Surgical Management Of Children Research Articles

Role of Urinary Carbohydrate Antigen 19-9 as a Practical Biomarker for Determining Conservative or Surgical Management of Children with Ureteropelvic Junction Obstruction

Purpose Previously, we reported elevated level of urine carbohydrate antigen 19-9 (CA 19-9) in childern with ureteropelvic junction obstruction (UPJO). In present study we aimed to investigate the role of urinary CA 19-9 as a predictive biomarker to serve as a surrogate in differentiating between children with UPJO in need of pyeloplasty and those with dilated nonobstructed kidneys suitable for conservative treatment. Material and Methods The study included 36 children with UPJO treated with pyeloplasty (GI) and 24 children with dilated nonobstructed kidneys who were treated conservatively (GII). Voided urine samples were obtained for CA 19-9 measurement before treatment, and every 3 months during follow-up. Additionally, ultrasonography in three-month intervals and annual renography were performed. Follow-up ranged from 12-27 months (average 16.4 months). pyeloplasty was considered for patients with >10% loss of renal function. Results In GI preoperative CA 19-9 was significantly higher than in GII and a cutoff value of 41.06 U/ml yielded a sensitivity of 96.7% and a specificity of 93%. Compared to initial measurements, CA 19-9 decreased significantly at 3 months after pyeloplasty in GI and in the 12th month in GII with significant correlation with changes in renal pelvis diameter. In three patients due to rising CA 19-9 levels during follow-up along with decline in renal function (mean 12.8%) pyeloplasty was considered. Conclusions Urinary CA 19-9 is a non-invasive clinically applicable marker for definition of management protocol in children with UPJO. The practical clinical implications of the biomarker for long-term follow-up of children with UPJO after pyeloplasty and those receiving conservative treatment are significant.

Clinical Characteristics of Adnexal Masses in Korean Children and Adolescents: Retrospective Analysis of 409 Cases

Study Objective To analyze the clinical characteristics of young Korean female children and adolescents who underwent surgery because of adnexal masses during the last 14 years. Design Retrospective cohort study (Canadian Task Force classification II-2). Setting University hospital. Patients Three hundred ninety-six young female patients aged 20 years or younger who underwent surgery because of adnexal masses between January 1995 and March 2009. Interventions None. Measurements and Main Results For over 14 years, 396 young patients underwent 409 operations because of adnexal masses (13 patients underwent 2 separate operations). Abdominal pain (n = 184 [45.0%]) was the most common initial symptom and was more frequent in group 1 (<11 years of age; n = 26 [70.4%]) than in group 2 (11–20 years of age; n = 370; [ 43.2%]) (p <.01). In group 2, menstrual problems were the second most common initial symptom (n = 80 [20.9%]), followed by incidental detection (n = 57; [14.9%]). In patients with malignant neoplasms, the incidence of menstrual problems was lower (p <.01) and abdominal distention was more common (p <.01) than in patients with benign neoplasms. The incidence of malignant neoplasms in our study was 14.9% and was correlated with increased mass size (p <.01). Conclusion Knowing the clinical characteristics of young Korean females with adnexal masses will provide insight into the evaluation and surgical management of children and adolescents.

Mechanischer Ileus im Kindesalter – Ursachen und operative Therapiemaßnahmen

The present study examines the causes and surgical management in children who underwent surgery for a mechanical Ileus. We studied all children up to the age of 18 years who had undergone a surgical intervention for a mechanical ileus between 1.1.1996 and 31.12.2006. 89 children were included in this retrospective study. Of the total of 89 children 15 were newborn (16.9 %), 23 babies (25.8 %), 19 toddlers (21.3 %) and 32 school children (36 %) at the time of the operation. 51 of the 89 children had undergone at least one previous abdominal operation. Intraoperative findings showed the cause for the ileus to be adhesions in 56 and a bowel invagination in the remaining 11 children. Associated malformations were found in 34 children, the most frequent being malformations of the heart and gastrointestinal tract. The most frequent surgical intervention was adhesiolysis in 56 children (62.9 %), followed by the reposition of invaginated intestine in 11 (12.4 %). Bowel resection was necessary in 23 children (25.8 %). The risk for developing an ileus due to adhesions increases with the number of previous operations. Surgical intervention for an ileus aims to decompress the overstretched bowel and to restore gastrointestinal flow by removing the mechanical obstruction. One third of the children with an ileus have accompanying malformations. Children with a mechanical ileus should undergo surgery as soon as possible.

Intraoperative Electrocorticography and Cortical Stimulation in Children

Intraoperative electrocorticography has been used in the surgical management of children with medically refractory epilepsy to localize anatomic areas of focal seizure onset, guide the extent, and completeness of resective epilepsy surgery, aid in functional mapping of cortical anatomy, and predict epilepsy surgical outcome. Evidence to support its utility for these purposes is somewhat controversial, particularly in children where the literature is substantially lacking. Usefulness is often dependent on the underlying pathology, and type of resective surgery. It seems to be valuable in the following circumstances: (1) tailoring the extent of hippocampal resection during temporal lobectomies, (2) guiding resection of cortical brain malformations, low-grade tumors, and other neocortical lesions, especially those involving eloquent cortex, and (3) monitoring for afterdischarges during functional cortical mapping. Most literature on this topic is not purely pediatric, and in most circumstances, is the result of combination of both children and adults cases. Cortical stimulation has been shown to be a useful, reliable and safe technique to assess motor, sensory, and speech function in children. As compared with adults, children manifest the following: (1) they need higher Amperage thresholds to elicit responses. In children younger than 10 years, cortical stimulation identifies language cortex at a lower rate than in children older than 10 years or in adults. (2) They have variability within the same individual in the stimulation threshold depending on the cortical site. This often results in the need to maximize stimulation of currents at each cortical site regardless of adjacent afterdischarge threshold. (3) They demonstrate more difficultly to evoke motor responses particularly with certain pathologies such as retrorolandic low-grade tumors. Often also the effective current intensity decreases after lesion removal. As a consequence of the above, the pulse width used for cortical stimulation in children often varies between 0.14 and 200 ms, the frequency ranges between 20 and 50 Hz, the current intensity between 0.5 and 20 mA, and the train between 3 and 25 seconds. Cortical stimulation can identify cortex with reorganized function secondary to congenital lesions and cerebral plasticity. These lesions include brain tumors, cortical dysplasia resulting in intractable epilepsy, and cavernous angioma causing epilepsy. When compared with other presurgical tests, cortical stimulation was shown to have results consistent with those of functional magnetic resonance imaging and Wada testing. It has the disadvantage of being invasive but the advantage of being highly accurate allowing for surgical tailored resections. Although the evidence for the utility of electrocorticography and cortical stimulation is exclusively level IV evidence, it is unlikely that randomized studies are going to be performed due to practical, ethical, and other reasons. The weight of the uncontrolled data at this stage is such that in children electrocorticography remains to be a useful test in some cases of cortical resection and that cortical stimulation is usually indicated when resection in or near eloquent cortex is needed.

Empyema thoracis: Surgical management in children

Empyema thoracis can produce significant morbidity in children if inadequately treated. Correct evaluation of the stage of the disease, the clinical condition of the child and proper assessment of the response to conservative treatment is crucial in deciding the mode of further surgical intervention. This ranges from intercostal chest tube drainage and video-assisted thoracoscopic surgery to open decortication. Surgical decortication becomes mandatory in neglected cases; it gives very gratifying results ameliorating the disease rapidly and is well tolerated by young patients. This article reviews the current literature and discusses the important considerations while managing these patients. Indications for surgery are highlighted, based on our large experience at a tertiary care center.

Anatomo‐electro‐clinical correlations: the Miami Children's Hospital, USA Case Report ‐ Case 04‐2008: MRI‐negative frontal lobe epilepsy with ipsilateral akinesia and reflex activation

The pre-operative assessment and surgical management of children and young adults with MRI-negative, frontal lobe epilepsy is often challenging owing to the semiologic expression being unusual or non-lateralizing. Localization based on functional tests may be non-convergent, further compounding the difficulty of surgical planning. We describe a patient with seizures presenting with early, subjective akinesia of the dominant hand that were at times triggered by repetitive motor tasks. Subdural EEG monitoring revealed seizure-origin in the ipsilateral dorsolateral frontal lobe. After resective surgery the patient has had a seizure free period of 9 months, and is free of deficits. This is the first report of frontal lobe seizure semiology consisting of ipsilateral ictal akinesia.

ELP07 Influence of motor fMRI on the surgical management of children with symptomatic focal epilepsy

ELP07 Influence of motor fMRI on the surgical management of children with symptomatic focal epilepsy

Neuropsychological Performance in School-Aged Children with Surgically Corrected Congenital Heart Disease

As surgical management of children with congenital heart disease (CHD) advanced, developmental outcome became the main focus of contemporary research. In this study, we specify the cognitive profile of children with CHD, 6 to 12 years postoperatively. Patients with CHD (n = 43, mean age 8 years, 8 months) and healthy controls (n = 43, mean age 8 years, 11 months), were examined with an abbreviated intelligence scale (Wechsler Intelligence Scale for Children-3rd edition, Dutch version) and a developmental neuropsychological assessment battery (NEPSY [a developmental NEuroPSYchological assessment]). We identified significantly lower scores for the CHD group on Estimated Full Scale IQ (P < .01). Neuropsychological assessment revealed lower scores for the CHD group on the cognitive domains of Sensorimotor Functioning (P < .001), Language (P < .001), Attention and Executive Functioning (P < .05), and Memory (P < .05). Children with CHD displayed more impulsive test behavior than healthy peers. No differences on IQ or cognitive domains were found between the cyanotic and the acyanotic CHD group. Six to 12 years postoperatively, children with CHD display a neuropsychological profile with mainly mild motor deficits and subtle difficulties with language tasks. Attention/executive functioning and memory also appear involved but to a lesser degree. Long-term follow-up of children with surgically corrected CHD, even when hemodynamically successful, is warranted, as they are at risk for neurodevelopmental delay at school age.

A New Classification for Genital Ambiguity and Urogenital Sinus Anomalies

The surgical management of children born with genital ambiguity and urogenital sinus anomalies is difficult and at times controversial. In attempting to describe the genitalia of such a patient, paediatric urologists have focused on the degree of masculinization, the length of the urogenital sinus, and the confluence of the reproductive tract and the urinary tract. Prader’s classification has been used to describe the degree of masculinization, and others have described the urogenital confluence as being either ‘high’ or ‘low’ [1,2].

Melanoma in Children: Heightened Awareness of an Uncommon but Often Curable Malignancy

Melanoma is thought to occur rarely in children. However, a number of recent publications and our own experience clearly indicate that a profound change in the natural history of melanoma is now occurring and that melanoma, indeed, is occurring much more frequently in children and teenagers. In this issue of Pediatrics , Ferrari et al report the experience of the Instituto Nazionale Tumori (Milan, Italy) with childhood melanoma over a 25-year time span.1 The clinical presentation, treatment, and outcome for children ≤14 years old are described in this retrospective study. The authors report that among 33 patients, half had what could be considered an atypical presentation, with amelanotic or other unusual lesion, and that children <10 years old as a group had better outcomes than children from 10 to 14 years old. There is increasing evidence that the incidence of melanoma is rising in children.2,3 In our own practice at the Johns Hopkins Melanoma Center, we have observed a noticeable increase in melanoma cases among the pediatric population over the past few years, particularly in adolescents. The importance of considering the diagnosis … Address correspondence to Julie R. Lange, MD, ScM, Department of Surgery, Johns Hopkins University, 600 N Wolfe St, Carnegie 681, Baltimore, MD 21212. E-mail: jlange{at}jhmi.edu

Surgical management of pelvic sarcomas in children

Pelvic sarcomas are uncommon in childhood. Survival rates of children with pelvic sarcomas have shown significant improvements over the past few decades. Correspondingly, there has been an increase in limb-sparing surgical procedures being performed in these children. This could be attributed in part to the newer generation imaging techniques, wider armamentarium of surgical techniques of reconstruction, and limb-salvage and advances in neo-adjuvant chemotherapy and radiotherapy. Reconstruction after resection of pelvic sarcomas while preserving function of the hip and limb can be extremely challenging especially in children where there are issues of growth potential and limb-length discrepancies. This article focuses on the presentation and epidemiology of different types of pelvic sarcomas in children, the current state-of-art of imaging and surgical management of children with pelvic sarcomas.

Health technology assessment: trying to bring empirical and ethical inquiry together

A comprehensive assessment of a health technology requires that a wide variety of questions are addressed. These range from whether the use of a technology results in achievement of its intended effects (e.g., better tumour control, pain relief, improved mobility, etc.) at acceptable costs and without incurring undue risks to the patient, to whether its use may challenge existing social arrangements and values (e.g., individual responsibility for preserving good health, the value of human life, etc.). Clearly, this is a major challenge, since it requires the use of quite different methods of inquiry. In the past decades, we have rarely witnessed assessments where both types of questions were addressed in a balanced way. Rather, a wide gap exists between inquiries with a strong empirical focus and an almost complete neglect of underlying normative issues, and inquiries which are largely discursive, but with a serious disregard of relevant empirical data. The complex interplay between normative frameworks and empirical data in the assessment of health technologies is illustrated in two case studies: the assessment of surgical management of children with glue ears, and the assessment of Extra Corporeal Membrane Oxygenation in neonates.

Anxiety in adolescents with congenital heart disease: anxiety sensitivity an influential factor?

The aim of this study was to describe heart transplantation in children with congenital heart disease and to compare the results with those in children undergoing transplantation for other cardiac diseases.Reports describe decreased survival after heart transplantation in children with congenital heart disease compared with those with cardiomyopathy. However, transplantation is increasingly being considered in the surgical management of children with complex congenital heart disease. Present-day results from this group require reassessment.The diagnoses, previous operations and indications for transplantation were characterized in children with congenital heart disease. Pretransplant course, graft ischemia time, posttransplant survival and outcome (rejection frequency, infection rate, length of hospital stay) were compared with those in children undergoing transplantation for other reasons (n = 47).Thirty-seven children (mean [±SD] age 9 ± 6 years) with congenital heart disease underwent transplantation; 86% had undergone one or more previous operations. Repair of extracardiac defects at transplantation was necessary in 23 patients. Causes of death after transplantation were donor failure in two patients, surgical bleeding in two, pulmonary hemorrhage in one, infection in four, rejection in three and graft atherosclerosis in one. No difference in 1- and 5-year survival rates (70% vs. 77% and 64% vs. 65%, respectively), rejection frequency or length of hospital stay was seen between children with and without congenital heart disease. Cardiopulmonary bypass and donor ischemia time were significantly longer in patients with congenital heart disease. Serious infections were more common in children with than without congenital heart disease (13 of 37 vs. 6 of 47, respectively, p = 0.01).Despite the more complex cardiac surgery required at implantation and longer donor ischemic time, heart transplantation can be performed in children with complex congenital heart disease with success similar to that in patients with other cardiac diseases.

Surgical management of urinary incontinence in children with anatomical bladder-outlet anomalies.

Pediatric urinary incontinence secondary to anatomical anomalies of the bladder outlet is relatively rare, and there is no consensus on its surgical treatment. We reviewed the clinical courses and surgical management of children with this pathology. From 1991 to 2001, we performed bladder neck reconstruction on seven children (three boys and four girls). The mean age at the first intervention was 7 years (range 5-12 years). The underlying diagnosis was bladder exstrophy in two children, pseudoureterocele-type ectopic ureter in three, bladder neck incompetence from unknown etiology in one boy with hypospadias, and bilateral single ectopic ureter associated with cloacal malformations in one child. Lower urinary tract was evaluated through various imagings, endoscopy, and urodynamic studies. The methods used to reconstruct the bladder neck was the Young-Dees-Leadbetter procedure (performed on four children); the Kropp procedure (two children); and the Pippi-Salle procedure (one child). Bladder augmentation with intestinal segment was performed on four children; Mitrofanoff continent stoma was created in all patients. Urethral catheterization could not be routinely used in all patients, because of pain, stricture, or complicated urethral anatomy. All patients achieved urinary continence. The treatment of pediatric urinary incontinence from anatomical anomalies is technically challenging. Depending on the underlying disorders and anatomy, one needs to decide which method of reconstruction to perform. It would be safer to employ simultaneous augmentation and to create catheterizable continent stoma.

Conservative surgical treatment of pulmonary hydatid disease in children: an analysis of 35 cases.

Hydatid cyst disease is a major health problem for people who live in endemic countries such as Turkey. The definitive cure for pulmonary hydatidosis is still surgical. This study evaluates our experience of treating pulmonary hydatidosis, focusing on the conservative surgical management of children with this disease. We retrospectively analyzed 35 children ranging in age from 3 to 13 years old, treated for pulmonary hydatidosis during a recent 4-year period. The 35 patients had a collective total of 48 cysts. Twenty-seven patients had a single cyst, 7 had unilateral multiple cysts, and 1 had bilateral multiple cysts. Six patients had multiple coexisting liver cysts. The 33 pulmonary cysts were intact and uncomplicated. Of the total 48 cysts, 34 were larger than 5 cm in diameter. Fever, cough, and dyspnea were the most common symptoms and chest radiography gave a correct diagnosis in 96.4% of the patients. Conservative surgical treatment was carried out in 33 of the 35 children (94%). There were few postoperative complications, and no mortality or recurrence in this series. Parenchyma-saving surgical procedures such as cystotomy and capitonnage are the preferred methods of treatment for pulmonary hydatid disease in childhood. These simple procedures are safe, reliable, and successful. Combined medical treatment can be given but not as an alternative to surgery. Simultaneous surgical procedures for coexisting liver cysts may be preferred because of the lower morbidity rates and hospitalization. Ultrasound or computed tomography scanning should be done to detect coexisting liver cysts in every patient with pulmonary hydatid disease.

Congenital heart disease in Papua New Guinean children.

The aim of the study was to analyse critically the programme for surgical management of children in Papua New Guinea (PNG) with congenital heart disease. A hospital record-based analysis was undertaken to document the pattern, management and short-term outcome of surgery in PNG children referred with a diagnosis of congenital heart disease to the Royal Alexandra Hospital for Children in Sydney, Australia. On admission, physical examination, chest radiogram, electrocardiogram, cross-sectional echocardiogram and, in most cases, cardiac catheterization were performed. Of the 170 children referred over the 17-year period, 1978-1994, 165 were confirmed to have congenital heart disease and were included in the study. Their ages ranged from 2 months to 16 years (median 5.5) and the male to female ratio was 1:1. One-sixth had delayed milestones and one-fifth long-term wasting. A large number were tachypnoeic, in heart failure or had pulmonary hypertension on admission. Ventricular septal defect, 34%, tetralogy of Fallot, 23%, and patent ductus arteriosus, 16.4%, were the predominant defects. lesions such as aortic stenosis, coarctation of the aorta and transposition of the great arteries are under-represented. Altogether, 133 children (81%) had surgery; 75% were open- and 25% closed-heart operations. The complications were unremarkable and the mortality rate (6%) acceptable for the era. The programme was therefore very successful for a small proportion of children born in PNG with congenital heart disease.

Medical versus surgical treatment in children with severe bilateral vesicoureteric reflux and bilateral nephropathy: a randomised trial

Nephropathy associated with vesicoureteric reflux (VUR) and urinary tract infection can result in end-stage renal failure, hypertension, or both. Whether long-term VUR contributes to these outcomes is unknown. We compared, in a randomised trial, medical with surgical management of children with bilateral severe VUR and bilateral nephropathy. We stratified by age and glomerular filtration rate (GFR) 25 boys and 27 girls aged 1-12 years and randomly assigned them to medical or surgical management. At enrolment and 4 years' follow-up we estimated GFR from the plasma clearance of 51Cr-labelled edetic acid (EDTA), and did intravenous urography. We also did a metastable 99mTc-labelled dimercaptosuccinic acid (DMSA) assay and contrast cystography. The change in GFR at 4 years, expressed as a percentage change between enrolment and 4 years, was available for 26 of 27 patients in the medical and 24 of 25 in the surgical group. We assessed GFR in 48 patients 10 years after enrolment. Mean GFR at enrolment was 72.4 mL/min per 1.73 m(2) (SD 24.1) in the medical and 71.7 mL/min per 1.73 m(2) (22.6) in the surgical group. The mean percentage change in GFR at 4 years was 2.4% (SE 4.5) versus 4.7% (5.0) in the medical and surgical groups, respectively. The difference in change in GFR at 4 years between the two groups was not significant (7.1%, 95% CI 6.4% to 20.6%). Our data do not lend support to the view that the outcome for renal function is improved by surgical correction of VUR in children with bilateral disease.

The pediatric challenge of heart surgery

Advances in the surgical management of children, in particular neonates with complex and previously lethal congenital heart disease has led to a dramatic improvement in survival. Nevertheless, complex heart surgery is sometimes associated with significant multi-organ disorders. These may originate from an adverse pre-operative condition, from post-operative circulatory failure and from the adverse effects of long-term intensive supportive therapy. Therefore, each neonate with a congenital heart defect must have a thorough workup for associated or genetically determined defects. Metabolic disturbances must be corrected before surgery as far as possible. After surgical correction, organ failure is almost exclusively the result of circulatory failure. Cardiac tamponade, also tamponade without pericardial fluid but by swelling of the heart within the pericardium and closed thorax, must be considered. If circulatory instability persists in spite of adequate heart rate and rhythm, optimized pre- and afterload and optimal myocardial support, the patient must be scrutinized for residual heart defects and surgical reintervention may be strongly indicated. Respiratory failure may be a sign of heart failure. Renal support therapy may facilitate fluid management and may be a lifesaving bridge to total or partial recovery of renal function, provided heart failure is overcome. However, there is no evidence for routine renal replacement therapy to prevent postsurgical multi-organ failure. Children with congenital heart defects can be treated appropriately only within a multidisciplinary team in which pediatric intensivists, heart surgeons, cardioanaesthesiologists, and pediatric cardiologists can rely on a high standard of care from other pediatric disciplines.

Medical or surgical management for children with vesico-ureteric reflux?

Medical or surgical management for children with vesico-ureteric reflux?

Medical or surgical management for children with vesico‐ureteric reflux?

A critical survey of the literature on treatment of children with vesico-ureteric reflux was carried out in order to create a basis for the new Swedish management policy. There are few studies that meet modern standards of scientific methodology and provide adequate patient numbers. The only large investigations that randomized patients to operative or non-operative treatment were the Birmingham Reflux Study and the International Reflux Study in Children. In these studies, long-term outcome of renal status and renal function, as well as the number of recurrent infections, were independent of treatment modality. Although pyelonephritic recurrences were less common in the surgically managed group, this did not influence appearance of renal damage. There is no evidence to indicate clear superiority of either medical or surgical management. Further studies are needed to address such questions as the optimal duration of antibacterial prophylaxis and the effect of a dilating reflux that persists into adulthood.