Journal of pediatric surgery
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Synchronous bilateral Wilms' tumor accounts for 4% to 6% of all Wilms' tumors. Renal salvage procedures (partial nephrectomy and enucleation) have been recommended to conserve renal parenchyma. The objective of this study was to review the results of renal salvage operations performed in children who had bilateral neoplasms. ⋯ Overall, 72% of the kidneys were preserved, and the 4-year survival rate was 81.7%. The surgical morbidity after a salvage procedure was comparable to that of a complete nephrectomy in patients with unilateral Wilms' tumor. Although the incidence of positive surgical margins is worrisome, it did not invariably lead to local recurrence in the remnant kidney or the tumor bed.
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Although mechanical ventilation for more than 7 to 10 days has been considered a contraindication to the application of extracorporeal life support (ECLS) in neonates, the outcome and respiratory morbidity for newborns placed on ECLS after more than 7 days of ventilation have not been well characterized. The purpose of this study was to determine the impact of pre-ECLS ventilation time on the rate of survival, the likelihood of the development of bronchopulmonary dysplasia (BPD), and the need for supplemental oxygen at the time of discharge. Examination of the Extracorporeal Life Support Organization (ELSO) Registry showed that 6,110 neonates were treated for respiratory failure with a pre-ECLS ventilation time of less than 14 days between January 1990 and May 1995. ⋯ The late group was less likely to survive (odds ratio, 1.8; 95% confidence interval [CI], 1.21 to 2.68). The late group also had approximately twice the risk for the development of BPD (odds ratio, 1.9; 95% CI, 1.2 to 3.04) and a trend toward an increased incidence of home oxygen use (odds ratio, 1.55; 95% CI, 0.92 to 2.60). The authors conclude that (1) there is a greater risk of mortality and BPD and a trend toward an increased need for home oxygen with increased time on the ventilator before ECLS; (2) at 14 days the predicted probability of survival is still 53% (95% CI, 31% to 74%); (3) at 14 days the predicted probability of BPD is 54% (95% CI, 28% to 78%); and (4) based on these data, it is reasonable to consider application of ECLS to patients who have had mechanical ventilation for up to 14 days.
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Clinical judgment is superior to diagnostic tests in the management of pediatric small bowel injury.
Traumatic solid organ injuries are easily recognizable on computed tomography (CT) scans and usually are treated nonoperatively. Small bowel injuries may be difficult to diagnose and require prompt operation. This study was done to assess the role of clinical examination versus diagnostic tests in evaluating these injuries. ⋯ Serum amylase, CT scan, and DPL are not reliable diagnostic tests to exclude these injuries. Patients can be observed until physical findings suggest bowel injury without increased morbidity. Associated injuries are common; thus, patients are best treated where multidisciplinary support is available.
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Between May 1,1992 and August 1, 1995, 599 consecutively treated children under 10 years of age evaluated by the authors for a known inguinal hernia were involved in a prospective protocol to determine whether diagnostic laparoscopy has a place for evaluation of the contralateral inguinal region. The experience with the first 221 patients was reported at the 1993 AAP meeting. In this total experience, 81 patients had known bilateral inguinal hernias and did not require diagnostic laparoscopy. ⋯ Of the 214 patients for whom CPPV on the contralateral side was documented during laparoscopy, only 41 (19%) had a positive finding on insufflation. This experience has convinced the authors that diagnostic laparoscopy is the most accurate means to ascertain whether a patient should undergo contralateral inguinal exploration. In addition, laparoscopy through the ipsilateral inguinal sac is now the preferred approach.
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Comparative Study
Helicopter transport of injured children: system effectiveness and triage criteria.
The authors compared air and ground transport to a level I pediatric trauma center to assess the effectiveness of helicopter transport of injured children. They also performed a retrospective assessment of triage criteria and utilization patterns for helicopter transports. The sample comprised 3,861 children who were admitted (consecutively) to an urban level I pediatric trauma center during a 4-year period and who were transported by emergency medical services. ⋯ ROC analysis identified GCS < 12 and heart rate > 160 beats per minute as optimal air triage criteria; these yielded 99% sensitivity and 90% specificity. Using these criteria, approximately 85% of air transports would be considered overtriage. The authors conclude that (1) helicopter transport was associated with better survival rates among urban injured children; (2) pediatric helicopter triage criteria based on GCS and heart rate may improve helicopter resource utilization without compromising care; and (3) current air triage practices result in overuse of helicopters in approximately 85% of flights.