VOLUME 23, 2004


Volume 23 No 01 JULY 2004


It is estimated that more than 1.5 million bites occur yearly in the United States. Most of them within the home setting in children younger than five years of age. When managing bites in children three general concepts must be observed: 1) Determine if the attacking animal has injected venom into its victim. For this to occur the history must provide the exact identification of the animal and type of venom. Once identified an specific antivenom can be utilized. 2) All bites wounds are considered contaminated wounds. This includes rabies and tetanus. Prophylaxis in either case should be provided. Furthermore the bite can produce significant tissue loss and destruction. Initial management should include thorough mechanical cleansing and debridement along with systemic antibiotics. 3) An assessment should be made of the long-term outlook for both disfigurement and loss of function of the wound. Wounds of the face do fairly better with primary closure no matter the inciting initial agent. Significant loss of tissue might need conservative management followed by reconstruction when adequate granulation tissue appears. Ischemic extremity from compartment syndrome might need fasciotomy. Fortunately we don't see snake bites in Puerto Rico. Few cases of spider bites has been reported. Dog bites (pit bull) are the most common bite seen in the emergency room affecting the extremity or face of young infants. Cat bites or scratch can produce a febrile condition associated with lymphadenopathy. Human bites carries the risk of HIV and hepatitis infestation.

1- Wagner CW: Chapter 97 - Animal Assaults: Bites and Stings, In Ziegler, Azizkhan and Weber "Operative Pediatric Surgery" Mc Graw Hill Co., 2003, pags. 1153-1158
2- Calkins CM, Bensard DD, Partrick DA, Karrer FM: Life-threatening dog attacks: a devastating combination of penetrating and blunt injuries. J Pediatr Surg 36(8):1115-7, 2001
3- Mcheik JN, Vergnes P, Bondonny JM: Treatment of facial dog bite injuries in children: a retrospective study. J Pediatr Surg 35(4):580-3, 2000
4- Lopoo JB, Bealer JF, Mantor PC, Tuggle DW: Treating the snakebitten child in North America: a study of pit viper bites. J Pediatr Surg 33(11):1593-5, 1998
5- Tuggle DW, Taylor DV, Stevens RJ: Dog bites in children. J Pediatr Surg 28(7):912-4, 1993

Ovarian Torsion

Ovarian torsion is a true surgical emergency mostly affecting woman during their first three decades of life. Ovarian torsion results from partial or complete twisting of the ovarian pedicle on its axis causing vascular compromise, congestion and hemorrhagic infarction. Clinically, most children present with an abrupt onset of low abdominal pain, low-grade fever, nausea and vomiting sometimes mimicking symptoms of acute appendicitis. Mean age is 12 years. Symptoms may be recurrent. Pain is localized toward the affected ovary. Most ovarian torsions are associated with a concomitant ovarian cystic or solid  mass. Neonates with ovarian torsion are usually diagnosed during prenatal ultrasound studies when a cystic mass is identified. Ultrasound is the imaging study of choice. An enlarged solid ovarian mass with peripheral cysts noted at US suggests the diagnosis of torsion and should be followed by diagnostic laparoscopy or exploration. A prepubertal child will have a complex mass. CT Scan demonstrates a heterogenous, retrovesical mass. Color Doppler US sometimes confirms the absence of ovarian blood flow. Management is established at exploration. Removal of a mass carrying a twisted ovary is standard therapy. Untwisting of  torsed adnexa and observation in case of absence of a mass (normal ovaries) are accepted modes of treatment. Most common encountered morbidity is postoperative fever. Contralateral oophoropexy in cases of torsion of a normal adnexum is advice.

1- Meyer JS, Harmon CM, Harty MP, Markowitz RI, Hubbard AM, Bellah RD: Ovarian torsion: clinical and imaging presentation in children. J Pediatr Surg 30(10):1433-6, 1995
2- Steyaert H, Meynol F, Valla JS: Torsion of the adnexa in children: the value of laparoscopy. Pediatr Surg Int 13(5-6):384-7, 1998
3- Eckler K, Laufer MR, Perlman SE: Conservative management of bilateral asynchronous adnexal torsion with necrosis in a prepubescent girl. J Pediatr Surg 35(8):1248-51, 2000
4- Templeman C, Hertweck SP, Fallat ME: The clinical course of unresected ovarian torsion. J Pediatr Surg 35(9):1385-7, 2000
5- Kokoska ER, Keller MS, Weber TR: Acute ovarian torsion in children. Am J Surg 180(6):462-5, 2000
6- Ozcan C, Celik A, Ozok G, Erdener A, Balik E: Adnexal torsion in children may have a catastrophic sequel: asynchronous bilateral torsion. J Pediatr Surg 37(11):1617-20, 2002

Vascular Rings

A vascular ring is a rare congenital anomaly of the arterial branchial arch system which can encircle and compress the trachea a/o esophagus. Most vascular rings results from a lack of regression of the eighth segment of the right dorsal aortic root. Vascular rings are classified as either complete or partial. The most common complete vascular ring is double aortic arch, while the most common partial vascular ring is right aortic arch with aberrant left subclavian artery (overall most common vascular ring). Symptoms from the vascular ring occur during the first six months of life. These include inspiratory stridor, expiratory wheezing, recurrent cough, recurrent respiratory infections and pneumonia. Compressive esophageal symptoms like choking and regurgitation occurs later in life of affected children. Diagnosis is suggested in the initial chest film. Esophagogram is diagnostic showing the classic esophageal indentation of the ring. MRI angiography describes the lesion. Repair of the vascular ring is indicated in children with either esophageal or tracheal symptoms of compression. Basic surgical procedure includes exposure through a left thoracotomy, complete identification of the anomaly and division of the constricting ring. The surgical risk is minimal and the long-term results are excellent.

1- Chun K, Colombani PM, Dudgeon DL, Haller JA Jr.: Diagnosis and management of congenital vascular rings: a 22-year experience. Ann Thorac Surg 53(4):597-602, 1992
2- van Son JA, Julsrud PR, Hagler DJ, Sim EK, Pairolero PC, Puga FJ, Schaff HV, Danielson GK: Surgical treatment of vascular rings: the Mayo Clinic experience. Mayo Clin Proc 68(11):1056-63, 1993
3- Roberts CS, Othersen HB Jr, Sade RM, Smith CD 3rd, Tagge EP, Crawford FA Jr.: Tracheoesophageal compression from aortic arch anomalies: analysis of 30 operatively treated children. J Pediatr Surg 29(2):334-7, 1994
4- Kocis KC, Midgley FM, Ruckman RN: Aortic arch complex anomalies: 20-year experience with symptoms, diagnosis, associated cardiac defects, and surgical repair. Pediatr Cardiol 18(2):127-32, 1997
5- Woods RK, Sharp RJ, Holcomb GW 3rd, Snyder CL, Lofland GK, Ashcraft KW, Holder TM: Vascular anomalies and tracheoesophageal compression: a single institution's 25-year experience. Ann Thorac Surg 72(2):434-8, 2001

Volume 23 No 02 AUGUST 2004

Peptic Ulcer Disease

With the advent of more powerful acid inhibiting drugs (H2 antagonists) and proton pump inhibitors, surgery for refractory peptic ulcer disease (PUD) is becoming something of the past. We now manage rare complications of PUD such as bleeding, perforation and obstruction. PUD is either primary or secondary in origin. Secondary PUD are more common and primarily seen in infants the result of an associated condition such as prematurity, steroids, burns, trauma, immune deficiency and brain tumors. Primary PUD occurs more commonly in older children and adolescents the result of an imbalance between acid secretion and gastric mucosal protection. Helicobacter pylori infestation plays a crucial role in the genesis of gastritis and primary duodenal ulcer formation. Successful management of PUD disease encompasses radication of Helicobacter infection. Initial management of PUD includes medication to reduce acid production (omeprazole, ranitidine, cimetidine) combined with agents that improve mucosal defense (sucralfate). Bleeding PUD manifests itself with either melena or hematochezia. The bleeding site must be visualized during upper endoscopy. Most cases will stop with prompt medical management or endoscopic diathermy. Beyond  50% blood volume loss in a short period of time (8-24 hours) is an indication for surgery.  Infants benefit from duodenotomy and bleeding ulcer ligation, while older children will need more definite ulcer surgery (vagotomy and pyloroplasty). Perforated PUD is the manifestation of a coexisting illness. Simple surgical closure with an omental patch is sufficient. Obstruction produces chronic vomiting due to pyloric scarring.

1- Kumar D, Spitz L: Peptic ulceration in children. Surg Gynecol Obstet 159(1):63-6, 1984
2- Drumm B, Rhoads JM, Stringer DA, Sherman PM, Ellis LE, Durie PR: Peptic ulcer disease in children: etiology, clinical findings, and clinical course. Pediatrics 82(3 Pt 2):410-4, 1988
3- Tsang TM, Saing H, Yeung CK: Peptic ulcer in children. J Pediatr Surg 25(7):744-8, 1990
4- George DE, Glassman M: Peptic ulcer disease in children. Gastrointest Endosc Clin N Am 4(1):23-37, 1994
5- Lazzaroni M, Petrillo M, Tornaghi R, Massironi E, Sainaghi M, Principi N, Porro  GB: Upper GI bleeding in healthy full-term infants: a case-control study. Am J Gastroenterol 97(1):89-94, 2002

Paraesophageal Hernias

Paraesophageal hernia (PEH), a rare entity in children, occurs when the stomach protrudes laterally through the esophageal hiatus toward the chest while the gastro-esophageal junction stays in anatomic position. Though most cases remain asymptomatic, PEH can cause upper bowel obstruction, gastroesophageal reflux, gastric volvulus, bleeding and perforation. Most PEH in children are acquired resulting after fundoplication. A small group of children are born with the PEH. Groups of patients with a higher incidence of developing PEH after fundoplication includes infants under the age of one, neurologic impaired children and surgical patients where a crural repair is not done after fundoplication. PEH is linked to gagging before an antireflux procedure in children. Diagnosis of PEH is confirmed during a barium swallow and upper gastrointestinal series. A small PEH can be managed non-operatively if the child is asymptomatic. With the presence of symptoms or enlargement of the hernia operative repair must be done. A transabdominal approach is preferred for reducing the stomach and crural repair of the diaphragm. The use of mesh hiatal reinforcement is recommended for patients undergoing reoperation for PEH and recurrent gastroesophageal reflux or if the diaphragmatic crura is thought to require reinforcement at the time of the original surgery.

1- Alrabeeah A, Giacomantonio M, Gillis DA: Paraesophageal hernia after Nissen fundoplication: a real complication in pediatric patients. J Pediatr Surg 23(8):766-8, 1988
2- Yadav K, Myers NA: Paraesophageal hernia in the neonatal period - another differential diagnosis of esophageal atresia. Pediatr Surg Int 12(5-6):420-1, 1997
3- Avansino JR, Lorenz ML, Hendrickson M, Jolley SG: Characterization and management of paraesophageal hernias in children after antireflux operation. J Pediatr Surg 34(11):1610-4, 1999
4- Lambert AW, Huddart SN: Mesh hiatal reinforcement in Nissen fundoplication. Pediatr Surg Int  17(5-6):491-2, 2001
5- Yazici M, Karaca I, Etensel B, Temir G, Gunsar C, Guclu C, Mutaf O: Paraesophageal hiatal hernias in children. Dis Esophagus 16(3):210-3, 2003


Excessive scarring is deposition of collagen out of the range of normal after surgery. Two types of excessive scarring seen in children and adults are hypertrophic scars and keloids. Hypertrophic scars are slight elevation of the scar restricted to the boundaries of the original wound, regress with time and rarely cause functional impairment. Hypertrophic scars rarely need to be removed. Keloids extend beyond the borders of the original wound, cause functional impairment, contain mast cells that release histamine and produce pruritus. Familial cases have been seen. Keloids do not regress over time and recur after surgical excision. Keloids contain large thick collagen fibers composed of numerous fibrils closely packed together. In contrast hypertrophic scars exhibit modular structures in which fibroblastic cells, small vessels, and fine, randomly organized collagen fibers are present. Earlobe piercing is the main etiological factor of earlobe keloids. Keloids removal is indicated in cases of functional impairment of a joint or for cosmetic reasons. Excision with intraoperative local injection of triamcinolone or alpha-2b interferon has produce some therapeutic advantage in severe cases. Early single postoperative fraction radiotherapy claims effectiveness in reducing keloid recurrences.

1- Ehrlich HP, Desmouliere A, Diegelmann RF, Cohen IK, Compton CC, Garner WL, Kapanci Y, Gabbiani G: Morphological and immunochemical differences between keloid and hypertrophic scar. Am J Pathol 145(1):105-13, 1994
2- Berman B, Flores F: Recurrence rates of excised keloids treated with postoperative triamcinolone
acetonide injections or interferon alfa-2b injections. J Am Acad Dermatol 37(5 Pt 1):755-7, 1997
3- Chowdri NA, Masarat M, Mattoo A, Darzi MA: Keloids and hypertrophic scars: results with intraoperative and serial postoperative corticosteroid injection therapy. Aust N Z J Surg 69(9):655-9, 1999
4- Marneros AG, Norris JE, Olsen BR, Reichenberger E: Clinical genetics of familial keloids. Arch Dermatol 137(11):1429-34, 2001
5- Ragoowansi R, Cornes PG, Moss AL, Glees JP: Treatment of keloids by surgical excision and immediate postoperative single-fraction radiotherapy. Plast Reconstr Surg 111(6):1853-9, 2003

Volume 23 No 03 SEPTEMBER 2004

Periappendiceal Mass

In the event of right lower abdominal pain caused by appendicitis, almost 15% of children will present with a right lower quadrant mass effect. The mass can be a phlegmon with a central inflamed appendix which appears after four to five days from the onset of abdominal pain accounting for 50% of appendiceal masses. Almost 20% of these masses will contain a frank abscess cavity. Periappendiceal masses are the result of perforated appendicitis. Due to the increase use of abdominal CT in the setting of abdominal pain more cases of periappendiceal phlegmon/abscess are discovered with this diagnostic modality. CT is reliable in distinguishing periappendiceal abscesses from phegmons and its use can be extended into percutaneously draining the abscess cavity. US with color Doppler demonstrates a hyperemic periappendiceal or pelvic fluid collection and periappendiceal soft-tissue hyperemia. Management of a periappendiceal abscess depends on the clinical condition of the child. Nontoxic patient with mild peritoneal signs warrants non-operative management with intravenous fluids and antibiotics until the acute process subsides. Rising heart rate, continued spiking fever, worsening peritoneal signs, intestinal obstruction or enlargement of the mass may require urgent surgery. Patients undergoing initial nonoperative management have a lower rate of complications. Six to eight weeks after resolution of the inflammatory process interval appendectomy is recommended to avoid recurrent abdominal pain. Laparoscopic appendectomy can be performed safely and effectively in such interval cases.

1- Barakos JA, Jeffrey RB Jr, Federle MP, Wing VW, Laing FC, Hightower DR: CT in the management of periappendiceal abscess. AJR Am J Roentgenol 146(6):1161-4, 1986
2- Karp MP, Caldarola VA, Cooney DR, Allen JE, Jewett TC Jr: The avoidable excesses in the management of perforated appendicitis in children. J Pediatr Surg 21(6):506-10, 1986
3- Vargas HI, Averbook A, Stamos MJ: Appendiceal mass: conservative therapy followed by interval laparoscopic appendectomy. Am Surg 60(10):753-8, 1994
4- Quillin SP, Siegel MJ: Diagnosis of appendiceal abscess in children with acute appendicitis: value of color Doppler sonography. AJR Am J Roentgenol 164(5):1251-4, 1995
5- Oliak D, Yamini D, Udani VM, Lewis RJ, Arnell T, Vargas H, Stamos MJ: Initial nonoperative management for periappendiceal abscess. Dis Colon Rectum 44(7):936-41, 2001
6- Samuel M, Hosie G, Holmes K: Prospective evaluation of nonsurgical versus surgical management of appendiceal mass. J Pediatr Surg 37(6):882-6, 2002


Postoperative adhesions are the main cause of acute and chronic mechanical bowel obstruction in children and adults. Adhesive small bowel obstruction (SBO) presents with bilious vomiting, abdominal distension, colicky abdominal pain and obstipation. Simple abdominal films demonstrate distended bowel loops with air-fluid levels. More than 80% of SBO develops within two years of the prior operations. Appendectomy and subtotal colectomy are the most common prior operations. The risk of developing an adhesive SBO is greater when there is more than one prior peritoneal procedure, and when there is established peritonitis. Initial therapy includes nasogastric decompression, hydration and serial abdominal examination. Most cases of adhesive SBO that will resolve, do so within 48 hours of admission. Failed conservative therapy or worsening abdominal signs warrant surgery. Signs heralding bowel strangulation includes spiking fever, pinpoint abdominal tenderness and leukocytosis. Delaying lysis of adhesion and entering the GI tract during surgery is associated with increased morbidity. Use of Gastrografin meal in adhesive small bowel obstruction is safe and reduces the need for surgery when conservative treatment fails

1- Janik JS, Ein SH, Filler RM, Shandling B, Simpson JS, Stephens CA: An assessment of the surgical treatment of adhesive small bowel obstruction in infants and children. J Pediatr Surg 16(3):225-35, 1981
2- Festen C: Postoperative small bowel obstruction in infants and children. Ann Surg 196(5):580-3, 1982
3- Akgur FM, Tanyel FC, Buyukpamukcu N, Hicsonmez A: Adhesive small bowel obstruction in children: the place and predictors of success for conservative treatment. J Pediatr Surg 26(1):37-41, 1991
4- van der Zee DC, Bax NM: Management of adhesive bowel obstruction in children is changed by laparoscopy. Surg Endosc 13(9):925-7, 1999
5- Choi HK, Chu KW, Law WL: Therapeutic value of gastrografin in adhesive small bowel obstruction after unsuccessful conservative treatment: a prospective randomized trial. Ann Surg 236(1):1-6, 2002

Retractile Testis

Retractile testes are very common in school age boys. A retractile testis is a testis that has completed the normal descent but is not in its normal scrotal position due to a hyperactive cremasteric reflex. The reflex pertains to the genitofemoral nerve at L1-L2 level. Retractile testes can be manually placed in the scrotum, but the reflex triggered by fear, cold,  stimulation of the upper inner aspect of the thigh, or anxiety causes the testis to ascend. This reflex is blunted by testosterone during puberty. On the contrary, true undescended testis cannot be brought manually to the scrotum. Mean average spermatogonial number and Sertoli cell index are significantly reduced in undescended testes. Human chorionic gonadotropin can assist in the diagnosis of retractile testes by stimulating descend in most cases. Children with retractile testes does not need immediate surgery (orchidopexy),  appear to be at highest risk for acquired cryptorchidism and should be followed yearly to detect changes in testicular volume which should prompt orchidopexy. Most children with retractile testes have spontaneous descent after puberty.

1- Bingol-Kologlu M, Demirci M, Buyukpamukcu N, Tanyel FC: Cremasteric reflexes of boys with descended, retractile, or undescended testes: an electrophysiological evaluation. J Pediatr Surg 34(3):430-4, 1999
2- Han SW, Lee T, Kim JH, Choi SK, Cho NH, Han JY: Pathological difference between retractile and cryptorchid testes. J Urol 162(3 Pt 1):878-80, 1999
3- Rusnack SL, Wu HY, Huff DS, Snyder HM 3rd, Zderic SA, Carr MC, Canning DA: The ascending testis and the testis undescended since birth share the same histopathology. J Urol 168(6):2590-1, 2002
4- Miller OF, Stock JA, Cilento BG, McAleer IM, Kaplan GW: Prospective evaluation of human chorionic gonadotropin in the differentiation of undescended testes from retractile testes. J Urol  169(6):2328-31, 2003
5- La Scala GC, Ein SH: Retractile Testis: An outcome analysis on 150 patients. J Pediatr Surg 39(7): 1014-1017, 2004

Volume 23 No 04 OCTOBER 2004

Ventriculo-Peritoneal Shunt Cysts

Ventriculo-peritoneal shunts (VP shunts) placement is standard form of therapy for children with communicating hydrocephalus and infants with non-communicating hydrocephalus. The proximal end of the system is inserted into a CSF reservoir, most commonly the lateral ventricle. The proximal catheter is connected to a valve that serves to regulate flow through the system. The valve is connected to the distal catheter which is inserted into a cavity which will serve as receptacle for the CSF such as the peritoneum, pleural cavity, central venous system or gallbladder. Complications of VP shunts needing revision consist of shunt malfunction (occlusion of the proximal catheter by debris of choroid plexus, glial or ependymal tissue), shunt infection, and intraabdominal pseudocysts formation. Abdominal pseudocysts are loculated pockets filled with unabsorbed CSF fluid. Chronic inflammation, low grade subclinical infection, multiple surgical procedures and elevated CSF protein causes the peritoneal mesothelial serous membrane to thickened reducing the absorbing power. Though most cases are asymptomatic showing no shunt malfunction, children with abdominal pseudocysts may present with raised intracranial pressure or symptoms such as abdominal pain, distension, vomiting, fever or anorexia. One-third are associated with an incipient infection. Diagnosis is established with Ultrasound or CT Scan. Treatment of the pseudocyst involves removing the peritoneal catheter with relocation to an absorbing peritoneal surface or atrium.

1- Briggs JR, Hendry GM, Minns RA: Abdominal ultrasound in the diagnosis of cerebrospinal fluid pseudocysts complicating ventriculoperitoneal shunts. Arch Dis Child 59(7):661-4, 1984
2- Hahn YS, Engelhard H, McLone DG: Abdominal CSF pseudocyst. Clinical features and surgical management. Pediatr Neurosci 12(2):75-9, 1985-86
3- Besson R, Hladky JP, Dhellemmes P, Debeugny P: Peritoneal pseudocyst--ventriculo-peritoneal shunt complications. Eur J Pediatr Surg 5(4):195-7, 1995
4- Roitberg BZ, Tomita T, McLone DG: Abdominal cerebrospinal fluid pseudocyst: A complication of ventriculoperitoneal shunt in children. Pediatr Neurosurg 29(5):267-73, 1998
5- Anderson CM, Sorrells DL, Kerby JD: Intra-abdominal pseudocysts as a complication of ventriculoperitoneal shunts: a case report and review of the literature. Curr Surg 60(3):338-40, 2003


Choledochocele is an extremely rare variant of choledochal cysts classified as type III by Alonso-Lej. The cystic dilatation occurs in the distal portion of the common bile duct most commonly in an intrapancreatic fashion protruding toward the duodenum. Patients with choledochocele can develop intermittent colic abdominal pain, obstructive jaundice and recurrent bouts of pancreatitis. Nearly half of the patients have previously undergone cholecystectomy. Diagnosis is suggested by ultrasonography and confirmed with HIDA scan, MRCP or ERCP. In the most common variety the ampulla opens into the choledochocele which in turns communicates with the duodenum via another small opening. Cyst distension explains the episodes of colicky pain. Adenocarcinoma has been reported arising from choledochocele, though some researchers believe choledochocele does not share the strong premalignant potential of the more common types of choledochal cysts. The mucosa lining of choledochocele is usually duodenal, arguing that the cyst is a duodenal duplication. Successful endoscopic management (papillotomy) of choledochocele has been reported when the lesion is small. Surgical management entails excision of the duodenal luminal portion of the cyst leaving the medial portion containing the ampulla intact. Prognosis after surgery is good.

1- Greene FL, Brown JJ, Rubinstein P, Anderson MC: Choledochocele and recurrent pancreatitis. Diagnosis and surgical management. Am J Surg 149(2):306-9, 1985
2- Ghazi A, Slone E: Endoscopic management of choledochocele. A case report and review of the English literature. Surg Endosc 1(3):151-4, 1987
3- Sarris GE, Tsang D: Choledochocele: case report, literature review, and a proposed classification. Surgery 105(3):408-14, 1989
4- Weisser M, Bennek J, Hormann D: Choledochocele--a rare cause of necrotizing pancreatitis in childhood. Eur J Pediatr Surg 10(4):258-64, 2000
5- Rabie ME, Al-Humayed SM, Hosni MH, Katwah RA, Dewan M: Choledochocele: the disputed origin. Int Surg 87(4):221-5, 2002

Perianal Abscess

Perianal abscess is a not so rare condition seen almost exclusively in infants less than two years of age. Most cases are seen in males infants. The infant presents with a history of increasing irritability, fever, erythema and induration of the perianal skin. In a period of 48 to 72 hours the area becomes fluctuant. Oral antibiotics are ineffective in controlling the infectious process. It is theorized that a perianal abscess arises from a developmental anomaly in the deep crypts of Morgagni which trap bacterias initiating a cryptitis that proceed to a perianal abscess. This abscess may open or not to become later a fistula in ano. Gut derived organisms are isolated from most cases of perianal abscess. Most abscess are located laterally equally divided between right and left. Perianal abscesses in children are best treated by incision, drainage and systemic antibiotics. A proportion of patients with perianal abscess later develop a fistula in ano. This fact has led some researchers to propose that primary treatment of perianal abscess in childhood involve a careful search for a coexisting fistula and treatment of this by fistulotomy. Long term recurrence is very rare. Recurrence should prompt a search for associated disorders such as Crohn's, immunodeficiency and autoimmune neutropenia.

1- Shafer AD, McGlone TP, Flanagan RA: Abnormal crypts of Morgagni: the cause of perianal abscess and fistula-in-ano. J Pediatr Surg 22(3):203-4, 1987
2- Piazza DJ, Radhakrishnan J: Perianal abscess and fistula-in-ano in children. Dis Colon Rectum 33(12):1014-6, 1990
3- Abercrombie JF, George BD: Perianal abscess in children. Ann R Coll Surg Engl 74(6):385-6, 1992
4- Festen C, van Harten H: Perianal abscess and fistula-in-ano in infants. J Pediatr Surg 33(5):711-3, 1998
5- Murthi GV, Okoye BO, Spicer RD, Cusick EL, Noblett HR: Perianal abscess in childhood. Pediatr Surg Int 18(8):689-91, 2002
6- Lejkowski M, Maheshwari A, Calhoun DA, Christensen RD, Skoda-Smith S, Dabrow S: Persistent perianal abscess in early infancy as a presentation of autoimmune neutropenia. J Perinatol 23(5):428-30, 2003

Volume 23 No 05 NOVEMBER 2004

Infantile Cholelithiasis

The finding of gallstones in neonates and infants is no longer rare. With the widespread use of abdominal sonography in a growing population of prematures TPN-fed survivals more cases of cholelithiasis in infants are reported. Stone formation increases with the duration of TPN. Other lithogenic factors are prolonged fasting, ileal resection, cystic fibrosis, polycythemia, multiple blood transfusions and inflammatory bowel disease. Approximately 80% of gallstones in children are not due to hemolytic disease. Clinically, the symptomatic infant with gallstone can develop colicky abdominal pain, postprandial nausea/vomiting, fatty-food intolerance and failure to thrive. Severe complications are seen in almost one-third of the infants with gallstones including jaundice by common bile duct obstruction, pancreatitis and perforation with bile peritonitis. Surgery is the treatment of choice for infants presenting with symptomatic cholelithiasis. Resolution of gallstones is seen in most asymptomatic infants between six months and one year of oral intake justifying a period of observation. Ursodeoxycholic acid is not effective in the treatment of pigmented stones. Laparoscopic cholecystectomy is recommended for the asymptomatic child younger than three years of age when echogenic shadows have been present for at least 12 months following resumption of oral feedings or when the gallstones are radiopaque (calcified).

1- Schirmer WJ, Grisoni ER, Gauderer MW: The spectrum of cholelithiasis in the first year of life. J Pediatr Surg 24(10):1064-7, 1989
2- Holcomb GW Jr, Holcomb GW 3rd: Cholelithiasis in infants, children, and adolescents. Pediatr Rev 11(9):268-74, 1990
3- Rescorla FJ, Grosfeld JL: Cholecystitis and cholelithiasis in children. Semin Pediatr Surg 1(2):98-106, 1992
4- St-Vil D, Yazbeck S, Luks FI, Hancock BJ, Filiatrault D, Youssef S: Cholelithiasis in newborns and infants. J Pediatr Surg 27(10):1305-7, 1992
5- Debray D, Pariente D, Gauthier F, Myara A, Bernard O: Cholelithiasis in infancy: a study of 40 cases. J Pediatr 122(3):385-91, 1993
6- Asabe K, Handa N: Infant cholelithiasis: report of a case. Surg Today 27(1):71-5, 1997
7- Gertner M, Farmer DL: Laparoscopic cholecystectomy in a 16-day-old infant with chronic cholelithiasis. J Pediatr Surg 39(1):E17-9, 2004

Chronic Pancreatitis

Chronic pancreatitis is an unusual condition seen in children. In contrast to adults, chronic pancreatitis have significant lifelong morbidity. Most common etiology of chronic pancreatitis in children consists of trauma, cystic fibrosis, hyperparathyroidism, hyperlipidemia, aminoaciduria, hereditary, congenital ductal anomalies and choledochal cyst. Main symptoms are recurrent abdominal (epigastric) pain associated with nausea and vomiting.  A transient elevation of amylase and lipase is associated with the pain. Once the diagnosis of chronic pancreatitis is suspected, the anatomy of the pancreatic duct should be defined using ERCP or MRCP (less invasive). In chronic pancreatitis, the pancreatic duct is frequently dilated with one or more obstructive lesions. Ongoing attacks of pancreatitis may lead to diabetes, steatorrhea and pancreatic stones. Early endoscopic sphincterotomy can slow the progressive nature of the disease and has been suggested as initial choice of  treatment.  With continued symptoms, lateral pancreaticojejunostomy (Puestow procedure) in dilated and obstructed ductal anatomy has been found to decrease significantly the pancreatitis episodes, relieve the recurring abdominal pain and arrest the progression of exocrine and endocrine insufficiency. Recently, the Frey procedure adding pancreatic head coring to the pancreaticojejunostomy has provided pain relieve in more than 85% of children with chronic pancreatitis.

1- Crombleholme TM, deLorimier AA, Way LW, Adzick NS, Longaker MT, Harrison MR: The modified Puestow procedure for chronic relapsing pancreatitis in children. J Pediatr Surg 25(7):749-54, 1990
2- Festen C, Severijnen R, vd Staak F, Rieu P: Chronic relapsing pancreatitis in childhood. J Pediatr Surg 26(2):182-3, 1991
3- Moir CR, Konzen KM, Perrault J: Surgical therapy and long-term follow-up of childhood hereditary pancreatitis. J Pediatr Surg 27(3):282-6, 1992
4- Perrelli L, Nanni L, Costamagna G, Mutignani M: Endoscopic treatment of chronic idiopathic pancreatitis in children. J Pediatr Surg 31(10):1396-400, 1996
5- Rios GA, Adams DB, Yeoh KG, Tarnasky PR, Cunningham JT, Hawes RH: Outcome of lateral pancreaticojejunostomy in the management of chronic pancreatitis with nondilated pancreatic ducts. J Gastrointest Surg 2(3):223-9, 1998
6- Weber TR, Keller MS: Operative management of chronic pancreatitis in children. Arch Surg 136(5):550-4, 2001
7- Rollins MD, Meyers RL: Frey procedure for surgical management of chronic pancreatitis in children. J Pediatr Surg 39(6): 817-820, 2004

EXIT Procedure
Large fetal neck masses can cause airway obstructions with potential fetal mortality after delivery. The EXIT procedure refers to EX-utero Intrapartum Treatment, a technique for safety managing airway obstruction at birth in which placental support is maintained until the airways is evaluated, surgically corrected and secure. The technique leaves an intact feto-placental circulation and guarantees a normal fetal oxygenation while fetal airway patency is secured. The EXIT procedure is indicated for infants diagnosed by prenatal ultrasonography and born with airway obstruction caused by laryngotracheal atresia and  head and neck masses including hemangiomas, teratomas, goiter, epignathus and lymphangiomas. These are tumors with a high mortality rate if airway control is not obtained before clamping the umbilical cord. During the EXIT procedure the infant can undergo bronchoscopy, tracheostomy or resection of the neck mass. For success a team approach consisting of a pediatric surgeon, obstetrician, anesthesiologist, operating room staff and neonatologist is warranted. Since the procedure depends on a cesarean section, mothers experience more postpartum wound complications and blood loss. Maternal outcome is good overall.

1- DeCou JM, Jones DC, Jacobs HD, Touloukian RJ: Successful ex utero intrapartum treatment (EXIT) procedure for congenital high airway obstruction syndrome (CHAOS) owing to laryngeal atresia. J Pediatr Surg 33(10):1563-5, 1998
2- Bui TH, Grunewald C, Frenckner B, Kuylenstierna R, Dahlgren G, Edner A, Granstrom L, Sellden H: Successful EXIT (ex utero intrapartum treatment) procedure in a fetus diagnosed prenatally with congenital high-airway obstruction syndrome due to laryngeal atresia. Eur J Pediatr Surg 10(5):328-33, 2000
3- Stevens GH, Schoot BC, Smets MJ, Kremer B, Manni JJ, Gavilanes AW, Wilmink JT, van Heurn LW, Hasaart TH: The ex utero intrapartum treatment (EXIT) procedure in fetal neck masses: a case
report and review of the literature. Eur J Obstet Gynecol Reprod Biol 100(2):246-50, 2002
4- Noah MM, Norton ME, Sandberg P, Esakoff T, Farrell J, Albanese CT: Short-term maternal outcomes that are associated with the EXIT procedure, as compared with cesarean delivery. Am J Obstet Gynecol 186(4):773-7, 2002
5- Hirose S, Sydorak RM, Tsao K, Cauldwell CB, Newman KD, Mychaliska GB, Albanese CT, Lee H, Farmer DL: Spectrum of intrapartum management strategies for giant fetal cervical teratoma. J Pediatr Surg 38(3):446-50, 2003
6- Hirose S, Farmer DL, Lee H, Nobuhara KK, Harrison MR: The ex utero intrapartum treatment procedure: Looking back at the EXIT. J Pediatr Surg 39(3):375-80, 2004

Volume 23 No 06 DECEMBER 2004

Ambulatory Laparoscopy

With the massive use of minimal invasive surgical procedures in children the next step in research design is deriving which procedure can be conveniently do on an ambulatory basis (meaning leaving the hospital a few hours after surgery), and which needs overnight hospitalization. Non-randomized studies in children have proved a safe benefit and low costs in performing diagnostic laparoscopy for non-palpable undescended testis, intersexual problems and contralateral inguinal hernia. Likewise, therapeutical laparoscopic procedures done ambulatory include cholecystectomy, interval and simple appendectomy, ovarian, omental and hepatic cysts, placement of dialysis catheter and PEG assisted procedures. Contraindication for ambulatory laparoscopy in children includes prematurity, cardio-respiratory and neurologic (cerebral palsy) conditions, labile coagulopathy, long distance from medical care facilities, procedures longer than two hours and poor social/educated conditions. Postoperative pain control is the Achilles tendon of ambulatory surgery. Several elements associated with reduced postoperative pain includes: use of low carbon dioxide intra abdominal pressure, low insufflation rate, local anesthesia infiltration at the start of the operation, warming carbon dioxide, use of humidified gas at body temperature, evacuate all intraperitoneal gas and a short laparoscopic procedure. After surgery narcotic analgesia is needed.  During and after the laparoscopic procedure any child who has significant oozing, conversion to open, excessive adhesions, vomiting, or pain should stay overnight for clinical observation.

1- Llorente J: Laparoscopic cholecystectomy in the ambulatory surgery setting. J Laparoendosc Surg 2(1):23-6, 1992
2- Sanfilippo JS, Lobe TE: Laparoscopic surgery in girls and female adolescents. Semin Pediatr Surg 7(1):62-72, 1998
3- Lobe TE: Laparoscopic surgery in children. Curr Probl Surg 35(10):859-948, 1998
4- Campanelli G, Cavagnoli R, Cioffi U, De Simone M, Fabbiani M, Pietri P: Can laparoscopic cholecystectomy be a day surgery procedure? Hepatogastroenterology 45(23):1422-9, 1998
5- Smith M 2nd, Wheeler W, Ulmer MB: Comparison of outpatient laparoscopic cholecystectomy in a private nonteaching hospital versus a private teaching community hospital. JSLS 1(1):51-3, 1997
6- Mouton WG, Bessell JR, Otten KT, Maddern GJ: Pain after laparoscopy. Surg Endosc 13: 445-448, 1999
7- Arnbjornsson E, Larsson LT, Lindhagen: Complications of laparoscopy-aided gastrostomies in pediatric practice. J Pediatr Surg 34(12):1843-6 , 1999


Neurilemmomas, also known as Schwannomas, are peripheral nerve tumors originating from neuronal sheath cells (Schwann cells). Most neurilemmomas occur later in life, generally after the age of  forty years. Most neurilemmomas are benign tumors. The few malignant cases are characterized by rapid tumor growth. Clinical picture depends on the anatomic site and size of origin. Have been reported to occur anywhere in the body with most cases originating in the head and neck region. Neurilemmomas in the cervical region arise from the cranial nerves with the vagus nerve or its branches being the most commonly affected. Other site for neurilemmomas reported in children includes the brachial plexus, cervical nerve roots, cervical sympathetic chain and small peripheral nerves of the hand. Bilateral vestibular schwannomas are associated with Neurofibromatosis type II. Imaging studies (US and CT-Scan) shows a solid encapsulated tumor. Delay in diagnosis and treatment is very common due to the slow growing nature of the tumor. Management consists of surgical removal whenever vital structures permit. Malignant variants receive chemo and radiotherapy.

1- Rice DH, Coulthard SW: Neurogenic tumors of the head and neck in children. Ann Plast Surg 2(5):441-4, 1979
2- Ahmed A, Morley A, Wilson JA: Extracranial neurilemmoma: a case report and review of the literature. J R Coll Surg Edinb 45(3):192-4, 2000
3- Oguzkurt P, Kayaselcuk F, Arda IS, Barutcu O, Tuncer I, Oz S: Anterior abdominal wall malignant peripheral nerve sheath tumor in an infant. J Pediatr Surg 36(12):1866-8, 2001
4- Nunes F, MacCollin M: Neurofibromatosis 2 in the pediatric population. J Child Neurol 18(10):718-24, 2003
5- Baglaj M, Markowska-Woyciechowska A, Sawicz-Birkowska K, Dorobisz U: Primary neurilemmoma of the thyroid gland in a 12-year-old girl.  J Pediatr Surg 39(9):1418-20, 2004


A felon is defined as a painful fusiform abscess (swelling) in the distal fat pad of the phalanx with increased tenderness over the flexor aspect and erythema (redness and cellulitis) distributed uniformly along the entire flexor aspect of the pulp space. Felon is very different from a paronychia. Paronychia is a more localized painful swelling on the extensor aspect of the distal digit located at the proximal extent of the sulcus. Initial management consists of antibiotics, warm soaks and elevation of the affected extremity. If the child does not improve rapidly with medical treatment, surgical incision and drainage are indicated to avoid involvement of the bony distal phalanx due to rapid extension of the infections process through synovial-lined spaces. Felons are managed with digital anesthetic block and incision along the ulnar aspect of the digit to produce drainage of the closed space infection. The incision is made along the ulnar aspect of the phalanx to avoid the possibility of a painful scar on the radial side of the phalanx which is the pinching side of the distal phalanx.  Cultures are routinely taken during surgery. Staphylococcus aureus is a common offending organism. Penrose drain for 48 hours is recommended.

1- Kilgore ES Jr, Brown LG, Newmeyer WL, Graham WP 3rd, Davis TS: Treatment of felons. Am J Surg 130(2):194-8, 1975
2- Lewis RC Jr.: Infections of the hand. Emerg Med Clin North Am 3(2):263-74, 1985
3- Shmerling RH: Finger pain. Prim Care 15(4):751-66, 1988
4- Connolly B, Johnstone F, Gerlinger T, Puttler E: Methicillin-resistant Staphylococcus aureus in a finger felon. J Hand Surg 25(1):173-5, 2000
5- Clark DC: Common acute hand infections. Am Fam Physician 68(11):2167-76, 2003

Journal Club