| Central
venous catheter (CVC) placement is an integral part in management of
many medical and surgical conditions in children. Percutaneous
placement of CVC in the subclavian or internal jugular vein is a blind
procedure using external anatomical landmarks technique. As such, they
carry an inherent risk of puncturing the artery or lung parenchyma with
its attendant complications associated with variation in venous anatomy
and depth of cannulating needle. Doppler ultrasound (US) guided CVC
placement permits direct visualization and cannulation of the central
veins in the neck (internal jugular vein), specially when placing CVC
in very small babies. US-guided CVC placement has also a reduced rate
of complications and the rate of needle punctures is also reduced.
Reducing the rate of needle punctures reduce the rate of venous
thrombosis. The right internal jugular vein is preferred with this
technique in most patients. Specific training in interventional
radiology is not essential to perform this technique safely and with a
low complication rate, but a learning curve is associated with
dominating this technique. US-guided CVC placement can be done safely
in children of all ages. References: 1- Verghese ST, McGill WA, Patel RI, Sell JE, Midgley FM, Ruttimann UE: Ultrasound-guided internal jugular venous cannulation in infants: a prospective comparison with the traditional palpation method. Anesthesiology. 91(1):71-7, 1999 2- MacIntyre PA, Samra G, Hatch DJ: Preliminary experience with the Doppler ultrasound guided vascular access needle in paediatric patients. Paediatr Anaesth. 10(4):361-5, 2000 3- Asheim P, Mostad U, Aadahl P: Ultrasound-guided central venous cannulation in infants and children. Acta Anaesthesiol Scand. 46(4):390-2, 2002 4- Machotta A, Kerner S, Höhne C, Kerner T: Ultrasound-guided central venous cannulation in a very small preterm neonate. Paediatr Anaesth. 15(4):325-7, 2005 5- Chuan WX, Wei W, Yu L: A randomized-controlled study of ultrasound prelocation vs anatomical landmark-guided cannulation of the internal jugular vein in infants and children. Paediatr Anaesth. 15(9):733-8, 2005 6- Arul GS, Lewis N, Bromley P, Bennett J: Ultrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures. J Pediatr Surg. 44(7):1371-6, 2009 |
| Melanoma
is very rare in children with approximately 400 new cases diagnosed
yearly in the United States and 2% of all melanoma cases. The incidence
of melanoma is increasing worldwide. With accurate diagnosis the
outcome for pediatric melanoma is good. Factors associated with an
increased risk of melanoma includes white race, female sex, fair
complexion, red or blonde hair, light eye color, tendency to burn with
ultraviolet light, dysplastic nevi, congenital nevi, increase number of
benign nevi, family history and immunosuppression. Early in infancy
melanoma arises from transplacental metastasis, congenital or large
nevi. Clinical signs suspicious of melanoma include increase or change
in lesion size or color, bleeding, irregular border or pigmentation
distribution, pruritus or enlarged regional lymph nodes. Trunk and
extremity are the most common location. Superficial spreading melanoma
is the most common histologic variant. Recurrence is more common in
black children and misdiagnosed cases. Increase awareness with biopsy
of suspicious lesions confirms the diagnosis while establishing depth
of tumor. Excision with sentinel lymph node (SL N) biopsy or complete
lymph node dissection is curative and improves stage-specific survival
in pediatric melanoma. The sentinel node status correlates with primary
tumor depth. Pediatric patients have a higher incidence of SLN
metastases than adults yet have a lower incidence of recurrence. References: 1- Roaten JB, Partrick DA, Pearlman N, Gonzalez RJ, Gonzalez R, McCarter MD: Sentinel lymph node biopsy for melanoma and other melanocytic tumors in adolescents. J Pediatr Surg. 40(1):232-5, 2005 2- Roaten JB, Partrick DA, Bensard D, Pearlman N, Gonzalez R, Fitzpatrick J, McCarter MD: Survival in sentinel lymph node-positive pediatric melanoma. J Pediatr Surg. 40(6):988-92, 2005 3- Strouse JJ, Fears TR, Tucker MA, Wayne AS: Pediatric melanoma: risk factor and survival analysis of the surveillance, epidemiology and end results database. J Clin Oncol. 23(21):4735-41, 2005 4- Livestro DP, Kaine EM, Michaelson JS, Mihm MC, Haluska FG, Muzikansky A, Sober AJ, Tanabe KK: Melanoma in the young: differences and similarities with adult melanoma: a case-matched controlled analysis. Cancer. 110(3):614-24, 2007 5- Lewis KG: Trends in pediatric melanoma mortality in the United States, 1968 through 2004. Dermatol Surg. 34(2):152-9, 2008 6- Gow KW, Rapkin LB, Olson TA, Durham MM, Wyly B, Shehata BM: Sentinel lymph node biopsy in the pediatric population. J Pediatr Surg. 43(12):2193-8, 2008 7- Aldrink JH, Selim MA, Diesen DL, Johnson J, Pruitt SK, Tyler DS, Seigler HF: Pediatric melanoma: a single-institution experience of 150 patients. J Pediatr Surg. 44(8):1514-21, 2009 |
| Rectal strictures in
children can occur after inflammatory bowel disease, trauma, or most
commonly postoperative following a coloanal anastomosis. Factors that
contribute to the formation of a postoperative rectal stricture include
ischemia, leakage and infection, inflammatory response to anastomotic
material, circular stapler size, and fecal contact with the
anastomosis. Stapling devices are associated with a higher rate of
postoperative strictures than handsewn anastomosis. Clinically, the
patient with a rectal stricture after surgery can develop partial or
complete bowel obstruction, frequent bowel movements, lower abdominal
fullness, sense of residual stools followed by anal pain, or the
stricture is diagnosed after preoperative imaging prior to closing a
diverting stoma. Anastomotic colorectal strictures are usually defined
as being less than 10 to 12 mm in diameter and are usually short (<
1 cm in length). A radiographic assessment of the stricture length must
be done. Depending on the diameter and length of the stricture
management might consist of transanal dilatations (manual or by
bougie), hydrostatic balloon dilatations, microwave coagulation
therapy, transanal incision, excision, or reanastomosis by means of a
circular stapler. Use of steroid injection (Kenalog) has also been
utilized. Postoperative strictures usually respond well to direct
dilatations. References: 1- Shimada S, Matsuda M, Uno K, Matsuzaki H, Murakami S, Ogawa M: A New Device for the Treatment of Coloproctostomic Stricture After Double Stapling Anastomoses. Ann Surg 224:603-608, 1996 2- Suchan KL, Muldner A, Manegold BC: Endoscopic treatment of postoperative colorectal anastomotic strictures. Surg Endosc 17: 1110-1113, 2003 3- Garcea G, Sutton CD, Lloyd TD, Jameson J, Scott A, Kelly MJ: Management of benign rectal strictures: a review of present therapeutic procedures. Dis Colon Rectum. 46(11):1451-60, 2003 4- Pabst M, Giger U, Senn M, Gauer JM, Boldog B, Scweizer W: Transanal treatment of strictured rectal anastomosis with circular stapler device: Simple and safe. Dig Surg 24: 12-14, 2007 5- McKee R, Pricolo V: Stapled revision of complete colorectal anastomotic obstruction. Am Journal Surg 195: 526-527, 2008 6- Lillehei CW, Leichtner A, Bousvaros A, Shamberger RC: Restorative proctocolectomy and ileal pouch-anal anastomosis in children. Dis Colon Rectum. 52(9):1645-9, 2009 |
We are inviting all of you to submit contribution of your own to the newsletter. Credit will be given to the authors keeping his or her name, institution and E-mail address on their work.A list of contributors will appear in the internet homepage.All works should be send to Dr. H. Lugo-Vicente to the e-mail: titolugo@coqui.net |
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