Introduction Congenital jejunal webs are a rare cause of intestinal obstruction, and presentation beyond infancy is uncommon. An incomplete (fenestrated) web causes chronic partial obstruction, which can delay the diagnosis. Case presentation A 14-month-old girl presented with progressive abdominal distension. Low-grade distension with transient vomiting began at 6 – 7 months of age, when weaning foods were introduced. The month prior to the presentation was free of vomiting. She was severely underweight and stunted (6.5 kg, weight-for-age z-score −3.1; length 68 cm, length-for-age z-score −3.1). Plain radiographs showed a distended stomach and several dilated proximal jejunal loops. A water-soluble contrast study showed markedly dilated proximal small-bowel loops that emptied slowly into multiple collapsed distal loops. Malrotation with Ladd bands was suspected preoperatively. She was taken to the operating room electively for an exploratory laparotomy. During the operation we confirmed that the intestinal rotation was normal. We found an incomplete jejunal web with an aperture of approximately 5 mm, 25 cm distal to the ligament of Treitz. After distal bowel patency was confirmed, the affected jejunal segment was resected and the ends put together with a primary anastomosis. Oral intake began on postoperative day 3, and she was discharged on postoperative day 7. At her follow up one month later she was tolerating feedings without vomiting and had a weight of 6.7 kg. Conclusion A fenestrated jejunal web should be suspected in toddlers who have chronic vomiting, failure to thrive, and dilated proximal bowel loops on imaging studies.
Introduction The management of pelvic Ewing sarcoma includes chemotherapy, surgery, and pelvic radiotherapy, which can impair future fertility. Laparoscopic ovarian transposition (LOT) is a fertility-preserving option, but experience in pediatric patients remains limited. Case presentation Case 1: An 11-year-old prepubertal girl with localized right iliac Ewing sarcoma received neoadjuvant vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide (VAC/IE), surgical resection, and 54 Gy adjuvant pelvic radiotherapy. Before irradiation, bilateral LOT was performed. Mean radiation doses to the transposed left and right ovaries were 0.57 Gy and 56.23 Gy, respectively. No perioperative complications occurred. At 28 months, ovarian morphology was normal on ultrasound, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels were normal, anti-Müllerian hormone (AMH) remained low, and menstrual cycles were regular. Regular cycles continued at 51 months. Case 2 A 13-year-old postpubertal girl with sacral Ewing sarcoma received VAC/IE chemotherapy. Complete tumor resection was not feasible, and pelvic/paravertebral radiotherapy to 54 Gy was planned. Bilateral LOT was performed before irradiation; mean ovarian doses were 2.35 Gy to the right ovary and 4.7 Gy to the left ovary. No perioperative complications occurred. At 16 months, ovarian morphology was normal on ultrasound, FSH and LH levels were normal, AMH remained low, and menstrual cycles were regular. Regular cycles continued at 39 months. Conclusion Laparoscopic ovarian transposition may be a feasible strategy to spare the ovaries from pelvic radiation in children.
Introduction Congenital diaphragmatic hernia (CDH) occurs in approximately 2.5 per 10,000 births; heterotopic liver tissue in the hernia sac is even more rare. Case 1 A female patient with prenatally diagnosed left-sided CDH (without herniation of the liver) was delivered at 37 weeks and underwent a primary surgical repair at two days of life. Intraoperatively, an anterior diaphragmatic defect was identified. A thin, long tail of hepatic tissue extended to the anterior diaphragmatic rim, where it was fused to the hernia sac. This was confirmed to be hepatic tissue. The patient recovered well and no hernia recurrence has been identified. Case 2 A female patient with prenatally diagnosed right-sided CDH (with herniation of liver) was delivered at 32 weeks 3 days and underwent a primary surgical repair at three days of life. A pleuroperitoneal membrane was superior to the liver and excised. On pathology, the membrane was confirmed as hernia sac with hepatic heterotopia. The patient was last seen at 6 months of age and is doing well. Conclusion Hepatic heterotopia may be discovered intraoperatively but is often only confirmed upon pathologic examination of the resected CDH specimen. Hepatic tissue within the sac of a CDH does not seem to have any clinical consequences in the short term.
Structured Abstract: Introduction: Severe septic shock secondary to Clostridium sordellii carries a historically high case-fatality rate and is exceedingly rare in the pediatric population. Furthermore, the application of central venoarterial extracorporeal membrane oxygenation (VA ECMO) in a pediatric patient with clostridial sepsis and an open abdomen presents unique clinical considerations. Case presentation: A previously healthy 22-month-old male presented with small bowel obstruction secondary to segmental volvulus. He underwent emergent exploratory laparotomy, small bowel resection, and temporary abdominal closure with the gastrointestinal tract left in discontinuity. Postoperatively, he developed refractory septic shock, profound leukocytosis, acute renal failure, and massive capillary leak. Plasma cell-free DNA metagenomic sequencing rapidly identified polymicrobial bacteremia, including Clostridium sordellii and Clostridium perfringens . Due to escalating hemodynamic instability despite aggressive conventional resuscitation, he was cannulated by a cardiothoracic surgeon via sternotomy to central VA ECMO with high flows up to 140 cc/kg/min while maintaining an open abdomen. He was successfully decannulated on ECMO day 8 without secondary bowel ischemia or hemorrhagic complications. An end ileostomy was created on hospital day 11, and the abdomen was closed on hospital day 13. The patient was extubated on hospital day 18, had fully recovered to baseline renal function, and was discharged home after six weeks with intact neurologic function, later undergoing an uneventful ileostomy takedown. Conclusion: High-flow central VA ECMO may serve as an effective rescue strategy in children with refractory clostridial pediatric septic shock. An open abdomen should not be viewed as an absolute contraindication to central cannulation.
Introduction Rib fractures in the pediatric population are uncommon but can result in severe morbidity, particularly when accompanied by flail chest. Traditional surgical management using rigid plate-and-screw fixation carries significant risk of growth disturbances in young children. Case presentation A 6-year-old male presented with severe polytrauma sustained in a high-velocity pedestrian-versus-vehicle collision. Injuries included flail chest with multiple displaced right-sided rib fractures (ribs 2–5), bilateral pulmonary contusions, pneumothoraces, hemothoraces, and bilateral mandibular fractures. The patient was intubated and admitted to the pediatric intensive care unit (PICU). On hospital day two, he underwent open reduction and suture-based fixation of ribs 2–5 using 0 polydioxanone (PDS) sutures via an infra-pectoral incision, with pectoralis muscle preservation, and figure-of-eight sutures at additional fracture sites. Hardware fixation was deliberately avoided due to the patient's age and growth potential. He was successfully extubated on post-operative day one, downgraded from the PICU on post-operative day two, and transitioned to oral non-opioid analgesia by post-operative day four. He was discharged on post-operative day nine following concurrent management of mandibular fractures by otolaryngology. At six-week follow-up, the patient demonstrated good chest wall stability, well-healed incisions, and was resuming normal activity. Conclusion Suture-based rib fixation appears to be a feasible, growth-preserving alternative to hardware fixation in pediatric flail chest.
