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Mediastinal Tumors

The mediastinum is the body compartment limited by the thoracic inlet superiorly, the sternum anteriorly, the spine dorsally, the diaphragm inferiorly, and both pleural cavities laterally. Although there are no anatomic boundaries between compartments, for teaching purposes, the mediastinum is divided into three parts: anterior, middle, and posterior. The boundaries of the anterior mediastinum are the sternum in front, the trachea, great vessels, and pericardium posteriorly…

Congenital Diaphragmatic Hernia and Eventration

Though overall survival has increased steadily over the last 25 years, management of congenital diaphragmatic hernia (CDH) remains a formidable challenge. Despite advances in prenatal identification/classification, perioperative management, operative techniques/approaches, and neonatal critical care, CDH remains a congenital anomaly with 20–30% mortality, significant morbidity, and long-term disability. Varying degrees of CDH severity harbor a wide spectrum of morbidity and mortality, dependent upon both patient and institutional…

Acquired Lesions of the Lung and Pleura

Parapneumonic Effusions Empyema is one form of a parapneumonic effusion (PPE) and is defined as the accumulation of pus in a body cavity. The word empyema is derived from the Greek word empyein , which means to “put pus in.” In medical terminology, it refers to pus in the pleural space. The most common etiology for a PPE is a reaction to adjacent pneumonia. However, other…

Congenital Bronchopulmonary Malformations

Congenital bronchopulmonary malformations are a continuum of developmental anomalies of the bronchopulmonary unit for which classification, nomenclature, and management remain in evolution. Although their exact pathogenesis has not been fully elucidated, the frequently observed overlapping histologic features and recent advances in the field of molecular diagnosis suggest that these lesions share a common origin, and their differences may be the result of variations in timing of…

Management of Laryngotracheal Obstruction in Children

Pediatric surgeons are often involved in the management of acute and chronic airway obstruction. Diseases that affect the larynx, trachea, and bronchus can be classified according to their etiology as congenital or acquired ( Table 21.1 ). Moreover, iatrogenic injury to the pediatric airway occasionally occurs. The large number of operative techniques for the treatment of laryngotracheal stenosis shows that no single procedure or technique is…

Chest Wall Deformities

Congenital chest wall deformities fall into two groups: those with overgrowth of the cartilages causing either a depression or protuberance and those with varying degrees of either aplasia or dysplasia. Pectus excavatum (PE), also known as an “excavated, sunken, or funnel chest,” is the most common chest wall anomaly in most countries around the world. Pectus carinatum (PC), a chest wall protuberance, makes up approximately 10–15%…

Neurosurgical Conditions

This chapter will provide a broad overview of the more common pediatric neurosurgical conditions seen in a children’s hospital setting, with the exception of trauma. Emphasis will be placed on conditions in which the pediatric surgeon and neurosurgeon interface in the care of the child. Also, tips on what to do when a neurosurgeon is not available will be discussed. Extra effort will be spent explaining…

Pediatric Orthopedic Trauma

Musculoskeletal trauma is the most common medical emergency in children. In children ages 1–14 years, injuries are the leading cause of death, more than from all other causes combined. However, not all orthopedic injuries sustained by children are life threatening. The chance of a child sustaining a fracture before age 16 is 50% for boys and 25% for girls. It has been estimated that 1–2% of…

Traumatic Brain Injury

Epidemiology and Anatomy Traumatic brain injury (TBI) is the most common cause of traumatic death in children. In the United States 475,000 children (0–14 years of age) sustain a TBI annually, with 435,000 emergency department visits, 37,000 hospitalizations, and over 2600 deaths. Worldwide, the annual incidence of TBI ranges between 47 and 280 per 100,000 children. Age distribution is bimodal, with children 0–2 years and 15–18…

Abdominal and Renal Trauma

In the United States, approximately 1 in 10,000 children sustain abdominal trauma each year. Approximately 8000 children are hospitalized with liver and/or spleen injury each year, and kidney and pancreatic injury account for an additional 600 and 200 admissions per year, respectively. In 2000, in response to significant variability in the care of children with abdominal trauma, the American Pediatric Surgery Association (APSA) Trauma Committee published…

Thoracic Trauma

Trauma is an important cause of morbidity and mortality in children. Although it accounts for a minority of trauma injuries (4–25%), thoracic trauma is associated with a 20-fold increase in mortality when compared with injured children without thoracic trauma. Isolated thoracic trauma in a child is associated with a mortality rate of approximately 5%, which is largely a result of penetrating trauma. However, children with head…

Early Assessment and Management of Trauma

Trauma remains the leading cause of mortality and morbidity in the United States in children ages 1–14 years. In 2015, it continued to result in more death and disability than all other childhood diseases combined, as nearly 4000 pediatric patients died from trauma. Moreover, in 2010, the last year for which comprehensive national data are available, trauma accounted for 8% of all pediatric hospitalizations. Although recent…

Burns

In 1953, a 49% total body surface area (TBSA) burn produced an expected mortality of 50% in a child. Today, the percent TBSA burn producing that same mortality is estimated at 99%. Despite several major advancements in burn care, burns continue to be a major cause of unintentional death and injury in children less than 14 years of age. In the United States, burns remain one…

Bites

Bites A wide variety of bites are seen in children. It is estimated that more than 1 million children are treated annually for bites ( Table 12.1 ). Much of the data on the incidence of infections and value of treatments are based on case series and retrospective studies that lack randomization and are biased based on the minority of patients who seek treatment for their…

Ingestion of Foreign Bodies

Esophageal Foreign Bodies Foreign body (FB) ingestions are a common occurrence in infants and young children. The exact incidence is unknown because many cases are not reported. In 2015, the Annual Report of the American Association of Poison Control Centers noted more than 94,000 cases of FB ingestion. More than 68,000 occurred in children ≤5 years of age. Of note, magnet ingestions have increased 8.5-fold over…

Fetal Therapy

Fetal surgery represents the therapeutic interventions on the maternal-fetal dyad for the benefit of the fetus. The evolution in fetal intervention began with advances in prenatal imaging techniques and genetic testing that allowed clinicians to make early and accurate diagnoses of fetal anomalies. As a result, the natural history and pathophysiology of many congenital anomalies was established. These advances in prenatal diagnosis have led to the…

Surgical Infectious Disease

Infection continues to be a significant source of mortality and morbidity for children despite improvements in antimicrobial therapy, aseptic surgical technique, and postoperative intensive care. Widespread unchecked antibiotic use has led to the development of more resistant organisms, leading to a rather complex and arduous process of selecting the appropriate antibiotic, especially as newer antibiotics are continually developed. In addition, infections with uncommon organisms are becoming…

Vascular Access

Obtaining vascular access of any kind is especially challenging in children. A peripheral intravenous (PIV) cannula is the most commonly used device for venous access. Placement of an intravenous catheter in children can be quite traumatic to the child, the parents, and the attendant health care providers. In some situations, it can be a fairly frustrating and time-consuming procedure, frequently requiring multiple attempts. The specific vascular…

Mechanical Ventilation in Pediatric Surgical Disease

Amazingly, ventilation via tracheal cannulation was performed as early as 1543, when Vesalius demonstrated the ability to maintain the beating heart in animals with open chests. This technique was first applied to humans in 1780, but there was little progress in positive-pressure ventilation until the development of the Fell–O’Dwyer apparatus. This device provided translaryngeal ventilation using bellows and was first used in 1887 ( Fig. 7.1…

Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO; sometimes called extracorporeal life support, or ECLS) is a lifesaving technology that employs partial heart/lung bypass for extended periods. It provides gas exchange and perfusion for patients with acute, reversible cardiac or respiratory failure. This allows the patient’s cardiopulmonary system to rest, during which the patient is spared the deleterious effects of high airway pressure, high Fi O 2 , traumatic mechanical…