PEDIATRIC SURGERY UPDATE ©

VOL 30 NO 04 APRIL 2008

Esophageal Foreign Bodies

The superior esophagus is the narrowest portion of the alimentary tract of children and the most common site for lodge foreign bodies. Due to the nature of infants and toddlers to place objects in their mouth, especially a coin, this represent the most common foreign body identified within the proximal esophagus. The child will develop cough, stridor, choking, drooling, pain and inability to swallow with a lodge esophageal foreign body. Complications secondary to the esophageal foreign body itself include erosion/perforation, stricture, migration, mediastinitis and airway complications. Since aspiration and perforation are immediate complications, the impacted foreign body mandates urgent surgical attention. A simple chest film will delineate the position of the lodge coin. With other type of non-opaque foreign bodies an esophagogram will be needed to help visualized the position and type of obstruction. Rigid esophagoscopy under general anesthesia or flexible esophagoscopy under sedation is the procedure of choice to remove the foreign body, though Foley balloon extraction under fluoroscopic control is an acceptable method of coin extraction with minimal morbidity. Other times the foreign body can be pushed toward the stomach using esophageal bougienage. Children younger than one years, those with a widened tracheoesophageal interface, not a smooth object or more than one week after ingestion seems to be at highest risk for esophageal edema, failure of balloon extraction and complications.

References:
1- Ozguner IF, Buyukyavuz BI, Savas C, Yavuz MS, Okutan H: Clinical experience of removing aerodigestive tract foreign bodies with rigid endoscopy in children. Pediatr Emerg Care. 20(10):671-3, 2004
2- Waltzman ML, Baskin M, Wypij D, Mooney D, Jones D, Fleisher G: A randomized clinical trial of the management of esophageal coins in children. Pediatrics. 116(3):614-9, 2005
3- Little DC, Shah SR, St Peter SD, Calkins CM, Morrow SE, Murphy JP, Sharp RJ, Andrews WS, Holcomb GW 3rd, Ostlie DJ, Snyder CL: Esophageal foreign bodies in the pediatric population: our first 500 cases. J Pediatr Surg. 41(5):914-8, 2006
4- Waltzman ML: Management of esophageal coins. Curr Opin Pediatr. 18(5):571-4, 2006
5- Tokar B, Cevik AA, Ilhan H: Ingested gastrointestinal foreign bodies: predisposing factors for complications in children having surgical or endoscopic removal. Pediatr Surg Int. 23(2):135-9, 2007
6- Weissberg D, Refaely Y: Foreign bodies in the esophagus. Ann Thorac Surg. 84(6):1854-7, 2007

Lipomas

Lipomas are benign tumors accounting for 6% of soft-tissue tumors found in the pediatric age. They are ubiquitous and can occur anywhere in the body with a predilection for the trunk. Lipomas develop as painless, gradually enlarging swellings, soft to palpation and with demarcated borders. These neoplasms are slow growing and may reach great proportions without producing significant symptoms depending on location. Mediastinal lipomas produce respiratory distress, while spinal cord lipomas are associated with significant neurological symptoms. Ultrasound will uncover the homogenous nature of the tumor, while CT or MRI will demonstrate the relation of the tumor with surrounding structures. Infiltration of surrounding structure rather than displacement suggests a malignant variant known as liposarcoma. Definite diagnosis can only be obtained by pathologic examination which must differentiate between lipoma, lipoblastoma, liposarcoma or myxoma. Needle aspiration biopsy can provide the diagnosis. Management consists of surgical resection to establish the diagnosis, alleviate symptoms if present and avoid local recurrence. Endoscopic excision or liposuction of large capsulated lipomas can be appropriate treatment and effective from a cosmetic point of view.

References:
1- Sakai Y, Okazaki M, Kobayashi S, Ohmori K: Endoscopic excision of large capsulated lipomas. Br J Plast Surg. 49(4):228-32, 1996
2- Mahomed AA, Beale P, Puri P: Mediastinal lipoma in children. Pediatr Surg Int. 13(2-3):218-9, 1998
3- de Jong AL, Park A, Taylor G, Forte V: Lipomas of the head and neck in children. Int J Pediatr Otorhinolaryngol. 43(1):53-60, 1998
4- Ilhan H, Tokar B: Liposuction of a pediatric giant superficial lipoma. J Pediatr Surg. 37(5):796-8, 2002
5- Inampudi P, Jacobson JA, Fessell DP, Carlos RC, Patel SV, Delaney-Sathy LO, van Holsbeeck MT: Soft-tissue lipomas: accuracy of sonography in diagnosis with pathologic correlation. Radiology. 233(3):763-7, 2004
6- Grandbois L, Vade A, Lim-Dunham J, Al-Masri H: MRI findings of an intermuscular lipoma in a 2-year-old. Pediatr Radiol. 36(9):974-6, 2006

Anal Canal Duplication

Anal canal duplication is a very rare congenital malformation: the most distal and least common duplication of the digestive tube. It can be confused with other types of anorectal pathology including hemorrhoids, fistula-in-ano, and perirectal abscess. Anal canal duplications are usually located posterior presenting as a one to 2 mm perineal opening just behind the anus in the midline. The tract runs along the posterior aspect of the anal canal without communication with the anorectum. Most cases are females. Simple perineal inspection makes the diagnosis. Older children will present with localized infection or pruritus. Most children are asymptomatic. Fistulography reveals a tubular structure or a cystic structure behind the normal anal canal whose length varies from 10 to 30 mm. Associated malformations include sacrococcygeal teratomas, dermoid cysts, sacral dysgenesis, hindgut anomalies and lumbosacral myelomeningocele. Non-invasive preoperative investigations consisting of pelvic X-ray, US examination, barium enema and fistulography, are sufficient in most cases; MRI is reserved to evaluate the presence of associated anomalies. Surgical treatment through a posterior sagittal approach or simple mucosectomy restores a normal perineal aspect without sequelae and avoids future complications like those described in other types of digestive duplications namely infection, ulceration, bleeding, and malignant changes during later adult life. Histology shows squamous epithelium on the surface of the fistula and columnar epithelium and goblet cells in the base, which confirms the diagnosis of an anal-canal duplication. Prognosis is good after surgery.

References:
1- Jacquier C, Dobremez E, Piolat C, Dyon JF, Nugues F: Anal canal duplication in infants and children--a series of 6 cases. Eur J Pediatr Surg. 11(3):186-91, 2001
2- Ochiai K, Umeda T, Murahashi O, Sugitoh T: Anal-canal duplication in a 6-year-old child. Pediatr Surg Int. 18(2-3):195-7, 2002
3- Choi SO, Park WH: Anal canal duplication in infants. J Pediatr Surg. 38(5):758-62, 2003
4- Tiryaki T, Senel E, Atayurt H: Anal canal duplication in children: a new technique. Pediatr Surg Int. 22(6):560-1, 2006
5- Lisi G, Illiceto MT, Rossi C, Broto JM, Jil-Vernet JM, Lelli Chiesa P: Anal canal duplication: a retrospective analysis of 12 cases from two European pediatric surgical departments. Pediatr Surg Int. 22(12):967-73, 2006

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Last updated: May 2008