Pediatric Surgical Service Research Articles

An easy technique for long-term central venous catheterization and subcutaneous tunneling of the silastic catheter in neonates and infants

Venous access is a common problem in the care of seriously ill infants and neonates on pediatric and pediatric surgical services, and recently there has been a high increase in indications for central venous lines. With the development of many types of silastic catheters, a new safe and fast method of catheter insertion, subcutaneous tunneling and fixation has been developed. Our method is based on Yoffa's (1965)1 description. In the past we used infraclavicular subclavian venipuncture,2 but now we prefer to use the supraclavicular subclavian venipuncture as the first choice in children. Thirty-one catheters were placed in 27 consecutive patients ranging in age from two days to ten years. Perioperative complications were nil, and those catheterized for a long period of time had relatively few complications.

The Surgical Neonate: Evaluation and Care

The Surgical Neonate , by Filston and Izant, is the second edition of a soft-cover text written specifically for the pediatric and general surgery house officer rotating through the Pediatric Surgical Service. Divided into the sections General of the Neonate, Recognition of Major Newborn Congenital Anomalies, and Management Outline of Common Pediatric Surgical Problems, the book is planned to enable the house officer to recognize the major congenital anomalies and manage affected patients. The initial section is heavily oriented toward parenteral fluid and electrolyte management and the methods for supporting intravenous therapy. The case examples and the practical guidelines used, particularly the Quadrant Scheme for estimating third-space losses, have an immediate practical application in writing the postoperative orders. The discussion of total parenteral nutrition could be strengthened by using similar case examples demonstrating the interrelationship of fluid volume, electrolytes, and caloric requirements. An emphasis on peripheral parenteral nutrition vs centrally

Diagnosis and management of congenital cystic disease of the lung in children

Pulmonary sequestration, congenital adenomatoid malformation (CAM), congenital lobar overinflation (CLO), and bronchogenic cysts are four congenital lesions that may present as abnormal cystic areas within the pleural cavity in early life. They share similar clinical and embryologic characteristics, are frequently difficult to diagnose, and all require surgical treatment. From December 1974 to January 1985, 22 patients were operated upon on the Pediatric Surgical Service for congenital cystic disease of the lung. There were eight females and 14 males, ranging in age from 1 day to 18 years; 12 were under 6 months of age, and 14 were under one year. There were 7 CAMs, 5 extralobar pulmonary sequestrations, 5 intralobar pulmonary sequestrations, 3 bronchogenic cysts, and 3 cystic lobes caused by CLO. One patient had bilateral pulmonary sequestrations, intralobar on one side and extralobar on the other, with both sharing a common systemic artery arising from the infradiaphragmatic aorta. All except two asymptomatic patients presented with either progressive respiratory distress or recurrent pulmonary infections, and had cystic changes noted on chest roentgenograms. The differentiation of these congenital lesions from resolvable inflammatory cysts is important. Diagnosis was aided by selective utilization of barium contrast studies, ultrasonography, computed tomography, and arteriography. Operation consisted of resection alone of the extralobar pulmonary sequestrations and bronchogenic cysts, and total lobectomy in CAM, intralobar sequestration, and CLO. One infant with CAM died 1 day postoperatively from bilateral hypoplastic lungs. The other 21 patients are alive and well with follow-up ranging from 1 month to 9 years, with a mean of 3.5 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Who should pay for resident education?

House staff stipends and other costs related to maintaining a residency are listed on hospital budgets as "education." This has become a tempting target for hospital administrators and third-party payors, who ask, "Should the patient pay for medical education?" We have studied the workload of house officers on a typical pediatric surgical service in a children's hospital. General surgical residents spend 56.3 hours per week in patient care. This does not count "lag" time or "on call" time, but work that someone else--either a physician, technician, or nurse practitioner would do if there was no residency. This study, as well as others, clearly indicates that residents provide an enormous amount of patient care. It is perfectly justified to include the costs of house officers in the hospital budget.

Stab wounds in children

The Pediatric Surgical Service of Harlem Hospital Center admitted 75 children, 16-years-old and younger, with stab wounds since 1969. Rapid resuscitation and triage of children with major injuries directly to the operating room achieved 100% survival. Review of the circumstance of injury revealed that 75% of the stab wounds were inflicted by children and 66% were known to have been intentional. Social service and psychiatric intervention for troubled children and their families is essential and may decrease the risk of subsequent traumatic injury.

Ten years' experience with pediatric gunshot wounds

Gunshot wounds in children have become a significant source of morbidity and mortality in our community in the last 10 yr. One hundred eight children, 16 yr of age and younger, were admitted to the Pediatric Surgical Service for gunshot wounds during this period; only 1 child was admitted for a gunshot wound in the 10 yr preceding this review. Rapid resuscitation and triage of major injuries directly to the operating room achieved a 94% survival. Review of the circumstances of injury revealed that 42% of the gunshot wounds were inflicted by children and 40% were known to have been intentional. Only 20% of the patients had known drug involvement; in general this was involvement in drug selling, not in drug abuse. Social service intervention can offer significant benefit to these children, but ultimately gun control laws with strict enforcement are needed to stop this type of violence toward children.

Anorectal anomalies--international classification.

80 patients with anorectal anomalies were admitted to the Paediatric Surgical Service of the National Hospital of Norway during the five year period 1970--74. The anomalies were classified according to the International Classification which was found to be of obvious value in comparing material and results. Intermediate and high deformities were generally treated with an initial colostomy and a subsequent sacroperineal pullthrough operation. The low anomalies were generally treated with an anoplasty in two procedures. Patients with poor functional results and incontinence can be improved with free muscle transplantation.

Familial Asplenia, Other Malformations, and Sudden Death

Two families have been presented. In one, asplenia occurred with and without gastrointestinal malformations. In the other, cardiovascular malformations occurred in one member and Ivemark syndrome in the other. All three children with asplenia died in infancy, two with evidence of sepsis. Sudden death in infancy may be due to sepsis in a child with isolated asplenia syndrome and impaired resistance to infection. Both isolated asplenia and some cases of congenital heart disease without asplenia may be related to Ivemark syndrome. New infants born in families with a history of congenital cardiovascular malformations, visceral heterotaxy, or other malformations associated with Ivemark syndrome should be tested for asplenia, primarily by searching for Howell-Jolly bodies. Infans with asplenia should be protected with prophylactic antibiotics. Pneumococcal polysaccharide vaccine is indicated at the age of 2 years. It would appear worthwhile for pediatric surgical or pediatric cardiologic services to perform a screening program for Howell-Jolly bodies.

The role of the physician's assistant in a university-based pediatric surgical service

Physician's Assistants (P.A.), recent additions to the health profession, have proved valuable as "extenders" for primary physicians in relatively remote rural areas. More specialized surgical assistants have been trained for the community-practicing surgeon. The introduction of physician's assistants into university centers has been proceeding at a slower pace. A need has existed for an accurate assessment of the role of the P.A. in a residency-training program. In subspecialties, such as pediatric surgery and thoracic surgery, an increasing patient load has usually required a corresponding increase in junior resident staff. This resident coverage is usually dependent upon the availability of general surgical house staff since pediatric surgical trainees are currently fixed in number. Foreign medical graduates are no longer available in large numbers and general surgical programs themselves are being reevaluated and the number of trainees decreased. In this setting physician's assistants can be used to augment patient coverage by acting as junior surgical residents.

Consultation on a pediatric surgical ward: creating an empathic climate.

Meaningful consultation to a pediatric surgical service must occur within an emotional climate that supports the consultative process. This paper examines the intangible qualities inherent in such a milieu and the consultant's role in structuring an atmosphere in which one's consultative skills can be utilized effectively.

Intraoperative nursing care of pediatric patients

Gayle Gatch, R N , is head nurse, major surgery, Shands Teaching Hospital, University of Florida, Gainesville. A n associate degree graduate from Daytona Beach Community College, Flu, she is also charge nurse o f pediatric surgery. The author acknowledges the assistance of Shirley Graves, MD, department of anesthesia, and Bradley Rodgers, MD, and James Talbert, MD, department of pediatric surgery, from the University of Florida. Pediatric surgery is a specialty in itself. An infant or child is not a small adult, and one must realize that a child has special requirements and priorities unique to a patient of his size and development level. Often, operating room personnel feel apprehensive when caring for an infant or small child. This review of intraoperative nursing care of the pediatric patient may help alleviate some of those fears. At Shands Teaching Hospital, Gainesville, Fla, the pediatric surgical service is a general surgery service for pediatric patients from birth through age 18. Several areas are important in providing quality nursing care for a pediatric patient in surgery including transportation patient communication position of the patient monitoring of vital signs temperature control blood and fluid loss and replacement preparation for emergencies. Considerations in these areas will vary directly with the size, developmental level, and clinical status of the pediatric patient. In preparing for a pediatric surgical procedure, the OR nurse should know enough about the patient to be able to apply these special considerations. Let us look at these areas in sequence during a surgical case of a patient from birth through 4 to 5 years. As soon as the patient arrives in the operating room, he becomes the responsibility of the nurse in the OR. Transferring a pediatric patient from the Isolette, crib, or bed to the OR table takes special consideration. The transfer should be smooth and carefully executed making sure that all restraints, tubing, and monitors are freed from the Isolette or crib and are supported and guarded. Also, extreme

Operative correction of pectus excavatum: an evolving perspective.

From 1949 to 1975, 220 children have undergone surgical reconstruction of pectus excavatum using a variety of operations on our Pediatric Surgical Service. The first 183 were previously reported and have had subsequent, careful followup evaluation. From 1970 to 1975, an identifiable group of 45 children had a standard operation, a modified Ravitch repair, with the addition of a three-point or tripod internal fixation technique for support of the sternum. These children have all obtained satisfactory reconstruction without prosthetic support of any kind. We have thus avoided the possible danger of foreign material within the chest and have obviated the need for another procedure to remove a supporting stent. The two groups have been analyzed and compared with respect to age distribution, postoperative complications and end results to see if we could detect any trends in the evolving management of children with this condition. The main indications for surgical correction remain cosmetic and postural. Specific trends which have emerged from our experience include an increased percentage of patients between 3 and 8 years of age (average 5.8 years); a decreased need for blood transfusion (10%); a near resolution of postoperative seromas with the use of substernal and subcutaneous suction drains; and in the last 45 children, a 100% excellent or acceptable result to date. We feel that age selection is an important factor in the improved operative result and in the emotional impact on these young patients. Eighty per cent of the children in the recent series were between 3 and 8 years of age at the time of repair. On the basis of this experience, we now feel confident in recommending our standardized operation for pectus excavatum at an elective age of 4 to 6 years.

Duodenal Atresia and Gastric Perforation

Sir .—Playing priority game is always a little risky in clinical medicine. They who claim in print to be first to describe a syndrome, cure a rare disease, or perform a particular will, unless they have done their homework well, find themselves victims of gleeful challenges in theletters to editorcolumn. Takebayashi et al 1 assert that their patient with duodenal atresia and gastric perforation is the second cured by operation, after Ogawa's report 2 of the first successful operation in 1966. When I was Chief Surgical Resident on Pediatric Surgical Service of Thomas V. Santulli, MD, at New York's Babies Hospital in 1962, I had opportunity to repair a gastric perforation and to bypass a duodenal atresia with annular pancreas in a premature female infant. Although Takebayashi et al cite article in which this case was described, 3 they may

Pediatric Surgery

MANY changes have occurred in the field of pediatric surgery since it was reviewed 20 years ago in the Journal,1 not only in the methods of treating certain diseases, but also in the development of pediatric surgery as a specialty. In 1955 Potts2 noted that there were then only eight pediatric surgical services in America. Today, most medical schools and major teaching hospitals include a division or department of pediatric surgery. In contrast, a department of pediatric surgery existed at the University of Prague 86 years ago.3 Parallel developments include formation of Sections of Surgery and Urology in the . . .

Childhood sacrococcygeal epidermoid cyst

<h3>To the Editor.—</h3> A defect during the complex embryological development of the sacrococcygeal area may give rise to a wide variety of lesions. The lesions presenting in the pediatric age group include benign and malignant teratomas, duplication cysts, anterior myelomeningoceles, neurogenic tumors, and, rarely, chordomas.¹Sacrococcygeal epidermoid cysts have been reported mainly in the female adult and are uncommonly encountered in pediatric practice.^2,3A 4-year-old male child with a precoccygeal epidermoid cyst is the subject of this case report. <h3>Report of a Case.—</h3> A 4-year-old Negro boy was admitted on Feb 16, 1969. to the pediatric surgical service of the Jefferson Medical College Hospital because of a posterior rectal mass. Six days before, during evaluation for nausea, vomiting, and abdominal pain, the mass was palpateld on rectal examination. The child's symptoms regressed spontaneously after 24 hours, and he remained asymptomatic until admission. A history of intermittent constipation since

Childhood Sacrococcygeal Epidermoid Cyst

To the Editor.— A defect during the complex embryological development of the sacrococcygeal area may give rise to a wide variety of lesions. The lesions presenting in the pediatric age group include benign and malignant teratomas, duplication cysts, anterior myelomeningoceles, neurogenic tumors, and, rarely, chordomas. 1 Sacrococcygeal epidermoid cysts have been reported mainly in the female adult and are uncommonly encountered in pediatric practice. 2,3 A 4-year-old male child with a precoccygeal epidermoid cyst is the subject of this case report. Report of a Case.— A 4-year-old Negro boy was admitted on Feb 16, 1969. to the pediatric surgical service of the Jefferson Medical College Hospital because of a posterior rectal mass. Six days before, during evaluation for nausea, vomiting, and abdominal pain, the mass was palpateld on rectal examination. The child's symptoms regressed spontaneously after 24 hours, and he remained asymptomatic until admission. A history of intermittent constipation since

RETROPHARYNGEAL ABSCESS SECONDARY TO THYROGLOSSAL CYST.

THE CERVICAL midline position of a thyroglossal cyst or duct is accepted as the rule. 3 Rare exceptions have been reported, however, where thyroglossal cysts were found either in a slightly lateral position or in the base of the tongue. 1,2 Airway obstruction or dysphagia is usually found in the lingual thyroglossal cysts only. The presence of a retropharyngeal abscess leading to acute respiratory distress and dysphagia, secondary to an infected lateral thyroglossal cyst in an infant, appeared unique to us and we have been unable to find another case report in the literature. Report of a Case A 2-week-old Negro girl was admitted to the Pediatric Surgical Service with the chief complaint of acute respiratory distress and dysphagia. The child was the product of a full-term pregnancy with normal delivery. When the infant was 1 week of age, the mother noticed a mass in the left anterior neck and

The Surgery of Infancy and Childhood: Its Principles and Techniques.

"The Surgery of Infancy and Childhood," by Robert E. Gross, should be read and studied by all pediatricians, general practitioners, and surgeons. The essentials in embryology, etiology, and clinical findings in this age group are most interestingly presented, with many diagrams, x-ray reproductions, and photographs of patients and pathological specimens, so that each subject is superbly presented. Methods of treatment are well discussed, and the tremendous clinical experiences are well edited and tabulated so as to indicate clearly to the reader the preferred methods of treatment. The descriptions and illustrations of surgical techniques used are unexcelled. There are 64 chapters, delving into practically all surgical problems of the premature infant, the infant, and the child (neurosurgery, orthopedic, and ear, nose, and throat surgery excluded). The chapter concerning preoperative and postoperative care should be a stimulus and guide to all pediatric surgical services. The common surgical problems of childhood are not

The Surgery of Infancy and Childhood: Its Principles and Techniques

"The Surgery of Infancy and Childhood," by Robert E. Gross, should be read and studied by all pediatricians, general practitioners, and surgeons. The essentials in embryology, etiology, and clinical findings in this age group are most interestingly presented, with many diagrams, x-ray reproductions, and photographs of patients and pathological specimens, so that each subject is superbly presented. Methods of treatment are well discussed, and the tremendous clinical experiences are well edited and tabulated so as to indicate clearly to the reader the preferred methods of treatment. The descriptions and illustrations of surgical techniques used are unexcelled. There are 64 chapters, delving into practically all surgical problems of the premature infant, the infant, and the child (neurosurgery, orthopedic, and ear, nose, and throat surgery excluded). The chapter concerning preoperative and postoperative care should be a stimulus and guide to all pediatric surgical services. The common surgical problems of childhood are not