VOLUME 42, 2014

PSU Volume 42 No 01 JANUARY 2014

Wilms in HSK

Wilms tumor (WT) is regarded as the most common malignant renal tumor in children. Several anomalies/syndromes are associated with WT, this includes: aniridia, hemihypertrophy, cryptorchidism, hypospadia, ectopia, duplication and horseshoe kidney (HSK). HSK is a common renal anomaly where the right and left kidneys are fused. HSK has a tendency toward neoplasia such as hypernephroma and WT. WT develops in HSK as a result of sequestered metanephric blastemas in the isthmus, which is known to harbor malignant potential. Most cases present with an asymptomatic abdominal mass. Almost in one-third of children with WT and HSK the diagnosis is not made preoperatively. Salient features in diagnosis using CT-Scan of WT in HSK  include malrotation of the kidney, hydronephrosis, and the presence of an isthmus.  HSK are normally situated lower than normal kidneys and have an anomalous blood supply with 4-6 renal arteries supplying the HSK. The blood supply to the isthmus may come from the renal artery, aorta WT in HSK is usually managed as WT in a solitary kidney and benefits from preoperative chemotherapy since a more planned and conservative procedure can be performed later, the surgical morbidity associated with tumor spillage and incomplete resection is reduced and more renal function is preserved. CT-reconstructed angiography is helpful in planning the final excision and mapping the blood supply in WT arising from HSK. During resection if the tumor involves one kidney in HSK the functional isthmus has to be resected along with the tumor to avoid a urinary fistula. If the tumor arises from the isthmus, isthmusectomy with bilateral lower pole nephrectomy is needed. Annual surveillance of children with HSK looking for WT development is not recommended. Estimated four-year survival of WT in HSK is above 80%.  

1- Lee SH, Bae MH, Choi SH, et al: Wilm's Tumor in a Horseshoe Kidney. Korean J Urol 53: 577-580, 2012
2- Yeluri SV, Duttaroy DD, Ghodgaonkar P, Karanth S: Wilm's Tumor arising in a horseshoe kidney. Indian J Med Science. 58(2): 72-73, 2004
3- Huang EY, Mascarenhas L, Mahour GH: Wilms' tumor and horseshoe kidneys: a case report and review of the literature. J Pediatr Surg. 39(2):207-12, 2004
4- Neville H, Ritchey ML, Shamberger RC, Haase G, Perlman S, Yoshioka T: The occurrence of Wilms tumor in horseshoe kidneys: a report from the National Wilms Tumor Study Group (NWTSG). J Pediatr Surg. 37(8):1134-7, 2002
5- Campaini C, Kubheka KR: Nephroblastoma in horseshoe kidney. Cent Afr J Med. 48(7-8):92-4, 2002
6- Talpallikar MC, Sawant V, Hirugade S, Borwankar SS, Sanghani H: Wilms' tumor arising in a horseshoe kidney. Pediatr Surg Int. 17(5-6):465-6 , 2001
7- Kapur VK, Sakalkale RP, Samuel KV, Meisheri IV, Bhagwat AD, Ramprasad A, Waingankar VS: Association of extrarenal Wilms' tumor with a horseshoe kidney. J Pediatr Surg. 33(6):935-7, 1998

Epididymal Cysts

Epididymal cysts (EC) are benign lesions diagnosed during evaluation of scrotal symptoms of pain, fullness or palpable scrotal masses in children and adolescents. The etiology of epididymal cysts is probably a congenital anomaly related to hormonal disorders during embryonic life, the result of maternal exposure to diethylstilbestrol or part of the testicular dysgenesis syndrome. An association of epididymal cysts with cryptorchidism, cystic fibrosis and von Hippel-Lindau disease has also been reported. Average age of appearance of EC in children is ten to fifteen years. Physical examination is very important, but not sufficient for the diagnosis and must be completed by scrotal ultrasonography, which shows an echo-free cystic epididymal structure. Associated findings in children with EC include hydrocele, varicocele and testicular microlithiasis. An association of EC with increased testicular size is also observed. EC occurs anywhere within the epididymis and does not contain sperm. Cyst size and symptoms play a role in deciding the choice of management. Some workers suggest conservative management for cyst smaller than 10 mm, while surgery should be reserved for cysts larger than 10 mm in diameter, but this fact dose not take into account the symptoms of the child. Conservative management of asymptomatic EC with serial ultrasound follow-up is  recommended since most EC involutes with time. Children with intractable scrotal pain or cyst enlargement should undergo surgery. Surgical management consists of cyst excision through a scrotal approach.

1-  Jelloul L, Billerey C, Ait Ali Slimane M, Mboyo A, Aubert D: [Epididymal cysts in adolescents]. Ann Urol (Paris). 33(2):104-8, 1999
2- Homayoon K, Suhre CD, Steinhardt GF: Epididymal cysts in children: natural history. J Urol. 171(3):1274-6, 2004
3- Chillon Sempere FS, Dominguez Hinarejos C, Serrano Durba A, Estornell Moragues F,
Martinez-Verduch M, Garcia Ibarra F: [Epididymal cysts in childhood]. Arch Esp Urol. 58(4):325-8, 2005
4- Posey ZQ, Ahn HJ, Junewick J, Chen JJ, Steinhardt GF: Rate and associations of epididymal cysts on pediatric scrotal ultrasound. J Urol. 184(4 Suppl):1739-42, 2010
5- Niedzielski J, Miodek M, Krakas M: Epididymal cysts in childhood - conservative or surgical approach? Pol Przegl Chir. 84(8):406-10, 2012
6- Erikci V, Hosgor M, Aksoy N, Okur O, Yildiz M, Dursun A, Demircan Y, Ornek Y, Genisol I: Management of epididymal cysts in childhood.  J Pediatr Surg. 48(10):2153-6, 2013

Genitofemoral Nerve Injury

The genitofemoral nerve (GFN) arises from the L1 and L2 nerve roots. The genital branches of the GFN consist of both motor and sensory fibers Motor fibers to the cremasteric muscle provide thermoregulation for the testes where sensory fibers supply a portion of the scrotal skin and upper thigh. The genital branch of the GFN passes through the abdominal inguinal ring and descends behind the spermatic cord to the scrotum. The femoral branch of the GFN is located caudad and lateral to the genital branch and travels on the anterior surface of the external iliac artery under the inguinal ligament to supply the skin of the mid-anterior thigh. There exists definitive risk of injuring the GFN during open inguinal hernia repair, appendectomy and laparoscopic varicocelectomy in children and adults. Mesh grafts, sutures and scar may injure the GFN during herniorrhaphy. In fact the constant bulging hernial sac by itself might be a cause of GFN entrapment and subtle injury before surgery. Injury to the GFN may present with pain radiating from the lower abdomen to the anterior thigh and labia majora in women and the scrotum in men. Postsurgical chronic pain after hernia repair may be caused by injury to the iliohypogastric, ilioinguinal or genitofemoral nerves. Is sometimes difficult to identify the specific nerve injury that is giving rise to a patient's post herniorrhaphy neuritic symptoms because these nerves are derived from overlapping nerve roots and closely localize in the area of surgery. Blocking the trunk nerve proximal to the site of injury by local anesthetic will help identify the nerve involved and provide temporary relief. Once identified the origin of persistent pain more permanent invasive treatment can be instituted using surgery, stimulation or percutaneous pulse radiofrequency. 

1- Nahabedian MY, Dellon AL: Outcome of the operative management of nerve injuries in the ilioinguinal region. J Am Coll Surg. 184(3):265-8, 1997
2- Rosenberger RJ, Loeweneck H, Meyer G: The cutaneous nerves encountered during laparoscopic repair of inguinal hernia: new anatomical findings for the surgeon. Surg Endosc. 14(8):731-5, 2000
3- Muensterer OJ: Genitofemoral nerve injury after laparoscopic varicocelectomy in adolescents. J Urol. 180(5):2155-7, 2008
4- Soyer T, Tosun A, Keles I, Inal E, Cesur O, Cakmak M: Electrophysiologic evaluation of genitofemoral nerve in children with inguinal hernia repair. J Pediatr Surg. 43(10):1865-8, 2008
5- Parris D, Fischbein N, Mackey S, Carroll I: A novel CT-guided transpsoas approach to diagnostic genitofemoral nerve block and ablation. Pain Med. 11(5):785-9, 2010
6- Bischoff JM, Aasvang EK, Kehlet H, Werner MU: Does nerve identification during open inguinal herniorrhaphy reduce the risk of nerve damage and persistent pain?Hernia. 16(5):573-7, 2012

PSU Volume 42 NO 02 FEBRUARY 2014


SIRS, refers to the Systemic Inflammatory Response Syndrome, a stress response defined by abnormalities of temperature, heart rate, respiratory rate and peripheral WBC. Two or more of the following disturbances make the diagnosis of SIRS: Core temperature above 38.5 or below 36 C; tachycardia defined as mean heart rate above two standard deviations above normal for age or bradycardia defined as mean heart rate less than the 10th percentile for age; tachypnea defined as mean respiratory rate above two standard deviations for age; leukocyte count elevated or depressed for age or 10% immature neutrophils. The pediatric group is divided in six clinically and physiologically meaningful age groups for age-specific vital sign and laboratory variables to meet SIRS criteria. There is a mandatory requirement for abnormality of temperature or leukocyte count to be present for a diagnosis of SIRS be considered. Since SIRS plus infection equal sepsis it is crucial to recognize SIRS in its initial phase to start adequate management. Multiple initializing triggers SIRS such as infection, trauma and surgery. Most pediatric cases of SIRS occur in the 2-5 year age group with a median age of 30 months. Severe sepsis refers to acute organ dysfunction or tissue hypoperfusion secondary to infection and septic shock is severe sepsis plus hypotension not reversed with fluid resuscitation. There is a high risk of developing sepsis in children with SIRS. Early SIRS diagnosis eventually leads to early goal-therapy for sepsis. Pediatric appendicitis that presents initially with SIRS have a higher length of stay and risk incidence of developing intraabdominal abscess. Systemic organ failure and intestinal dysfunction are strong risk factors for postoperative SIRS in children. These preexisting conditions lead to disruption of normal intestinal flora or barrier function predisposing children to dramatic SIRS episodes after intestinal surgery.

1- Dellinger RP, Levy MM, Rhodes A, et al: Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Critical Care Medicine. 41(2): 580-637, 2013
2- Pavare J, Grope I, Gardovska D: Prevalence of systemic inflammatory response syndrome (SIRS) in hospitalized children: a point prevalence study. BMC Pediatr. 9:25, 2009
3- Juskewitch JE, Prasad S, Salas CF, Huskins WC: Reliability of the identification of the systemic inflammatory response syndrome  in critically ill infants and children. Pediatr Crit Care Med. 13(1):e55-7, 2012
4- Wheeler DS, Jeffries HE, Zimmerman JJ, Wong HR, Carcillo JA: Sepsis in the pediatric cardiac intensive care unit. World J Pediatr Congenit Heart Surg. 2(3):393-9, 2011
5- Chawla BK, Teitelbaum DH: Profound systemic inflammatory response syndrome following non-emergent intestinal surgery in children. J Pediatr Surg. 48(9):1936-40, 2013
6- Raines A, Garwe T, Wicks R, Palmer M, Wood F, Adeseye A, Tuggle D: Pediatric appendicitis: The prevalence of systemic inflammatory response syndrome upon presentation and its association with clinical outcomes.  J Pediatr Surg. 48(12):2442-5, 2013


The term splenoma refers to a splenic hamartoma. Splenoma is a very rare and benign lesion in the pediatric age. Approximately 80% of splenic hamartomas produce no clinical symptoms. Splenic hamartomas may be solitary or multiple and are usually well defined but not encapsulated. There is no predilection for sex or age. Most patients with splenic hamartomas are asymptomatic and found as an incidental finding at laparotomy or autopsy. A few splenic hamartomas have clinical findings. Common clinical findings include bleeding tendency caused by thrombocytopenia, digestive symptoms as abdominal pain and loss of appetite from compressive symptoms. Spontaneous rupture with bleeding has been reported. In children, hamartoma of the spleen with haematologic abnormalities may be followed by growth retardation, frequent infections, fever and night sweating.  Histologically splenic hamartomas can be classified as red pulp hamartomas when they contain sinuses and structures equivalent to the pulp cords, white hamartomas when they contain mostly lymphoid tissue, and mixed type when they have a mixture of the above. Ultrasound characteristic of splenic hamartomas include hyperechoic nodules with a cystic component. CT-Scan will need intravenous contrast material to see the difference between the hamartoma seen as a solid homogenous mass without calcification and the normal splenic tissue. Radiocolloid scintigraphy demonstrates uptake within the lesion, but less than that of normal spleen. In MRI imaging the tumor is isointense relative to normal splenic tissue on T1-weighted and of increased intensity with T2 weighting. The management of symptomatic splenic hamartoma is excision by either total or partial splenectomy depending on the size, age  and splenic involvement.

1- Havlik RJ, Touloukian RJ, Markowitz RI, Buckley P: Partial splenectomy for symptomatic splenic hamartoma. J Pediatr Surg. 25(12):1273-5, 1990
2- Thompson SE, Walsh EA, Cramer BC, Pushpanathan CC, Hollett P, Ingram L, Price D: Radiological features of a symptomatic splenic hamartoma. Pediatr Radiol. 26(9):657-60, 1996
3- Hayes TC, Britton HA, Mewborne EB, Troyer DA, Saldivar VA, Ratner IA: Symptomatic splenic hamartoma: case report and literature review. Pediatrics. 101(5):E10, 1998
4- Yoshizawa J, Mizuno R, Yoshida T, Kanai M, Kurobe M, Yamazaki Y: Spontaneous rupture of splenic hamartoma: a case report. J Pediatr Surg. 34(3):498-9, 1999
5- Abramowsky C, Alvarado C, Wyly JB, Ricketts R: "Hamartoma" of the spleen (splenoma) in children. Pediatr Dev Pathol. 7(3):231-6, 2004
6- Basso SM, Sulfaro S, Marzano B, Fanti G, Chiara GB, Lumachi F: In
cidentally discovered asymptomatic splenic hamartoma with rapidly expansive growth: a case report. In Vivo. 2012 Nov-Dec;26(6):1049-52, 2012

Transport Surgical Neonate

Transporting a neonate with a surgical condition from one institution to another involve pre-transport intensive care level of resuscitation, stabilization and continuing transport to ensure the baby arrives in stable condition. Good communication and coordination between referring and receiving hospital is of upmost importance. Transport can occur in-utero, by road or air (helicopter or airline). In-utero is the best mode of transfer to a facility that has NICU with working pediatric surgeons. High-risk neonates are more likely to survive when they are delivered in a perinatal center compared with local delivery followed by transfer. When using air transport physiologic changes due to altitude and decreased atmospheric pressure can cause a decrease in oxygen concentration and expansion of gases causing increased oxygen requirement and tachypnea. This issue is important in patients with air trapped in closed cavities such as pneumothorax, pneumoperitoneum, volvulus and bowel obstruction. Before leaving these cavities must be drained since gases will expand and cause respiratory distress. Should there be a possibility the child might require ventilation during transfer it is safer to electively intubate and ventilate before leaving the source institution. If the baby is unstable or on high ventilatory setting, the baby should not be transported. During transport all tubes should be secured safely, and running IVF's with medication should be working properly. Each institution should have a pre-departure checklist with the essential transport equipment and medication available. In cases of NEC if there is an evident perforation of the bowel, insertion of a peritoneal drain with or without lavage with normal saline should be considered to improve ventilation and acidosis.

1- Tholkes DR: Air transport of the neonate with a congenital diaphragmatic hernia. Aviat Space Environ Med. 57(2):183-5, 1986
2- Cornish JD, Carter JM, Gerstmann DR, Null DM Jr: Extracorporeal membrane oxygenation as a means of stabilizing and transporting high risk neonates. ASAIO Trans. 37(4):564-8, 1991
3- Bjerke HS, Barcliff L, Foglia RP: Neonatal survival during a 2,500-mile flight. Hawaii Med J. 1992 Dec;51(12):332-5.
4- Bergman KA, Geven WB, Molendijk A: Referral and transportation for neonatal extracorporeal membrane oxygenation. Eur J Emerg Med. 9(3):233-7, 2002
5- McAdams RM, Dotzler SA, Pole GL, Kerecman JD: Long-distance air medical transport of extremely low birth weight infants with pneumoperitoneum. J Perinatol. 28(5):330-4, 2008
6- Cabrera AG, Prodhan P, Cleves MA, Fiser RT, Schmitz M, Fontenot E, McKamie W, Chipman C, Jaquiss RD, Imamura M: Interhospital transport of children requiring extracorporeal membrane oxygenation support for cardiac dysfunction. Congenit Heart Dis. 6(3):202-8, 2011

PSU Volume 42 No 03 MARCH 2014

Component Separation Technique

The component separation technique (CST) was initial developed in 1990 to repair primary large ventral hernias defects without using mesh or prothesis. CST was originally described as incising the external oblique aponeurosis and releasing the external oblique from the internal oblique. This release leads to improved tissue mobility and decreases tension allowing fascial approximation closure either to be done primarily or intercalating a mesh when the defect is very large. The CST does not compromise the innervation and blood supply of the muscles. The procedure is performed in adults to repair large giant ventral hernias with lost of abdominal domain. The procedure is rarely used in children. In short the technique encompass identifying the borders of the hernial defect, creating bilateral tissue flaps (skin and subcutaneous tissue) until the external oblique aponeurosis is exposed, bilateral longitudinal incision of the external oblique fascia one centimeter lateral to the rectus muscle dividing the external oblique muscle from the internal oblique muscle until the midline can be approximated with minimal tension. At this moment of closure the surgeon might use onlay or underlay biologic mesh to support the midline closure. The mesh can alleviate further the tension that exists with the hernia repair and provide a scaffold for cellular growth. In adults with large ventral defects the risk of recurrence is decreased when the CST closure is supported by either mesh onlay or underlay. In children, CST can be utilized for large ventral hernia defects after initial management of abdominal wall defects such as omphalocele and gastroschisis. The CST offers the potential for definitive repair as a newborn as well as avoidance of the morbidity associated with recurrent hernias and multiple operations. Complications associated with the CST include wound infection, seroma, hematoma or skin necrosis.      

1-  Jernigan TW, Fabian TC, Croce MA, Moore N, Pritchard FE, Minard G, Bee TK: Staged management of giant abdominal wall defects: acute and long-term results. Ann Surg. 238(3):349-55, 2003
2- de Vries Reilingh TS, van Goor H, Charbon JA, Rosman C, Hesselink EJ, van der Wilt GJ, Bleichrodt RP: Repair of giant midline abdominal wall hernias: "components separation technique"
versus prosthetic repair : interim analysis of a randomized controlled trial. World J Surg. 31(4):756-63, 2007
3- van Eijck FC, de Blaauw I, Bleichrodt RP, Rieu PN, van der Staak FH, Wijnen MH, Wijnen RM: Closure of giant omphaloceles by the abdominal wall component separation technique in infants. J Pediatr Surg. 43(1):246-50, 2008
4- Beres A, Christison-Lagay ER, Romao RL, Langer JC: Evaluation of Surgisis for patch repair of abdominal wall defects in children. J Pediatr Surg. 47(5):917-9, 2012
5- Heller L, McNichols CH, Ramirez OM: Component separations. Semin Plast Surg. 26(1):25-8, 2012
6- Levy S, Tsao K, Cox CS Jr, Phatak UR, Lally KP, Andrassy RJ: Component separation for complex congenital abdominal wall defects: not just for  adults anymore. J Pediatr Surg. 48(12):2525-9, 2013

Immune Thrombocytopenic Purpura

Immune thrombocytopenia purpura (ITP) is an acquired autoimmune disease characterized by platelet destruction due to antiplatelet autoantibodies. The reticuloendothelial system engulfs the affected platelets causing early destruction hence thrombocytopenia. In children is self-limited with a 6-month remission rate in more than 70% of cases. After six months the condition is termed chronic ITP and it occurs in 20% of all cases. Clinically mean age at onset is six years, males and females are equally  affected, and the disease usually follows an infection. Most children present with simple petechiae and bruising symptoms. Most children with ITP experience spontaneous resolution without medication. Severe bleeding is more likely in children with severe thrombocytopenia from ITP. First-line therapy for symptomatic and/or severely thrombocytopenic patients include steroids, anti-D antibody, or intravenous gamma globulin. Second-line therapy is  reserved for those who have severe bleed or are refractory to first-line medical therapy and include high-dose steroids, rituximab, and other chemotherapeutics. Laparoscopic splenectomy is a safe, efficacious, and cost-effective strategy option for children with uncontrolled chronic ITP or life-threatening hemorrhage complicating acute ITP. Unfortunately there is no clear prediction which patient will benefit from splenectomy. Almost 70% of cases respond favorably and persistently to splenectomy. Steroid-resistant children are most likely to have complete respond to splenectomy. Older age, longer duration of ITP, and male gender correlates with complete response.  Splenectomy improves quality of life of children with ITP. Intracranial hemorrhage is a devastating complication of ITP preceded by headache and mucosal bleeding which can be precipitate in the event of aspirin intake, extreme exercise, head trauma or a congenital vascular cerebral lesion.

1- Vianelli N, Galli M, de Vivo A, Intermesoli T, Giannini B, Mazzucconi MG, Barbui  T, Tura S, Baccaranion M; Gruppo Italiano per lo Studio delle Malattie Ematologiche dell'Adulto: Efficacy and safety of splenectomy in immune thrombocytopenic purpura: long-term  results of 402 cases. Haematologica. 90(1):72-7, 2005
2- Kahne T, Blanchette V, Buchanan GR, Ramenghi U, Donato H, Tamminga RY, Rischewski
J, Berchtold W, Imbach P; Intercontinental Childhood ITP Study Group: Splenectomy in children with idiopathic thrombocytopenic purpura: A prospective study of 134 children from the Intercontinental Childhood ITP Study Group. Pediatr Blood Cancer. 49(6):829-34, 2007
3- Psaila B, Petrovic A, Page LK, Menell J, Schonholz M, Bussel JB: Intracranial hemorrhage (ICH) in children with immune thrombocytopenia (ITP): study of 40 cases. Blood. 26;114(23):4777-83, 2009
4- Wood JH, Partick DA, Hays T, Ziegler MM: Predicting response to splenectomy in children with immune thrombocytopenic purpura. J Pediatr Surg. 45: 140-144, 2010
5- Hollander LL, Leys CM, Weil BR, Rescorla FJ: Predictive value of response to steroid therapy on response to splenectomy in children with immune thrombocytopenic purpura. Surgery. 150(4):643-8, 2011
6- Gwilliam NR, Lazar DA, Brandt ML, Mahoney Jr DH, Wesso DE, Mazziotti MV, Nuchtern JG, Lee TC: An analysis of outcomes and treatment costs for children undergoing splenectomy for chronic immune thrombocytopenia purpura. J Pediatr Surg. 47: 1537-1541, 2012


Lipofibromatosis (LF) is a rare benign fibrofatty tumor of childhood largely composed of adipose tissue traversed by bundles of spindle fibroblastic-like cells. Most lipofibromatosis are found in the distal extremity. Clinically, LF presents as a slow growing painless mass with a propensity to affect the hands and feet. The lesion is subcutaneous in location or in the deep soft tissue with poorly demarcated margins. The lesion usually measures one to 3 cm, with a median size of 2 cm. LF can infiltrate adjacent structures like vessels, nerves and muscle. Functional impairment is very rare. The findings at MRI are nonspecific, but it can evaluate the extension of the lesion and involvement of adjacent structures. Hyperintense signal on T1W and T2W images with loss of signal on fat-saturated images confirm the lipomatous content of the lesion. Diagnosis can be made easily with distinctive histopathologic features without an indication of immunohistochemistry. Mitotic rate is low and there is usually no cellular atypia. Management of LF is complete surgical excision if at all feasible. Due to its infiltrative nature, LF has a high rate of recurrence. The following events were more common in the group with recurrent or persistent disease: congenital onset, male sex, hand and foot location, incomplete excision, and mitotic activity in the fibroblastic element.

1- Fetsch JF, Miettinen M, Laskin WB, Michal M, Enzinger FM: A clinicopathologic study of 45 pediatric soft tissue tumors with an admixture of adipose tissue and fibroblastic elements, and a proposal for classification as lipofibromatosis. Am J Surg Pathol. 24(11):1491-500, 2000
2- Sari A, Tunakan M, Bolat B, Cakmakai H, Ozer E: Lipofibromatosis in a two-year-old girl: a case report. Turk J Pediatr. 49(3):319-21, 2007
3- Taran K, Woszczyk M, Kobos J: Lipofibromatosis presenting as a neck mass in eight-years old boy--a case report. Pol J Pathol. 59(4):217-20, 2008
4- Costa Dias S, McHugh K, Sebire NJ, Bulstrode N, Glover M, Michalski A: Lipofibromatosis of the knee in a 19-month-old child. J Pediatr Surg. 47(5):1028-31, 2012
5- Leuschner I: [Lipofibromatosis in a 6-year-old girl: a case report]. Pathologe. 31(2):150-2, 2010

PSU Volume 42 No 04 APRIL 2014

Long-Gap Esophageal Atresia

Long gap in esophageal atresia (EA), a major surgical challenge considered when an anatomic gap of more than three centimeters (or three vertebral bodies) is identified between the two stumps of the esophagus precluding a safe anastomosis. Long gap is more commonly seen in pure esophageal atresia not associated with a tracheoesophageal fistula. Surgeons have also used this term in cases of  EA with distal tracheoesophageal fistula when an anastomosis is not possible. No single technique to accomplish this goal is effective in all patients. When confronted with this situation surgeons should reproduce several alternatives of management with the central caveat that the baby own esophagus should be preserved and is far superior to an esophageal replacement technique. In cases of long gap with pure EA initial management consist of a gastrostomy for two purposes: enteral feeding and future imaging studies to determine the esophageal gap. Should the gap be less than 2 cm a primary anastomosis can be accomplished safely. Some of the commonly used technique for long gap approximation includes proximal esophageal dilatation with distal gastric bolus feedings in an effort to exert pressure on both stumps for spontaneous lengthening, a technique that takes to much time to accomplish its goal. This has prompted surgeons to developed faster technique such as sequential proximal pouch elongation (Kimura advancement) and mechanical stretching of both stumps with sutures (Foker). Still other techniques when the distal stump is extremely small encompassed isoperistalsis tubularization of a piece of stomach (Scharli) to include the esophageal stump, and creating concomitant antireflux valve procedures (Collis-Nissen). Finally,  replacement of the defect with stomach (gastric transposition), small bowel or colon is a last resort technique when all other means fails.

1- Stringel G, Lawrence C, McBride W: Repair of long gap esophageal atresia without anastomosis. J Pediatr Surg. 45(5):872-5, 2010
2- Nakahara Y, Aoyama K, Goto T, Iwamura Y, Takahashi Y, Asai T: Modified Collis-Nissen procedure for long gap pure esophageal atresia. J Pediatr Surg. 47(3):462-6, 2012
3- Friedmacher F, Puri P: Delayed primary anastomosis for management of long-gap esophageal atresia: a meta-analysis of complications and long-term outcome. Pediatr Surg Int. 28(9):899-906, 2012
4- Nasr A, Langer JC: Mechanical traction techniques for long-gap esophageal atresia: a critical
appraisal. Eur J Pediatr Surg. 23(3):191-7, 2013
5- Miyano G, Okuyama H, Koga H, Okawada M, Doi T, Takahashi T, Nakamura H, Suda K, Lane GJ, Okazaki T, Yamataka A: Type-A long-gap esophageal atresia treated by thoracoscopic esophagoesophagostomy after sequential extrathoracic esophageal elongation (Kimura's technique). Pediatr Surg Int. 29(11):1171-5, 2013
6- Bairdain S, Ricca R, Riehle K, Zurakowski D, Saites CG, Lien C, Anderson GF, Wahoff DC, Linden BC: Early results of an objective feedback-directed system for the staged traction repair of long-gap esophageal atresia. J Pediatr Surg. 48(10):2027-31, 2013
7- Beasley SW, Skinner AM: Modified Scharli technique for the very long gap esophageal atresia.  J Pediatr Surg. 48(11):2351-3, 2013

Embryonal Liver Sarcoma

Undifferentiated  embryonal sarcoma of the liver (UESL) is an uncommon malignant hepatic tumor of mesenchymal origin in children. UESL accounts for almost 5% of all pediatric malignant hepatic tumors occurring mainly between five and 10 years of age without a gender predilection. Clinical presentation is typically an abdominal mass that may be accompanied by pain and systemic symptoms such as fever, weight loss or vomiting. Due to its high malignant potential UESL often metastasizes to the lung, peritoneum and pleura resulting in a poor prognosis. The tumor presents as a large (above 10 cm) solitary solid mass mainly localized in the right hepatic lobe with a solitary clear boundary. US reveals a mixed echoic mass containing an irregular anechoic region with multiple small capsular spaces. CT reveals cystic lesions due to hemorrhage, necrosis and liquefaction. Diagnosis requires biopsy. Microscopically the tumor consists of rather loose foci of pleomorphic, stellate or giant cells with hyperchromatic nuclei, and numerous mitosis. Immunohistochemistry of the tumor shows positive expression of SMA, a-ACT, desmin, vimentin and actin, while Alpha fetoprotein, CEA, CA 19-9 and cytokeratin are negative. Rarely UESL is misdiagnosed as hepatoblastoma. The key management of UESL is complete surgical resection followed by postoperative multiagent chemotherapy. Very large tumors can be managed with preop chemotherapy followed by surgery. Hepatic transplantation is an effective therapeutic method for UESL patients whose tumor unresectable or  those who have postoperative recurrence of the tumor. Prognosis has improved significantly over the years.

1- Bisogno G, Pilz T, Perilongo G, Ferrari A, Harms D, Ninfo V, Treuner J, Carli M:Undifferentiated sarcoma of the liver in childhood: a curable disease. Cancer. 94(1):252-7, 2002
2- Chowdhary SK, Trehan A, Das A, Marwaha RK, Rao KL: Undifferentiated embryonal sarcoma in children: beware of the solitary liver cyst.  J Pediatr Surg. 39(1):E9-12, 2004
3- Wei ZG, Tang LF, Chen ZM, Tang HF, Li MJ: Childhood undifferentiated embryonal liver sarcoma: clinical features and immunohistochemistry analysis. J Pediatr Surg. 43(10):1912-9, 2008
4- Plant AS, Busuttil RW, Rana A, Nelson SD, Auerbach M, Federman NC: A single-institution retrospective cases series of childhood undifferentiated embryonal liver sarcoma (UELS): success of combined therapy and the use of orthotopic liver transplant. J Pediatr Hematol Oncol. 35(6):451-5, 2013
5- Gao J, Fei L, Li S, Cui K, Zhang J, Yu F, Zhang B: Undifferentiated embryonal sarcoma of the liver in a child: A case report and review of the literature. Oncol Lett. 5(3):739-742, 2013
6- Geel JA, Loveland JA, Pitcher GJ, Beale P, Kotzen J, Poole JE: Management of undifferentiated embryonal sarcoma of the liver in children: a case series and management review. S Afr Med J. 103(10):728-31, 2013
7- Ismail H, Dembowska-Baginska B, Broniszczak D, Kalicinski P, Maruszewski P, Kluge P, Swieszkowska E, Kosciesza A, Lembas A, Perek D: Treatment of undifferentiated embryonal sarcoma of the liver in children--single  center experience. J Pediatr Surg. 48(11):2202-6, 2013

Trachea Diverticulum

Tracheal diverticulum is a very rare condition with a congenital or acquired origin. Congenital tracheal diverticulum is even rarer, smaller, located approximately 4–5 cm below vocal cords or just above the carina, is more common in males and can be considered as a supernumerary malformed branch of the trachea. Most reported cases of tracheal diverticulum are acquired after esophageal or tracheal surgery, orotracheal intubation or increased intraluminal pressure through a weak area of tracheal wall. It occurs more often after surgery for tracheoesophageal fistula when the fistula is not divided sufficiently close to the trachea. In this case the diverticulum becomes a remnant of esophageal epithelium created at the time of repair of the TEF. In either congenital or acquired cases the diverticulum acts as a reservoir for pooling of secretions that may  spill over into the tracheobronchial tree predisposing affected patients to cough, dyspnea, stridor and chronic chest infection. CT-Scan imaging with thin slices or bronchoscopy is diagnostic. Surgical treatment of congenital tracheal diverticulum is rarely advocated. Excision of the acquired diverticulum may be needed in patients with severe respiratory symptoms, either a large diverticulum and airway compression or a suspected recurrent fistula. Another less invasive and effective alternative management is endoscopic carbon dioxide laser fulguration of the tracheal diverticulum mucosa.

1- Sharma BG: Tracheal diverticulum: a report of 4 cases. Ear Nose Throat J. 88(1):E11, 2009
2- Berlucchi M, Pedruzzi B, Padoan R, Nassif N, Stefini S: Endoscopic treatment of tracheocele in pediatric patients. Am J Otolaryngol. 31(4):272-5, 2010
3- Gaissert HA, Grillo HC: Complications of the tracheal diverticulum after division of congenital
tracheoesophageal fistula. J Pediatr Surg. 41(4):842-4, 2006
4- Johnson LB, Cotton RT, Rutter MJ: Management of symptomatic tracheal pouches. Int J Pediatr Otorhinolaryngol. 71(4):527-31, 2007
5- Cheng AT, Gazali N: Acquired tracheal diverticulum following repair of tracheo-oesophageal fistula: endoscopic management. Int J Pediatr Otorhinolaryngol. 72(8):1269-74, 2008
6- Shah AR, Lazar EL, Atlas AB: Tracheal diverticula after tracheoesophageal fistula repair: case series and review of the literature.  J Pediatr Surg. 44(11):2107-11, 2009

PSU Volume 42 No 05 MAY 2014

Gliomatosis Peritonei

Gliomatosis peritonei (GP) refers to a very rare entity characterized by miliary disseminated implants composed of mature glial (fibrous astrocytes) tissue throughout the serosal surface of the abdominal peritoneal cavity including recesses, cul-de-sac and intestinal surfaces. Though the picture is of an advance stage of neoplasia, its behavior is almost invariably benign since its differentiated cells lack proliferative activity. The majority of cases of GP are associated with an immature ovarian teratoma, though only rarely with mature teratoma. Almost 25% of immature teratoma can develop GP. Hypothesis for development of GP includes implantation and subsequent maturation of neural precursor cells detached from the primary tumor or peritoneal metaplasia from stem cells induced by growths factors. Peak incidence of GP is in the second decade with an average age of 15 years. GP can occur after capsular rupture during surgery or spontaneously. The overall prognosis of mature GP is excellent and chemotherapeutic management is rarely necessary except with high-grade or immature deposits. Implants can grow rapidly. Serum markers such as CA125 and alpha fetoprotein are elevated in GP. Histologically GP demonstrates large amounts of well-differentiated glial tissue with extensive endothelial proliferation of vessels similar to brain tumors, minimal atypia and only rare mitosis. Surgical sampling should be as extensive as possible to evaluate the maturity of the glial deposits to establish a diagnosis of GP. Immature glial tissue or other teratomatous component heralds metastatic disease and should be managed aggressively. GP does not adversely affect the prognosis of ovarian teratoma. A conservative surgical approach without adjuvant therapy or chemotherapy is recommended.

1- Harms D, et al: Gliomatosis peritonei in childhood and adolescence. Clinicopathological study of  13 cases including immunohistochemical findings. Pathol Res Pract. 184(4):422-30, 1989
2- Chaung JH, Chen L: Ovarian teratoma with gliomatosis peritonei. J Pediatr Surg. 27(5):662-4, 1992
3- Hamada Y(1), Tanano A, Sato M, Tsuji M, Sakaida N, Okamura A, Hioki K: Ovarian teratoma with gliomatosis peritonei: report of two cases. Surg Today. 28(2):223-6, 1998
4- Hill DA(1), Dehner LP, White FV, Langer JC: Gliomatosis peritonei as a complication of a ventriculoperitoneal shunt: case report and review of the literature. J Pediatr Surg. 35(3):497-9, 2000
5- Hsieh YL, Liu CS: Progression from an immature teratoma with miliary gliomatosis peritonei to growing teratoma syndrome with nodular gliomatosis peritonei. Pediatr Neonatol. 50(2):78-81, 2009
6- Yoon NR, Lee JW, Kim BG, Bae DS, Sohn I, Sung CO, Song SY: Gliomatosis peritonei is associated with frequent recurrence, but does not affect overall survival in patients with ovarian immature teratoma. Virchows Arch. 461(3):299-304, 2012

Neutropenic Colitis

Neutropenic colitis (NC) refers to a potentially life-threatening necrotizing inflammation of the cecum and colon the result of a chemotherapeutic complication of leukemia treatment, acquired immunodeficiency syndrome or as a complication of bone marrow transplantation. The clinical triad of neutropenic colitis includes neutropenia, abdominal pain/tenderness and fever.  The integrity of the bowel wall is compromised due to factors including mucosal injury by cytotoxic drugs, neutropenia, and impaired host defense to intestinal organisms. This leaves the bowel vulnerable to bacterial invasion, necrosis and perforation. Most cases involve the cecum and ascending colon. It is sometimes difficult to differentiate NC from appendicitis in the early onset. Critical key points for diagnosis of NC are neutropenia (absolute neutrophil counts below 500 cells/µL), high fever, bloody stool and aggressive progress. Diagnostic accuracy is increased with the use of US or CT-Scans when there is a bowel wall thickening above 3 mm. Factors associated with development of NC include age greater than 16 years, mucositis, stem cell transplantation and chemotherapy within the prior two weeks of symptoms. Initial management should consist of aggressive hemodynamic support, bowel rest/decompression, supplemental nutrition, broad-spectrum antibiotic therapy and  G- CSF. Measurements of C-reactive protein in blood may be of benefit when assessing the clinical course. Indications for surgical intervention include diffuse peritonitis, pneumoperitoneum, persistent gastrointestinal bleeding and continued clinical deterioration despite medical therapy. The most common surgical indication is bowel perforation. Recommended surgical procedures include hemicolectomy, ileostomy and secondary anastomosis or drainage. Primary bowel anastomosis is not a good choice due to the high risk of leakage, intraperitoneal infection, abscess, intestinal adhesion and obstruction. Most children do not require surgery. Overall mortality is lower in children (5%).

1- Moran H, Yaniv I, Ashkenazi S, Schwartz M, Fisher S, Levy I: Risk factors for typhlitis in pediatric patients with cancer. J Pediatr Hematol Oncol. 31(9):630-4, 2009
2- Sundell N, Bostram H, Edenholm M, Abrahamsson J: Management of neutropenic enterocolitis in children with cancer. Acta Paediatr. 101(3):308-12, 2012
3- McCarville MB(1), Adelman CS, Li C, Xiong X, Furman WL, Razzouk BI, Pui CH, Sandlund JT: Typhlitis in childhood cancer. Cancer. 104(2):380-7, 2005
4- Schlatter M(1), Snyder K, Freyer D: Successful nonoperative management of typhlitis in pediatric oncology patients.  J Pediatr Surg. 37(8):1151-5, 2002
5- Fike FB(1), Mortellaro V, Juang D, St Peter SD, Andrews WS, Snyder CL: Neutropenic colitis in children. J Surg Res. 170(1):73-6, 2011
6-Li K, Zheng S, Dong K, Gao Y, Wang H, Liu G, Gao J, Xiao X: Diagnosis and outcome of neutropenic enterocolitis: experience in a single tertiary pediatric surgical center in China. Pediatr Surg Int. 27(11):1191-5, 2011


Thyroid carcinoma is the third most common solid tumor in children and adolescent. The incidence is rising. Most cases of thyroid carcinoma are well differentiated papillary or follicular tumors. As previously stated they are best managed with total thyroidectomy and postoperative radioiodine therapy in most cases. There are several scoring systems used to classify thyroid cancer. MACIS refer to a recently developed prognostic scoring system utilized for differentiated thyroid carcinoma  in children and adults that has resulted in recognition of low- and high risk patient categories allowing meaningful comparison of a variety of treatment approaches. MACIS stand for the presence of Metastasis, Age, Completeness of resection, local Invasion and tumor Size. MACIS was designed in 1993 to predict disease specific survival in patients with differentiated thyroid carcinoma. The cutoff score has been set at a score above four heralding a poor prognosis for children less than 21 years of age. MACIS score correlates well with the response to initial therapy in children and is useful in predicting outcome.  MACIS appear the most useful prognostic system taking completeness of resection into account.  

1- Palme CE(1), Waseem Z, Raza SN, Eski S, Walfish P, Freeman JL: Management and outcome of recurrent well-differentiated thyroid carcinoma. Arch Otolaryngol Head Neck Surg. 130(7):819-24, 2004
2- Voutilainen PE(1), Siironen P, Franssila KO, Sivula A, Haapiainen RK, Haglund CH: AMES, MACIS and TNM prognostic classifications in papillary thyroid carcinoma. Anticancer Res. 23(5b):4283-8, 2003
3- Powers PA(1), Dinauer CA, Tuttle RM, Francis GL: The MACIS score predicts the clinical course of papillary thyroid carcinoma in children and adolescents. J Pediatr Endocrinol Metab. 17(3):339-43, 2004
4- Kjellman P(1), Zedenius J, Lundell G, Bäckdahl M, Farnebo LO, Hamberger B, Larsson C, Wallin G: Predictors of outcome in patients with papillary thyroid carcinoma. Eur J Surg Oncol. 32(3):345-52, 2006
5- Jang HW(1), Lee JI, Kim HK, Oh YL, Choi YL, Jin DK, Kim JH, Chung JH, Kim SW: Identification of a cut-off for the MACIS score to predict the prognosis of differentiated thyroid carcinoma in children and young adults. Head Neck. 34(5):696-701, 2012

PSU Volume 42 NO 06 JUNE 2014


Appendicostomy refers to a novel surgical procedure utilized as an antegrade continent enema for the management of fecal incontinence, soiling, colonic dysmotility and intractable slow transit constipation in children and adults. The appendix is brought to the skin, usually through the navel, as a small stomal conduit, to be catheterized on a daily basis or regularly and used for antegrade colonic irrigation washouts achieving socially acceptable fecal continence and cleansing. The appendicostomy procedure can be done open or laparoscopically.  The laparoscopy approach has less operative trauma, less pain, better cosmetic results and can be performed as an outpatient procedure. During the procedure a silastic catheter or a Chait button is inserted. Cecal wrap and fixation as antireflux measures have been recommended but they  have not eliminated fecal leak or reflux and increase operative time.   The most important variables that predict outcome are patient compliance, regular use of the irrigations and patient age. Complications of using the appendix as conduit include painful catheter insertion related to stomal stenosis since many children avoid regular prophylactic catheter insertion. This problem can also be overcome using constantly an indwelling tube or the Chait button. Mucus leak is common during the first 6-8 weeks. The washout regime can cause significant pain due to volume or content (senna). Other less common complications of the appendicostomy include bleeding, granulation tissue, perforation, infection, embarrassment about the catheter and fecal leak. The appendicostomy procedure effectively reduces soiling in more than 80% of children with idiopathic constipation so long as the parents are motivated to perform the antegrade enemas on a daily basis. Abdominal pain common in chronic constipation is significantly reduced in severity and frequency in these patients. In the preschool child the benefits are earlier cleanness before starting school with less incidence of stenosis and leakage.

1- Marshall J, Hutson JM, Anticich N, Stanton MP: Antegrade continence enemas in the treatment of slow-transit constipation. J Pediatr Surg. 36(8):1227-30, 2001
2- Cascio S, Flett ME, De la Hunt M, Barrett AM, Jaffray B: MACE or caecostomy button for idiopathic constipation in children: a comparison of complications and outcomes. Pediatr Surg Int. 20(7):484-7, 2004
3- Koivusalo A, Pakarinen M, Rintala RJ: Are cecal wrap and fixation necessary for antegrade colonic enema appendicostomy? J Pediatr Surg. 41(2):323-6, 2006
4- Kim J, Beasley SW, Maoate K: Appendicostomy stomas and antegrade colonic irrigation after laparoscopic antegrade continence enema. J Laparoendosc Adv Surg Tech A. 16(4):400-3, 2006
5- Chatoorgoon K(1), Pena A, Lawal T, Hamrick M, Louden E, Levitt MA: Neoappendicostomy in the management of pediatric fecal incontinence. J Pediatr Surg. 46(6):1243-9, 2011
6- Stenstrom P(1), Graneli C, Salo M, Hagelsteen K, Arnbjornsson E: Appendicostomy in preschool children with anorectal malformation: successful early bowel management with a high frequency of minor complications. Biomed Res Int. Volume 2013, Article ID 297084, 8 pages

Fibrous Soft Tissue Tumors

Fibrous soft tissue tumors (FSTT), also known as fibromatosis or desmoid tumors, refer to a group of non-neoplastic spindle cell proliferations that behave locally aggressively but without a propensity to metastasize. They have an increase propensity for local invasiveness and recurrence. FSTT comprised almost 12% of all soft tissue tumors in infants and children. Mean age of presentation is five years. FSTT are firm circumscribed masses, with a white-tan cut surface, glistening or a whorled appearance. They rarely have evidence of hemorrhage or necrosis. Histologically FSTT appears as proliferation of spindle shaped, well-differentiated fibroblast arranged in fascicle in a background of mature collagen with a few or none typical mitotic figures. Included in this group of FSTT are infantile digital fibromatosis, fibromatosis colli, aggressive fibromatosis, fibrous hamartoma of infancy and others. Management of FSTT encompasses local surgical excision with a recommended surgical margin of 1 cm and excision in depth to include the adjacent normal tissue plane. Though having negative margins at resection is the ideal goal of therapy, this is sometimes difficult to achieve if there is going to be sacrifice of structure or function. Local recurrence has been reported in more than 10% of FSTT due to inadequate primary excision. Recurrence of FSTT has been associated with younger age, incomplete resection and specially when involving digital or extremity lesions. However, even with incomplete excision, FSTT has a low recurrence rate and carries an excellent prognosis. Radiotherapy and/or pharmacologic treatment is reserved for patients with unresectable or progressive disease. 

1- Lee JT, Girvan DP, Armstrong RF: Fibrous hamartoma of infancy. J Pediatr Surg. 23(8):759-61, 1988
2- Aldrink JH(1), Nicol K, Wang W, Teich S: Fibrous soft tissue tumors: factors predictive of recurrence. J Pediatr Surg. 48(1):56-61. 2013
3- Gatibelza ME(1), Vazquez BR, Bereni N, Denis D, Bardot J, Degardin N:Isolated infantile myofibromatosis of the upper eyelid: uncommon localization and long-term results after surgical management. J Pediatr Surg. 47(7):1457-9, 2012
4- Seguier-Lipszyc E(1), Hermann G, Kaplinski C, Lotan G: Fibrous hamartoma of infancy. J Pediatr Surg. 46(4):753-5, 2011
5- Gold JS(1), Antonescu CR, Hajdu C, Ferrone CR, Hussain M, Lewis JJ, Brennan MF, Coit DG: Clinicopathologic correlates of solitary fibrous tumors. Cancer. 15;94(4):1057-68, 2002
6- Blakely ML(1), Spurbeck WW, Pappo AS, Pratt CB, Rodriguez-Galindo C, Santana VM,  Merchant TE, Prichard M, Rao BN: The impact of margin of resection on outcome in pediatric nonrhabdomyosarcoma soft tissue sarcoma. J Pediatr Surg. 34(5):672-5, 1999

Diaphragmatic Rupture

Diaphragmatic rupture almost always occurs after a traumatic event, most probably a motor-vehicle accident followed by falls. Blunt trauma accounts for more than 80% of diaphragmatic injuries. More than 50% of cases have an associated injury. Several anatomic factors predisposing to diaphragmatic rupture include a thinner abdominal wall, more horizontal position of the diaphragm, ribs more cartilaginous and elastic rupturing at areas of fixed attachment especially the costal origin which is longer and weaker. Regardless of the mechanism of injury, the early detection of an occult diaphragmatic rupture usually depends on a high index of suspicion. Isolated diaphragmatic injuries do occur in children more frequently than in adults and diaphragmatic rupture prevails in the left posterolateral side. The right side is protected by the liver. Preoperative chest X-ray and CT Scan are diagnostic of most diaphragmatic ruptures in children. Early management determines the effectiveness of treatment and avoids the consequence of missed injuries. Delayed diagnosis can lead to intestinal obstruction and strangulation of the intestine, sepsis and death. Contributing factor for  delay in diagnosis also is the extent of diaphragmatic rupture as well as the site of rupture. Short length of diaphragmatic rupture may not manifest initially but as the extent of rupture increases, more and more intraabdominal viscera will herniate into the thoracic cavity as a result of negative intra-thoracic pressure and create symptoms. Most of the delayed cases are seen in the right side. Diaphragmatic rupture is usually repaired using a laparotomy in the acute setting. With delayed diagnosis surgeons prefer a thoracic approach for repair. Operative strategies should be planned based on the localization, size of the rupture, associated injuries and stability of the patient.

1-Al-Salem AH:Traumatic diaphragmatic hernia in children. Pediatr Surg Int. 2012 Jul;28(7):687-91
2- Soundappan SV, Holland AJ, Cass DT, Farrow GB:Blunt traumatic diaphragmatic injuries in children. Injury. 36(1):51-4, 2005
3- Khan TR, Rawat J, Maletha M, Singh S, Rashid KA, Wakhlu A, Kureel SN: Traumatic diaphragmatic injuries in children: do they really mark the severity of injury? Our experience. Pediatr Surg Int. 25(7):595-9, 2009
4- Shehata SM, Shabaan BS: Diaphragmatic injuries in children after blunt abdominal trauma. J Pediatr Surg. 41(10):1727-31, 2006
5- Okur MH, Uygun I(2), Arslan MS, Aydogdu B, Turkoglu A, Goya C, Icen M, Cigdem MK, Onen A, Otcu S: Traumatic diaphragmatic rupture in children. J Pediatr Surg. 49(3):420-3, 2014
6- Hwang SW, Kim HY, Byun JH: Management of patients with traumatic rupture of the diaphragm. Korean J Thorac Cardiovasc Surg. 44(5):348-54, 2011

Journal Club