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Background/purpose: Lipoblastoma/lipoblastomatosis, a rare benign pediatric tumor composed of embryonic fat, most often presents as a rapidly growing mass in children younger than 3 years. This benign tumor locally recurs up to 25% of the time. This retrospective review was done to emphasize problems with diagnosis, management, and the approach to follow-up care., Methods: Sixteen cases of pathologically proven lipoblastoma presenting to a single institution over a 16-year period (1988-2004) were reviewed retrospectively for clinical features and outcome., Results: There were 11 males and 5 females ranging in age from 18 days to 12.75 years. Preoperative diagnoses were accurate in only 3 cases. Two lesions recurred locally over a period of 10 months and 5 years. One lesion presented with local infiltration. Six lesions were right-sided, 5 were left-sided, and 5 were midline., Conclusions: It is important to consider lipoblastoma in the diagnosis of a rapidly enlarging fatty mass in children. Complete resection is the only definitive treatment and should not be delayed when impingement on surrounding structures is imminent. There is a tendency for these lesions to recur despite presumed complete excision. Therefore, follow-up for a minimum of 5 years is recommended.

Background: "Atypical Malrotation" has been increasingly diagnosed at the authors' institution., Methods: The authors reviewed retrospectively 201 consecutive operations for malrotation over 5 years to anatomically classify, and describe results of operation for, atypical malrotation. The ligament of Treitz (LOT) was classified as high if left of midline and above the 12th thoracic vertebra, low if left of midline and below the 12th thoracic vertebra, and typical if absent or right of midline., Results: A total of 201 patients underwent operation for malrotation, in 176 there were adequate radiologic studies to allow classification of the LOT. Typical malrotation was present in 75 patients, low LOT in 56, and a high LOT in 45. Volvulus was more common in the Typical group compared with the other 2 groups (12 of 75 v 1 of 56 low; 1 of 45 high; P <.05) as were internal hernias (18 of 75 v 6 of 56 low, 1 of 45 high; P <.05). Complications occurred in 13% of typical versus 22% low and 21% of high patients (P =.10). Low and high LOT patients had 13% and 11% incidence of persistent symptoms postoperatively versus 0% of typical patients., Conclusion: Atypical malrotation patients are at significantly lower risk of volvulus and internal hernia compared with typical malrotation patients, and operation appears to come with increased morbidity., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Background/purpose: Repair of recurrent diaphragmatic hernia continues to be a difficult problem. An innovative method using a nonabsorbable polypropylene prosthetic mesh plug placed via the thoracic approach using minimal dissection is presented., Methods: A retrospective analysis showed 39 children with congenital diaphragmatic hernia (CDH) who underwent repair between January 1997 and March 2000. Five children suffered a recurrence and underwent repair via the thoracic approach using the Bard Marlex Mesh Perfix Plug (C.R. Bard Inc, Billerica, MA). Follow-up was available in all children and ranged from 1 to 33 months (average, 13.8 months)., Results: Age at recurrence ranged from 2 to 48 months (average, 14.8 months), and the average time between initial repair and recurrence was 8.2 months (range, 2 to 16 months). There were no recurrences after the transthoracic mesh plug diaphragmatic hernioplasty. One child died of multiple congenital anomalies 6 months after repair., Conclusion: The transthoracic repair of recurrent diaphragmatic hernias using a nonabsorbable polypropylene prosthetic mesh plug represents an innovative approach to a difficult problem in which 5 repairs have been accomplished without recurrence in nearly 14 months of follow-up. J Pediatr Surg 36:1768-1769., (Copyright 2001 by W.B. Saunders Company.)

Nasogastric (NG) decompression has traditionally been used after major abdominal surgery in pediatric patients. This study was designed to determine if NG tubes could be routinely omitted in pediatric patients undergoing major abdominal procedures. Between January 1993 and December 1995, 83 patients had follow-up prospectively without NG decompression after a variety of major abdominal surgeries. NG tubes were inserted for persistent vomiting or abdominal distension. Exclusion criteria included bowel obstruction, intestinal atresia, and perforation of the stomach or duodenum. Ages ranged from 13 days to 22 years. Seventy-four patients (89%) were treated successfully without postoperative NG decompression. There were no cases of pneumonia, wound dehiscence, anastomotic leak, or delay in return of gastrointestinal function. Nine patients required NG tubes for persistent vomiting or abdominal distension. An anastomotic leak developed in one patient after endorectal pull-through. NG decompression is unnecessary after most major abdominal operations in pediatric patients. The endorectal pull-through may represent a group of patients that benefit from routine decompression.

The presence of delayed gastric emptying in neurologically impaired children with gastroesophageal reflux has led to controversy regarding appropriate surgical management. The authors reviewed the charts of neurologically impaired children requiring fundoplication to answer two questions: (1) is pyloroplasty needed in addition to fundoplication for delayed gastric emptying? and (2) Does delayed gastric emptying influence the morbidity associated with fundoplication? To answer the first question, 40 neurologically impaired children with delayed gastric emptying undergoing fundoplication were divided into two groups: Nissen and pyloroplasty (n = 21) and Nissen only (n = 19). The Nissen and pyloroplasty group had significantly more postoperative complications (23.8% v 5.0%) and took longer to reach full feeding (14.6 v 3.9) days. There were no differences in the incidence of recurrent symptoms, readmissions, or reoperations. To answer the second question, 58 neurologically impaired children undergoing fundoplication were grouped based on gastric emptying scan results: normal gastric emptying (> 32% in 1 hour) (n = 29) and delayed gastric emptying (n = 29). There were no differences in postoperative feeding tolerance, postoperative complications, recurrent symptoms, readmissions, or reoperations between the two groups. Delayed gastric emptying in neurologically impaired children with gastroesophageal reflux did not increase postoperative morbidity after fundoplication, and the addition of a pyloroplasty to fundoplication provided no additional benefit. The authors conclude that the procedure of choice for neurologically impaired children with gastroesophageal reflux is a fundoplication without pyloroplasty, regardless of the degree of delay in gastric emptying.

Thymic cysts are considered uncommon lesions in the differential diagnosis of pediatric neck masses. They have been described as asymptomatic and of little clinical consequence. Recent reports have stressed the possibility of respiratory compromise associated with these lesions. We reviewed our experience with cervical thymic cysts with emphasis on respiratory problems. Ten pediatric patients underwent surgery and were found to have cervical thymic cysts. Ages ranged from newborn to 14 years. There were four boys and six girls. Two were found to have the thymic cysts at time of neck exploration for Grave's disease and hyperparathyroidism. Of the remaining eight patients, all had mobile cystic masses, located anterior to but extending beneath the lower third of the sternocleidomastoid muscle. The size of the mass ranged from 3.0 to 8.5 cm. Preoperative diagnosis included cystic hygroma/branchial cleft cyst (five), lymphoma (one), teratoma (one), and thymic cyst (one). All had a history of rapidly developing neck mass. Seven of the eight gave a history of upper respiratory tract infection (URI) prior to the development of the mass. Five had imaging studies that showed tracheal compression. Three of these required airway management in the early postoperative period. All were excised through a neck incision, with two requiring sternal extension. Histology showed cholesterol crystals, Hassall's corpuscles, and giant cell reaction diagnosis of thymic cysts. There has been no recurrence and no permanent respiratory sequela in the ten patients. Cervical thymic cysts are benign lesions that may be more common than literature suggests.(ABSTRACT TRUNCATED AT 250 WORDS)

The ideal wound-support material would reinforce a wound early in the healing process when intrinsic wound strength is the weakest, yet disappear over time, preventing many of the untoward late effects seen with currently utilized nonabsorbable materials. This study was designed to evaluate the effectiveness of a newly designed absorbable material, polyglycolic acid mesh (Dexon), as a buttress for abdominal wounds closed under moderate tension. Young male rats (n = 211) were divided into three experimental groups. Animals in groups 1 (n = 96) and 2 (n = 95) had a 1.2 cm2 midline abdominal wall defect created and closely primarily. Animals in group 2 had a 2 X 5 cm piece of polyglycolic acid mesh sutured to the anterior abdominal wall overlying the closed abdominal defect. Animals in group 3 (n = 20) were unoperated controls. The animals in groups 1 and 2 were killed 1, 2, 3, 4, and 5 weeks after surgery. The entire anterior abdominal wall was removed and placed upon a bursting strength testing device. Bursting strength determinations of the supported and unsupported abdominal closures revealed that the strength of the wounds reinforced with polyglycolic acid mesh was significantly greater than unsupported wounds at 1, 2, and 3 weeks after surgery. Wounds supported with mesh had bursting strengths similar to unoperated abdomens by the first postoperative week. This study demonstrates that abdominal wall defects in rats closed primarily develop increased wound strength when the closure is supported by absorbable polyglycolic acid mesh. The use of an absorbable material may alleviate potential late complications associated with implantation of nonabsorbable materials. The clinical application of such a material remains to be determined.

Snake bites in children remain an uncommon injury. In general, there is a wide disagreement by knowledgeable authorities on a uniform approach to therapy. In the last 5 years, 29 children have been treated in our institution for snake bites, all with signs of envenomation. Treatment consisted of diagnostic laboratory studies, intravenous fluids, tetanus prophylaxis, antibiotics, bed rest, elevation, and observation. There were no deaths. A fasciotomy was required in three children. Cryotherapy initiated elsewhere resulted in tissue loss. Seven children received antivenin. All developed signs and symptoms to serum sickness. From this experience, it appears that the majority of snake bites in children, especially copperhead bites, can be treated selectively and conservatively. Care must be exercised in using antivenin as it is associated with a high rate of serum sickness. Cryotherapy adds to the morbidity of the bite and is not to be used.

The association between pyelonephritis and vesicoureteral reflux (VUR) following pediatric renal transplantation is unclear. To understand the relationship of vesicoureteral reflux with urinary tract infection (UTI) and pyelonephritis, 67 patients were evaluated for reflux and pyelonephritis. Sixty-seven pediatric patients, aged 2 to 18 (39 males and 28 females) underwent renal transplantation. Beginning in 1982, all patients underwent voiding cystourethrography or radionuclide voiding studies 1 to 3 months postoperatively to assess the incidence of VUR. Techniques of ureteroneocystostomy (UNC) included the Leadbetter-Politano (L-p) in 39 cases, and two different modifications of the LICH (herein called LICH-1 and LICH-2) in 30 cases. Urinary cultures were performed routinely. Pyelonephritis was considered present in any patient with UTI and increased serum creatinine or fever greater than 38.5. VUR occurred in 36% of patients; highest in LICH-1 (79%), intermediate in L-P (22%), and lowest in LICH-2 (9%). VUR was not statistically significantly higher in females (43%) v males (31%). UTI occurred in 37% of patients. The difference in incidence between females (54%) and males (26%) was significant (P less than .05). The frequency of UTI in patients with VUR was 46% v 33% in patients without reflux (NS). However, pyelonephritis that occurred in 16% of cases overall was present in 82% of UTIs in patients with reflux v 14% of UTIs in patient without reflux (P less than .01). Pyelonephritis is significantly increased in pediatric renal transplant patients with UTI was have VUR. A nonrefluxing UNC is advocated in all patients. All renal transplant patients should have routine monitoring of urinary cultures and should be evaluated of VUR posttransplant.