyeloplasty in infants and children?

ObjectivesTo compare antegrade and retrograde internal double-J stenting for pyeloplasty drainage in children. The success of placing the stent in position and the complications were compared in both groups. MethodsBetween October 2001 and December 2004, 42 children with unilateral pelviureteral junction obstruction underwent pyeloplasty by a single surgeon. Antegrade and retrograde double-J stenting was attempted in 17 children (mean age 1.3 years) and 25 children (mean age 1.5 years), respectively. Antegrade stenting was attempted during the pelviureteral anastomosis, and the retrograde stent was placed just before the operation by cystoscopy. Fluoroscopy was not routinely used to confirm stent placement in either group. The stents were removed 4 weeks later at cystoscopy. ResultsSuccessful stent placement without malpositioning was achieved in 14 (82%) of 17 and 24 (96%) of 25 children, respectively, in the antegrade and retrograde groups. The cause of unsuccessful stenting in both groups was the inability to cross the ureterovesical junction. The mean time taken for retrograde stenting was 9 minutes (range 6 to 15). All children with successful stent placement by either technique were discharged within 72 hours after the operation. The hospital stay for children with unsuccessful double-J stent placement varied from 7 to 10 days. No stent malpositioning occurred with retrograde stenting; 1 child in the antegrade stent group had a malpositioned stent in the distal ureter, which was retrieved at ureteroscopy. ConclusionsIn our experience, retrograde double-J stenting seems more reliable than antegrade stenting for pediatric pyeloplasty, with greater success and lower complication rates.

OVERNIGHT CATHETER DRAINAGE IN CHILDREN WITH POORLY COMPLIANT BLADDERS IMPROVES POST-OBSTRUCTIVE DIURESIS AND URINARY INCONTINENCE

Overnight catheter drainage (OCD) has been suggested as a treatment for boys with valve bladder syndrome as well as those with polyuric renal failure. We report our experience using overnight catheter drainage in children with poorly compliant bladders. Between 1999 and 2004 OCD was initiated in 6 boys and 5 girls (median age 7.5 years) with poorly compliant bladders in whom aggressive daytime intermittent catheterization and anticholinergic use had failed. Etiologies of bladder dysfunction included posterior urethral valves in 1 case, The Hinman-Allen syndrome in 4, myelomeningocele in 2, neuroblastoma in 1, prune-belly syndrome in 1, transverse myelitis in 1 and sacral agenesis in 1. The amount of post-obstructive diuresis was calculated during urodynamics as the volume drained minus volume instilled divided by weight per hour. Other parameters evaluated included serum creatinine, degree of upper tract dilatation, and episodes of urinary tract infection (UTI) and incontinence. Median duration of OCD and followup was 28 months, respectively. One patient did not tolerate overnight drainage. Of 9 patients who were incontinent before OCD daytime urinary incontinence resolved in 6 and improved in 3. Recurrent febrile UTIs in 3 children were eliminated. Despite no change in serum creatinine with overnight drainage, 7 of 8 patients (88%) with upper tract dilatation improved on followup ultrasound. In select children with poorly compliant bladders OCD reduces diuresis, reduces the frequency of UTIs, improves upper tract dilatation and improves continence. Overnight drainage in conjunction with daytime clean intermittent catheterization may prove to be an alternative to bladder augmentation in select children with poorly compliant bladders and early stages of renal compromise.

Beneficial effects of continuous overnight catheter drainage in children with polyuric renal failure: B. Montane, C. Abitbol, W. Seeherunvong, et al. Br J Urol Internal 92:447–451 (September) 2003

Continuous overnight catheter drainage (COCD) was used in 4 boys and 3 girls with progressive polyuric renal failure associated with dysfunctional bladders. All were on intermittent catheterization during the day. Five had previous surgical bladder augmentation. All had significant polyuria with a mean urine output of 2,370 mL/m2/d. The mean glomerular filtration rate at the start of COCD was 49 (SD 21) mL/min/m2, which is currently stable in 5 patients. The mean duration of COCD was 4.9 (SD 2) years. Six showed benefit for COCD with significant attenuation in the slope of renal functional decay (P = .02) and a mean prolongation of the predicted time to end-stage renal disease of 12.2 (SD 5.6) years (P < .002). Hospital admissions for febrile UTI were also decreased from a mean of 1.7 to 0.4 in the first year and eliminated by the second year.

Percutaneous imaging-guided abdominal and pelvic abscess drainage in children.

Percutaneous imaging-guided drainage is the first-line treatment for infected or symptomatic fluid collections in the abdomen and pelvis, in the absence of indications for immediate surgery. The technology and expertise needed to perform percutaneous abscess drainage are widely available and readily adapted for use in the pediatric population. Catheter insertion procedures include the trocar and Seldinger techniques. Imaging guidance for drainage is most commonly performed with ultrasonography (US), computed tomography, or US and fluoroscopy combined. Abscesses in locations that are difficult to access, such as those deep in the pelvis, subphrenic regions, or epigastric region, can be drained by using the appropriate approach-transrectal, transgluteal, intercostal, or transhepatic. Although the causes of abscesses in children differ slightly from those of abscesses in the adult population, the frequency of successful treatment with percutaneous abscess drainage in children is 85%-90%, similar to that in adults. With expertise in imaging-guided drainage techniques and the ability to adjust to the special needs of children, interventional radiologists can successfully drain most abscesses and obviate surgery. Successful adaptation of abscess drainage techniques for pediatric use requires attention to the specific needs of children with respect to sedation, dedicated resuscitation and monitoring equipment, avoidance of body heat loss, minimization of radiation doses, and greater involvement of family compared with that in adult practice.

Beneficial effects of continuous overnight catheter drainage in children with polyuric renal failure.

To determine the possible beneficial effect of providing decompression of the collecting system by continuous overnight catheter drainage (COCD) in children with progressive renal disease and dysfunctional bladder syndrome, commonly associated with polyuria which may overwhelm bladder capacity. COCD was used in seven patients (four boys) with progressive polyuric kidney failure associated with dysfunctional bladders (current age 18.7 years, SD 5; age at COCD 12 years, SD 6). Five children had surgical bladder augmentation and all were prescribed daytime intermittent catheterization (IC) for a mean (SD) of 4.7 (3.4) years before COCD. All had significant polyuria, with a mean (SD) urine output of 2370 (971) mL/m2 per day. The mean (SD) glomerular filtration rate at the start of COCD was 48 (21) mL/min/1.73 m2, which is currently stable in the five patients continuing treatment. The mean (SD) duration of COCD was 4.9 (2) years. One patient showed no improvement and had a pre-emptive transplant within 1.2 years; another was transplanted after 5.5 years. Six patients showed evidence of benefit from COCD, with significant attenuation in the slope of renal functional decay (P = 0.02) and a mean (sd) prolongation of the predicted time to end-stage renal disease of 12.2 (5.6) years (P < 0.002). Hospitalization for febrile urinary tract infections was decreased from a mean (sd) of 1.7 (1.4) to 0.4 (0.7) times (P = 0.03) in the first year of COCD and eliminated by the second year (P < 0.01). COCD of the dysfunctional bladder in patients with progressive polyuric renal failure appears to offer the potential for preserving kidney function in selected patients. It does not replace surgical bladder augmentation or daytime IC in the core management.