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ABSTRACT: To determine the optimal timing of surgery for recurrent intussusception.
We retrospectively reviewed medical records of patients aged from 0 to 18 years old with diagnosis of intussusception in the Pediatric Department at Mackay Memorial Hospital between January 1995 and May 2010.
During the study period, there were 686 children (divided into three age groups: 367 < 2 years, 289 aged 2 to 5 years, 30 > 5 years) with diagnoses of intussusception. Eighty-five of the 686 patients had recurrent intussusception, of whom 56 had two, 16 had three, 11 had four, and 2 had five episodes. The recurrence rate after the first, second, third, and fourth barium enema reductions were 15.7%, 37.7%, 68.4%, and 100.0%, respectively. The incidence of recurrence and failure rate of barium enema reduction did not differ significantly among these three age groups. Surgery was performed in 177 children (146 during the first episode and 31 in recurrent cases). The probability of eventual surgery after first enema reduction was 21.8%, after the second 35.7%, and after the third 70.0%. Lead points were found in 15 children, and all of them were found during surgery for the first episode of intussusception.
The probability of recurrence was 100% after the fourth episode of intussusception in our study. After the third episode of intussusception, the probability of recurrence and eventual surgery were 68% and 70%, respectively. From this study, surgical intervention should be considered at the third episode of intussusception.
Pediatrics & Neonatology 10/2012; 53(5):300-3. · 0.75 Impact Factor
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ABSTRACT: To assess whether constipation or fecal incontinence is a major late complication after posterior sagittal anorectoplasty in patients with anorectal malformation (ARM).
We retrospectively enrolled 188 children, 85 low-type ARM (L-ARM) and 103 high-type ARM (H-ARM), who had complete medical records of bowel habits and medication histories after posterior sagittal anorectoplasty for anorectal malformation in Mackay Memorial Hospital. Stool characteristics as well as physical and medication history were evaluated. The symptom severity (SS) scoring system was used to assess changes in bowel habits.
During a mean follow-up period of 4.3 years, constipation was found to be the most common late complication in both groups of patients (64.5% in the L-ARM group and 78.6% in the H-ARM group). Compared to constipation, stool incontinence was much less frequent, with 4.7% in L-ARM and 3.9% in H-ARM. There was no significant difference in mean SS scores between the two groups.
Constipation was the most common late sequela in children after correction of ARM in our study.
Pediatrics & Neonatology 08/2012; 53(4):252-6. · 0.75 Impact Factor
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ABSTRACT: To classify and evaluate the clinical spectrum of congenital webs in the gastrointestinal (GI) tract, including clinical courses and related factors.
A retrospective chart review was performed on 37 patients with congenital GI webs at a pediatric care teaching hospital in north Taiwan. All of the related parameters were collected and analyzed.
Twelve patients had gastric webs, 22 had duodenal webs, and three had jejunal webs. The mean time to diagnosis was 1576 days for gastric webs, 116 days for duodenal and 230 days for jejunal webs. There was a statistically significant difference between the gastric and duodenal groups (p = 0.001). The major symptom was vomiting (78%). Patients with duodenal webs had a high association with congenital anomalies (50%). The major anomalies included cardiac (27%) and GI anomalies (18%). Endoscopy was performed in 10 gastric cases, and all of them were noted to have positive findings, including a fixed nonfolded stenotic ring following a second gastric chamber and a real pylorus. All of the patients received surgery except for three with gastric webs, and no mortality was noted. The mean postoperative days of tolerated feeding was 6 for those with gastric webs, 10 for those with duodenal and 11 for those with jejunal webs.
The clinical course of gastrointestinal webs may be chronic or obscure. A delay from onset of symptoms to treatment may exist, especially in gastric webs. We suggest that prompt endoscopic confirmation and surgical intervention for these lesions, when suspected due to clinical and radiologic abnormalities, will decrease the morbidity of unexplained recurrent symptoms or signs of GI obstruction in these patients.
Pediatrics & Neonatology 02/2012; 53(1):12-7. · 0.75 Impact Factor
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ABSTRACT: Primary yolk sac tumor of the diaphragm in children is very rare, and diagnosis of a diaphragmatic tumor poses challenges to clinical physicians. Here, we report a primary diaphragmatic yolk sac tumor in a 9-month-old girl, together with a review of 4 earlier reported cases in the English literature. Carboplatin-containing regimen successfully decreased the tumor size and a total resection of the tumor was made subsequently. The patient was disease-free 8 months after the completion of treatment.
Journal of Pediatric Hematology/Oncology 03/2011; 33(2):e77-9. · 1.16 Impact Factor
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ABSTRACT: The aim of the study was to assess the presentation, imaging findings, management, and outcome of segmental multicystic dysplastic kidney (MCDK) in children.
Six patients with segmental MCDK were diagnosed and observed at our hospital. We reviewed the medical records to collect data on initial symptoms, results of imaging studies, associated urinary tract anomalies, operation, and outcome.
Three patients had abnormal prenatal ultrasound and were diagnosed by further postnatal imaging; they were asymptomatic after birth. The other 3 children presented with a renal mass, recurrent urinary tract infection, or urinary incontinence. Five patients had associated ipsilateral or contralateral urinary tract abnormalities, including vesicoureteral reflux, ureterocele, duplex collecting system, ureteropelvic junction stenosis, and ectopic ureter. Lower tract reconstruction was performed in 3, and open biopsy was done in 1 child. None underwent partial or total nephrectomy, and all had involution of the cysts for a mean of 40 months.
Most of the cases occur in the upper pole of a duplex kidney and often involute spontaneously without significant complication. The clinical presentation and imaging findings depend on the associated anomalies and complications. Although the latter may require surgery to resolve, segmental MCDK itself rarely requires resection.
Journal of Pediatric Surgery 09/2010; 45(9):1856-62. · 1.45 Impact Factor
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ABSTRACT: Duplication cyst of the duodenum is rare. This study describes a case of duodenal duplication and evaluates its clinical features through a literature review.
A case of duodenal duplication is reported, and related articles published from 1999 to 2009 on PubMed were reviewed. Clinical manifestations, diagnostic examinations, and methods of management were analyzed.
Including this report, there had been 38 citations in literature that provide adequate descriptions of 47 cases of duodenal duplication cysts. Nineteen (40.4%) were discovered before 10 years of age, whereas 10 (21.3%) were found in the second decade. The remaining 18 patients (38.3%) were older than 20 years. The case number decreased as age increased. Overall, 80% of cases presented with abdominal pain, and 53% were complicated with pancreatitis.
The most common symptom in duodenal duplication cysts is abdominal pain with or without nausea or vomiting. The most common complication is pancreatitis. Differential diagnoses of pancreatitis, hepatitis, cholestasis, or intussusception should include duplication cyst of the duodenum.
Journal of Pediatric Surgery 08/2010; 45(8):1598-606. · 1.45 Impact Factor
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ABSTRACT: Congenital Bochdalek diaphragmatic hernia (CDH) is easily recognized if it is present shortly after birth. However, cases of delayed CDH presentation are more subtle and therefore less easily diagnosed.
We retrospectively analyzed 85 patients who were under 18 and diagnosed with CDH between June 1987 and May 2007. Those diagnosed before 1 month of age were categorized as having early-presenting CDH and those diagnosed after 1 month were categorized as having late-presenting CDH.
Of the 85 cases, 68 (80%) were early-presenting and 17 (20%) were late-presenting CDH. Respiratory symptoms were more common in early-presenting CDH, while gastrointestinal complaints were more dominant in the late-presenting group, particularly in patients with left diaphragmatic defects. Late-presenting CDH, which was more likely to be associated with chronic gastrointestinal symptoms, was associated with a lower mortality than acute early-presenting CDH with respiratory symptoms, despite the more prompt diagnosis of the latter. The small bowel was the organ most commonly herniated into the thorax. Congenital heart disease was the most commonly associated malformation, but the presence of associated anomalies did not increase mortality.
Early-presenting CDH shows acute symptoms, is readily diagnosed, and requires prompt intervention to prevent death. In contrast, late-presenting CDH shows more subtle symptoms and is more difficult to diagnose. Although the late-presenting CHD has better prognosis, it still requires surgery intervention to alleviate the symptoms. Clinicians must maintain a high index of suspicion for CDH, regardless of its presentation.
Pediatrics & Neonatology 02/2010; 51(1):26-30. · 0.75 Impact Factor
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ABSTRACT: From 1990 to 2004, there were 23 consecutive patients with hepatoblastoma treated at Mackay Memorial Hospital in Taipei, Taiwan. There were 7 patients of stage I, 3 of stage II, 13 of stage III, and none had stage IV disease. Two siblings had congenital hepatoblastoma and both survived. Two patients were prematurity. Beckwith-Wiedemann syndrome, isosexual precocity, chronic B hepatitis presented in 1 patient each. In addition to surgery, we used cisplatin 90 mg/m/d on day 1 and epirubicin 25 mg/m/d for days 1 to 3 as first-line chemotherapy. Each course was repeated every 3 weeks. Epirubicin was chosen because of its lower cardiotoxicity. Carboplatin/etoposide and vincristine/cyclophosphamide/5-fluorouracil were the second-line chemotherapy for considering cumulative toxicity of first-line chemotherapy. If initial total excision was feasible, postoperative chemotherapy of 4 to 6 courses were given. Three patients died of progressive disease, infection, and relapse 1 each. The median duration of follow-up for 20 survived patients was 94 months. The 5-year event-free and overall survival rates were 73.9%+/-9.2% (SE) and 87%+/-7.0%, respectively. Tumor recurred in 5 patients. The commonest toxicity was febrile neutropenia. There was no cardiotoxicity event. In conclusion, with sequential combination of surgery and chemotherapy, the treatment results for hepatoblastoma were satisfactory as compared with other groups.
Journal of Pediatric Hematology/Oncology 10/2009; 31(10):718-22. · 1.16 Impact Factor
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ABSTRACT: Croup is common in children but recurrent croup is unusual. A 4-year-11-month-old boy presented with recurrent croup. Physical examination revealed decreased breath sounds over left lower chest. Chest x-ray disclosed segmental atelectasis over left lower chest and a mass shadow over mediastinum.
European Journal of Pediatrics 10/2009; 169(2):249-51. · 1.88 Impact Factor
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ABSTRACT: Sonography is used to diagnose infantile hypertrophic pyloric stenosis, but Little information is available about the appearance of postoperative sonographs. The purpose of this study was to evaluate the morphology of the pylorus in association with an obstruction before and after pyloromyotomy.
Pyloric length, diameter, muscle thickness and intermuscular space were measured sonographically at diagnosis and daily after pyloromyotomy until discharge in 12 infants with infantile hypertrophic pyloric stenosis. The ratios of pyloric wall thickness and intermuscular space to the entire pyloric diameter were measured.
The pylorus still appeared hypertrophied after pyloromyotomy on the sonograms. The traditional measurement of linear dimensions of the pylorus was not significantly changed from the preoperative values by the time of discharge, except for muscle thickness. The intermuscular space increased from 4.8+/-0.8 mm preoperatively to 7.3+/-2.1 mm by postoperative day 3 (p=0.10). Lowe's pyloric ratio at diagnosis was a mean of 0.32, decreasing to 0.29 on postoperative day 3 and 0.29 on the day of discharge (p=0.82). The alternative pyloric ratio increased significantly by postoperative day 2 (0.24+/-0.09 on day 2 vs. 0.11+/-0.07 preoperatively, p=0.02).
The pyloric ratio appears to be a reliable parameter in evaluating the regression of pyloric stenosis after pyloromyotomy, and also aids in the diagnosis of pyloric stenosis.
Pediatrics & Neonatology 07/2009; 50(3):117-20. · 0.75 Impact Factor
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ABSTRACT: Fungal peritonitis (FP) is a serious complication in patients on continuous ambulatory peritoneal dialysis (CAPD). We report a case of CAPD-related FP caused by Paecilomyces lilacinus in a 15-year-old uraemic boy. The infection was successfully treated by combination therapy consisting of oral voriconazole and terbinafine, which has not been previously reported in the treatment of FP.
Journal of Medical Microbiology 01/2009; 57(Pt 12):1581-4. · 2.50 Impact Factor
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ABSTRACT: Gastric perforation among neonates is a rare but frequently fatal condition of uncertain etiology. The aim of this study was to review the clinical course of neonatal gastric perforation and to evaluate possible prognostic factors.
We retrospectively analyzed the medical records of 15 patients with neonatal gastric perforation over a 19-year period. Another 97 patients described in the medical literature, for whom the gestational ages and birth weights were clearly stated, were also reviewed.
In our series, there were three girls and 12 boys, nine of whom were full-term infants and six preterm infants. The most common initial manifestations were poor activity, abdominal distension, and respiratory distress. The overall mortality was 47% (7/15). Prematurity was the only statistically significant risk factor; 83% (5/6) of premature infants died compared with 22% (2/9) of term babies (p < 0.05). Combining our series with the patients reported in the literature, there were a total of 50 premature infants and 62 term infants. Gastric perforation occurred on postnatal days 2-7 and presented with nonspecific manifestations. The mortality was significantly higher in premature than in term infants (31/50, 62% vs. 16/62, 26%; p < 0.001). A trend towards higher mortality in infants with lower birth weights was observed (>2500 g, 28%; 1501-2500 g, 52%; 1000-1500 g, 60%; <1000 g, 100%). Infants with birth weights <2500 g had a significantly higher mortality than infants with birth weights >2500 g (32/58, 55% vs. 15/54, 28%; p<0.05).
Neonatal gastric perforation is associated with high mortality, particularly in premature infants. There is also a trend towards higher mortality in lower-birth-weight infants.
Pediatrics & Neonatology 06/2008; 49(3):65-70. · 0.75 Impact Factor
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ABSTRACT: Tracheal duplication is a very rare infant congenital airway anomaly. We report a bronchogenic cyst communicating with a tracheal duplication. This is the first reported case of pathologically confirmed duplication of trachea communicating with a bronchogenic cyst.
Journal of Pediatric Surgery 04/2007; 42(3):561-3. · 1.45 Impact Factor
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ABSTRACT: Intussusception in children may recur after surgical correction. Ileopexy has popularly been used as a procedure to prevent recurrent intussusception, but its effect has not been well evaluated. The present study compared the incidence of recurrent intussusception after several different surgical procedures for intussusception in children. The charts of 278 children undergoing surgical reduction of ileocolic intussusception over 17 years were retrospectively reviewed. The incidence of recurrent intussusception was compared among the three surgical procedures: simple manual reduction, manual reduction plus ileopexy, and segmental resection. Simple manual reduction was performed in 67 (24.1%) of the 278 patients, manual reduction plus ileopexy in 186 (66.9%), and resection of the involved segment in 25 (9.0%). There were four episodes of recurrence in three (4%) patients who had had manual reduction, nine episodes in eight (4%) patients who had undergone ileopexy, and none after segmental resection. There was no statistical difference in recurrent rate among the three groups (reduction vs. ileopexy, P = 0.95; reduction vs. resection, P = 0.28; ileopexy vs. resection, P = 0.29). Ileopexy is not better than simple manual reduction in preventing recurrence of ileocolic intussusception in children.
Pediatric Surgery International 10/2006; 22(9):725-8. · 1.25 Impact Factor
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ABSTRACT: To determine predictive variables associated with a perforated appendix in pediatric patients with acute appendicitis.
This is a retrospective, cross-sectional, observational study from a medical center with more than 2000 beds (230 beds in Department of Pediatrics and Pediatric Surgery), with a mean admission of more than 12000 cases and 2200 surgeries per year. The outcome variable was perforated appendix, and the predictive variables included demographic and clinical factors.
During a 6-year period, appendectomies were performed on 274 patients ranging in age from 1 to 18 years. Perforated appendix was found in 100 children (36.5%). Predictive factors significantly associated with perforated appendix were age younger than 9 years, abdominal pain of more than 2 days' duration, temperature of more than 37.9 degrees C, peritoneal signs, and erythrocyte sedimentation rate of more than 25 mm/h. Abdominal ultrasound was performed in 89 patients (32%). For perforated appendix, the ultrasound had a sensitivity of 35%, specificity of 98%, positive predictive value of 95%, and negative predictive value of 55%. Indications for an abdominal ultrasound were determined from a scoring system using the predictive variables significantly associated with perforated appendix.
The use of our proposed scoring system to determine the indications to perform an abdominal ultrasound may prove to assist in deciding treatment (medical vs surgical) for children with perforated appendix. Initial antibiotic treatment followed by interval appendectomy would become a more likely treatment option if our study results can be validated in a prospective study.
Pediatric emergency care 08/2006; 22(7):475-9. · 0.92 Impact Factor
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ABSTRACT: We reviewed our experience over 10 years with pyeloplasty for ureteropelvic junction obstruction. Preoperative and postoperative isotope renal scans were performed to assess the surgical outcome, with particular emphasis on the postoperative change in renal function (RF). We retrospectively reviewed the medical records of 137 consecutive children with ureteropelvic obstruction operated between January 1994 and December 2003. A total of 109 kidneys in 102 patients were evaluated with renal echo and (99m)Tc-diethylenetriaminepentaacetic renography both before and after Anderson-Hynes dismembered pyeloplasty. The improvement of RF >5% was noted in 67 kidneys (61.5%), the function remained stable in 30 kidneys (27.5%), and it deteriorated (>5%) in 12 kidneys (11.0%). Five patients (4.6%) required repeat pyeloplasty for either prolonged urine leakage or reobstruction with deterioration in RF. Dismembered pyeloplasty in children with ureteropelvic junction obstruction is safe. The renal functional improvement can be expected in the majority of kidneys that have impaired function at presentation.
Pediatric Surgery International 06/2006; 22(6):519-23. · 1.25 Impact Factor
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ABSTRACT: This study analyzed the clinical presentation, postoperative morbidity and mortality and incidence of associated extrahepatic biliary atresia in children with biliary cysts in Taiwan.
We retrospectively reviewed the records of 158 pediatric patients with biliary cysts seen between June 1981 and July 2004, with follow-up ranging from 12 months to 22 years (mean, 11.2 +/- 6.1 years). Patients were divided into three groups: biliary atresia-associated biliary cyst (BABC, 21 patients), non-biliary atresia-associated choledochal cyst (NBACC) in infancy (37 patients), and late NBACC (> 1 year of age, 100 patients).
BABC accounted for 36.2% of the infantile biliary cysts in this study. Extrahepatic cysts in late NBACC had a greater mean diameter than those in infantile NBACC and BABC (21.5 mm vs. 16.0 mm vs. 7.9 mm, p < 0.001). Cholangitis was the most serious complication within 3 months postoperatively in all three groups, resulting in four deaths (two in the infantile NBACC group and one each in the other two groups). Liver cirrhosis developed during long-term follow-up in nine of the 21 patients with BABC, four of whom died. Three of these nine patients underwent liver transplantation and remained well during follow-up. Chronic complications in NBACC occurred mainly in late IVa cases, with persistent intrahepatic dilatation developing in 12 of 35 patients and intrahepatic stones in five. Elevation of serum alanine aminotransferase (ALT) was found preoperatively in 85% of late NBACC and 35% of infantile NBACC cases. Postoperative normalization of ALT occurred after a mean of 152 +/- 23 days and 158 +/- 67 days in late NBACC and infantile NBACC, respectively. Higher ALT levels before operation were associated with a longer period until normalization.
The possibility of BABC must be included in the differential diagnosis when a small extrahepatic cyst (< 8 mm in diameter) with prolonged jaundice is found in infancy. Postoperative follow-up is essential for patients with NBACC due to their frequently prolonged elevation of serum ALT and possibility of residual intrahepatic dilatation. Cholangitis was the major cause of death within 3 months postoperatively in this study.
Journal of the Formosan Medical Association 02/2006; 105(2):118-24. · 1.13 Impact Factor
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ABSTRACT: We sought to assess the clinical and imaging findings in intermittent hydronephrosis secondary to ureteropelvic junction obstruction, with particular emphasis on the characteristic ultrasonographic findings.
This prospective, longitudinal, observational study included all children who had intermittent ureteropelvic junction obstruction and presented with abdominal pain over 6 years. Renal ultrasound was used as an initial screening tool to detect intermittent hydronephrosis. Renal ultrasonography was repeated every 1 to 2 days to record serial changes from the symptomatic to the asymptomatic stage. Their clinical manifestations and imaging findings were studied.
Eighteen patients (14 boys, 4 girls) were studied. Most had sharp pain that began acutely and typically lasted for <2 days. Most of the children (16 of 18) had nausea and vomiting that accompanied the pain. The acute episode generally resolved spontaneously and was followed by a pain-free interval that ranged from days to months. Factors that predisposed to an attack included increased water intake, vigorous exercise, or bladder distention. All patients had clearly demonstrable obstruction of the renal pelvis during an acute attack, a finding that diminished or resolved during the symptom-free intervals. During convalescence, all patients had renal pelvic wall thickening on ultrasonography. This finding appeared on the second or third day after a painful episode subsided, persisted for 6 to 9 days, and then disappeared in the symptom-free stage. Pyeloplasty was performed in 17 patients, none of whom had recurrent pain on follow-up. Extrinsic obstructions were found in 9 patients.
The keys to diagnosis are awareness of the syndrome, a detailed history, and immediate and serial imaging studies during painful crises. A thickened renal pelvic wall during convalescence is an important ultrasonic sign of intermittent hydronephrosis.
PEDIATRICS 01/2006; 117(1):139-46. · 4.47 Impact Factor
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Prenatal Diagnosis 09/2005; 25(8):721-3. · 2.11 Impact Factor
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ABSTRACT: The authors report 2 cases of 4- and 5-month-old male infants who had esophageal stenosis after Pseudomonas aeruginosa sepsis. These 2 babies were immunocompetent. A focal narrowing of esophagus at the level of C7-T1 was found on esophagogram.
Journal of Pediatric Surgery 04/2005; 40(3):E11-3. · 1.45 Impact Factor
