Opportunity for Reduction of Intensive Care Unit Resource Utilization in Pediatric Blunt Liver and Spleen Injuries: A National Trauma Data Bank Analysis.

INTRODUCTION: Guidelines for blunt liver and spleen injury (BLSI) by the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium (ATOMAC) emphasize hemodynamic stability over injury grade when considering non-operative management (NOM). In this study, we examined rates of intensive care unit (ICU) admission for children with isolated low-risk BLSI among US hospitals. METHODS: The National Trauma Data Bank (NTDB) was queried for patients ages 1-15 admitted between 2017 and 2019 with BLSI. Patients with penetrating injuries and/or concomitant non-abdominal injuries with AIS score ≥3 were excluded. Isolated BLSI was considered low-risk if the patient had normal admission vitals and did not require operative intervention. Primary outcomes measured were ICU admission, ICU length of stay (LOS), and overall LOS. RESULTS: 5777 patients ages 15 and under presented with isolated BLSI during the study period. 2031/5777 (35.2%) were considered low-risk. Low-risk patients had lower rates of ICU admission compared to high-risk patients (30.9% vs. 41.6%, p < 0.001) and had shorter ICU LOS (median 2 days vs. 2, p < 0.001) and shorter overall LOS (median 41 h vs. 54, p < 0.001). Pediatric verified and non-pediatric verified trauma centers had similar rates of ICU admission (36.8% vs. 38.9%, p = 0.11). CONCLUSION: Further work is needed to capture opportunities for reduction in ICU utilization in isolated BLSI. LEVEL OF EVIDENCE: III.

Chromosomal Microarray Testing in NEC: A Case Report.

Necrotizing enterocolitis (NEC) remains the most common reason for emergent surgery in the neonatal intensive care unit. The common pathophysiology in all NEC involves alteration in gut microflora, abnormal blood supply to the intestine, and uncontrolled cytokine release. We report a full-term neonate who developed NEC. The neonate had surgical resection of approximately 120cms of bowel. After an initial proximal jejunostomy she underwent a successful jejuno-ileal anastomosis with preservation of her ileocolic valve at 6 weeks of age. A little more than one year of age, she is being weaned off her parenteral nutrition (PN) as her bowel adaptation continues. A chromosomal microarray analysis (CMA) resulted in the identification of a 15q13.3 microdeletion.

We thought we would be perfect: medication errors before and after the initiation of Computerized Physician Order Entry.

BACKGROUND: Because the Institute of Medicine demanded health care improvement, electronic medical records have been implemented with the hopes of eliminating iatrogenic injury caused by avoidable mistakes. Electronic orders and electronic medical records survived its initial slow adoption and have since had a myriad of identifiable flaws as it becomes incorporated nationally. MATERIALS AND METHODS: This retrospective study at a university teaching hospital analyzed all medication order errors (OEs) for the 26 wk of paper-order entries before computer physician order entry (CPOE) and 26 weeks after CPOE was initiated. All OEs were included and documented by month as well as severity using standard taxonomy. RESULTS: Results indicated that CPOE yielded a significant increase in overall medication OE with five of six severity categories remaining the same or increasing in OE. Severity categories A and E saw a significant increase once CPOE began (P < 0.01). Pre-CPOE OEs were 1741, whereas Post-CPOE OEs were 2226, showing an increase in overall medication errors (P < 0.01). After CPOE began, the cumulative successive errors recorded were 112, 290, 267, 307, 412, 399, and 439 with an R(2) value of 0.849 and a P value of 0.003 in the analysis of variance to test regression relation. CONCLUSIONS: As CPOE adapts for its real-world applications, it may eventually prove useful in reducing errors; however, perfection and error free order entry will not be achieved unless objective data analysis guides its evolution.

NEC in Twin Pregnancies: Incidence and Outcomes.

BACKGROUND: Necrotizing Enterocolitis (NEC) is the most common gastrointestinal emergency in neonates. Previously established risk factors for the development of NEC include prematurity and low birth weight. However, it is not clear to date as to whether the etiology of NEC is due to host, environmental, or yet other unknown factors. We analyzed the differences in incidence of NEC in twin pregnancies to further clarify its etio-pathogenesis. METHODS: After IRB approval, a retrospective search of the medical records of the Department of Pediatric Surgery was done to identify all the neonates treated for surgical NEC from 2006-2013. Patients that had been treated for NEC elsewhere and subsequently transferred in to our facility were excluded. The medical records of the resulting 45 patients were then analyzed for demographics, antenatal screening, risk factors, treatment (medical and surgical), and outcomes. The resulting data was then analyzed using relative risk calculations and standard statistical tests. RESULTS: Of the 45 patients who developed surgical NEC, 9 neonates (20%) were born of a twin pregnancy. There were no cases in which both twin A and twin B developed NEC. NEC in twin pregnancy neonates showed a female preponderance (p less than 0.0001) and developed universally in the first born of the twins. Birth weight, time of onset of NEC, hospital stay and mortality were similar between twin and non-twin NEC. There was an average lead-time of three weeks to development of NEC in both singletons and twin pregnancies. CONCLUSION: There is a remarkable higher incidence of NEC amongst twins. Abnormal colonization of the gastrointestinal tract appears to be an immediate postpartum event. NEC in twin pregnancy does not appear to have a deleterious outcome compared to NEC in singleton pregnancy.

Laparoscopic resection of antenataly identified duodenal duplication cyst.

We report the first case of complete laparoscopic resection of a duodenal duplication cyst (DDC) in an 8-mo-old patient. The cyst was diagnosed by routine antenatal ultrasound performed at 3 mo of gestational age. Although the baby was born asymptomatic without any congenital abnormalities, the cyst had continued to increase on serial sonographic examinations. Previous reports have described treatment of DDC by surgical resection (laparotomy) or endoscopic marsupialization; we describe here, the first report of laparoscopic approach to resect DDC in a pediatric patient with a favorable outcome.

Management of Duodenal Atresia in the setting of Congenital Leukemia with Massive Hepatomegaly.

Down's syndrome (DS) is associated with duodenal atresia (DA) in about 8-10% of cases. Transient Myeloproliferative Disorder (TMD)/Acute Myeloid Leukemia (AML) is also associated with the trisomy 21 mutation. The occurrence of the two conditions together complicates the diagnosis and surgical management of the DA. We discuss the technical aspects of management of the DA in this clinical setting.

Pseudo double bubble: jejunal duplication mimicking duodenal atresia on prenatal ultrasound.

Prenatal ultrasound showing a double bubble is considered to be pathognomonic of duodenal atresia. We recently encountered an infant with prenatal findings suggestive of duodenal atresia with a normal karyotype who actually had a jejunal duplication cyst on exploration. A finding of an antenatal double bubble should lead to a thorough evaluation of the gastrointestinal tract and appropriate prenatal/neonatal testing and management as many cystic lesions within the abdomen can present with this prenatal finding.

Role of trace elements in parenteral nutrition support of the surgical neonate.

BACKGROUND: Parenteral nutrition (PN) has transformed the outcome for neonates with surgical problems in the intensive care unit. Trace element supplementation in PN is a standard practice in many neonatal intensive care units. However, many of these elements are contaminants in PN solutions, and contamination levels may, in themselves, be sufficient for normal metabolic needs. Additional supplementation may actually lead to toxicity in neonates whose requirements are small. METHODS: An electronic search of the MEDLINE, Cochrane Collaboration, and SCOPUS English language medical databases was performed for the key words "trace elements," "micro-nutrients," and "parenteral nutrition additives." Studies were categorized based on levels of evidence offered, with randomized controlled trials and meta-analyses accorded the greatest importance at the apex of the data pool and case reports and animal experiments the least importance. Articles were reviewed with the primary goal of developing uniform recommendations for trace element supplementation in the surgical neonate. The secondary goals were to review the physiologic role, metabolic demands, requirements, losses, deficiency syndromes, and toxicity symptoms associated with zinc, copper, chromium, selenium, manganese, and molybdenum supplementation in PN. RESULTS: Zinc supplementation must begin at initiation of PN. All other trace elements can be added to PN 2 to 4 weeks after initiation. Copper and manganese need to be withheld if the neonate develops PN-associated liver disease. The status of chromium supplementation is currently being actively debated, with contaminant levels in PN being sufficient in most cases to meet neonatal requirements. Selenium is an important component of antioxidant enzymes with a role in the pathogenesis of neonatal surgical conditions such as necrotizing enterocolitis and bronchopulmonary dysplasia. Premature infants are often selenium deficient, and early supplementation has shown a reduction in sepsis events in this age group. CONCLUSION: Appropriate supplementation of trace elements in surgical infants is important, and levels should be monitored. In certain settings, it may be more appropriate to individualize trace element supplementation based on the predetermined physiologic need rather than using bundled packages of trace elements as is the current norm. Balance studies of trace element requirements should be performed to better establish clinical recommendations for optimal trace element dosing in the neonatal surgical population.

Teaching single-incision laparoscopic appendectomy in pediatric patients.

INTRODUCTION: Laparoscopic appendectomy is accepted as the gold standard technique for the treatment of acute appendicitis. Recently single-incision laparoscopic surgery (SILS) was tried in the pediatric population and was shown to be both feasible and safe. We describe our early experience in teaching the SILS procedure for appendicitis in a large community hospital center surgical residency program. METHODS: SILS appendectomy was performed in 40 consecutive patients with acute appendicitis who were admitted by a single surgeon from May 2011 to August 2011. All patients over the age of 4 y presenting with noncomplicated and complicated appendicitis (perforated) were offered SILS appendectomy. Execution of the technical aspects of 20 SILS operations done by 3 PGY III residents was evaluated. RESULTS: The average age of the patient was 11.1 y (range, 7 to 15). SILS was performed successfully in 19 out of 20 patients. Nineteen patients underwent emergent or urgent appendectomy, while 1 patient underwent an interval procedure. Nine patients were found to have perforated appendicitis, while the other 11 had noncomplicated acute appendicitis. One patient was converted to conventional 3-port laparoscopy due to difficulties during the procedure. The mean operative time was 73 min (range, 47 to 112). A significant learning curve to successfully execute the critical steps of the SILS procedure was noted in all residents evaluated. CONCLUSION: SILS technology appears promising for the treatment of acute appendicitis. However, its successful incorporation into surgical training programs will depend on the development of innovative simulation strategies.

Laparoscopic orchidopexy: the easy way to go.

BACKGROUND/PURPOSE: Intraabdominal testes represent less than 10% of cryptorchid testicles, and yet, they are the most challenging to correct. In the last 15 years, the two-stage Fowler-Stephens orchidopexy has gained popularity. The traditional approach includes laparoscopic or open clipping of the testicular vessels (first stage) and open inguinal orchidopexy (second stage). We present our experience with 2-stage orchidopexy with both stages done through a laparoscopic approach. MATERIALS AND METHODS: Over a recent 5-year period, we reviewed patients operated for intraabdominal testis using a two-stage laparoscopic orchidopexy with a minimum of 1-year follow-up. In this study, success is defined as a nonatrophic, intrascrotal testis. Fifteen patients met the inclusion criteria, and none were lost to follow-up. RESULTS: In the 15 patients, 11 had a unilateral intraabdominal testis, and 4 had bilateral cryptorchidism, with one of the 2 testes intraabdominal. The first stage was done at a mean age of 32 months, and the average time between the two stages was 9.7 months. All procedures (31) were done on an outpatient basis. Only 2 complications occurred, one scrotal hematoma and one redo first stage because of unsuccessful clipping noted at the time of planned second stage. The success rate is 93.3% (14/15). All testicles are intrascrotal, and all but 1 have maintained preoperative volume. CONCLUSION: Two-stage laparoscopic orchidopexy is a fairly easy surgical procedure with minimum morbidity and high short term success rate. A larger cohort of patients with long-term follow-up is needed to substantiate these findings.

Prognostic factors in jejuno-ileal atresia.

OBJECTIVE: Primarily to study morbidity and mortality in jejuno-ileal atresias (JIA) and prognostic factors for outcome. Secondarily to look at the incidence of reintervention. METHODS: Retrospective review of 63 patients diagnosed with JIA over a 30-year period (1975-2005). RESULTS: Sixty-three patients (34 male) of mean gestational age 36 weeks and mean birth weight 2,858 g with JIA were studied. There were 14 type I, 14 type II, 16 type IIIA, 9 type IIIB, and 10 type IV atresias. Thirty-three patients (52%) had associated anomalies. Fifty-one patients underwent resection and anastamosis, five patients Bishop-Koop procedure, five ileostomies, and one strictureplasty. Intestinal dilatation severe enough to warrant surgical intervention was seen in seven patients with the more severe variants of atresia. Five tapering procedures, one Bianchi operation and one STEP procedure were performed. Average hospital stay was 41 days (8-332 days). Fifty-six were alive at follow ups averaging 1.7 years (6 months to 11 years). Nine patients needed reoperations for adhesions before the first year of life. There were seven deaths. Most patients who died had associated anomalies (P = 0.017) or types IV/V atresias (P = 0.007). CONCLUSION: Mild atresias have an excellent prognosis and long-term survival. Severe atresias are associated with longer PN support and secondary procedures for intestinal failure. Associated anomalies adversely affect outcomes in JIA.

One patent intracranial collateral predicts tolerance of flow reversal during carotid angioplasty and stenting.

Internal carotid artery (ICA) flow reversal is an effective means of cerebral protection during carotid stenting. Its main limitation is that in the absence of adequate collateral flow it may not be tolerated by the patient. The purpose of this study was to determine if preoperative identification of intracranial collaterals with computerized tomographic (CTA) or magnetic resonance (MRA) angiography can predict adequate collateral flow and neurological tolerance of ICA flow reversal for embolic protection. This was a study of patients undergoing transcervical carotid angioplasty and stenting. Neuroprotection was established by ICA flow reversal. All patients underwent preoperative cervical and cerebral noninvasive angiography with CTA or MRA and had at least one patent intracranial collateral. Mean carotid artery back pressure was measured. Neurological changes during carotid clamping and flow reversal were continuously monitored with electroencephalography (EEG). Thirty-seven patients with at least one patent intracranial collateral on brain imaging with CTA or MRA were included. Mean carotid artery back pressure was 58 mm Hg. All procedures were technically successful. No EEG changes were present with common carotid artery occlusion and ICA flow reversal. One patent intracranial collateral provides sufficient cerebral perfusion to perform carotid occlusion and flow reversal with absence of EEG changes. Continued progress in noninvasive imaging modalities is becoming increasingly helpful in our understanding of cerebral physiology and selection of patients for invasive carotid procedures.

Laparoscopic reduction of intussusception: an evolving therapeutic option.

INTRODUCTION: Intussusception (IS) is a common cause of bowel obstruction in the pediatric population. Traditionally, unsuccessful hydrostatic reduction has been followed by laparotomy. With the advent of minimally invasive surgery, centers have adopted laparoscopic reduction as a surgical option. We reviewed our experience with IS and investigated whether there were any advantages to performing laparoscopy over conventional laparotomy in unsuccessful air enema reduction (AE). METHODS: All the records of patients admitted from January 2001 to August 2004 with a diagnosis of IS (diagnosis code 560.0) were reviewed. Parameters investigated included age, sex, weight, radiological intervention, operative procedure, length of stay (LOS), and days to oral intake (p.o.). Statistical analysis was performed with the 2-tailed t test to compare outcomes and Fisher's exact test to assess differences in nominal frequencies. RESULTS: Seventeen males and 9 females diagnosed with IS were identified. The mean age was 2.5 years (range, 1 month to 14 years), and the average weight was 5.65 kg (range, 4.65 to 95). Twenty-three of the 26 patients (88.5%) underwent AE reduction, with success in 13 (57%). One recurred after initial successful AE, 9 failed multiple attempts at AE, and 2 attempted reductions were complicated by perforations. Fifteen patients underwent surgical reduction for unsuccessful AE or to address a pathological lead point. The success rate of laparoscopic reduction was 85%. The average time to resumption of p.o. intake for patients with successful AE was 0.5 days, and after laparoscopic reduction, the average time to p.o. intake was 1.5 days, while it was 4 days after laparotomy (P=0.05). After laparoscopic reduction, the average LOS was 6 days, but LOS was 7 days after laparotomy (P=0.66). CONCLUSION: Many children who present with IS can be treated by AE. In patients who fail AE, laparoscopy offers a safe, effective alternative to laparotomy.

Cerebral oxygenation in major pediatric trauma: its relevance to trauma severity and outcome.

INTRODUCTION: Trauma is the commonest cause of death in the pediatric population, which is prone to diffuse primary brain injury aggravated by secondary insults (eg, hypoxia, hypotension). Standard monitoring involves intracranial pressure (ICP) and cerebral perfusion pressure, which do not reflect true cerebral oxygenation (oxygen delivery [Do(2)]). We explore the merits of a brain tissue oxygen-directed critical care guide. METHODS: Sixteen patients with major trauma (Injury Severity Score, >16/Pediatric Trauma Score [PTS], <7) had partial pressure of brain tissue oxygen (Pbto(2)) monitor (Licox; Integra Neurosciences, Plainsboro, NJ) placed under local anesthesia using twist-drill craniostomy and definitive management of associated injuries. Pbto(2) levels directed therapy intensity level (ventilator management, inotrops, blood transfusion, and others). Patient demographics, short-term physiological parameters, Pbto(2), ICP, Glasgow Coma Score, trauma scores, and outcomes were analyzed to identify the patients at risk for low Do(2). RESULTS: There were 10 males and 6 females (mean age, 14 years) sustaining motor vehicle accident (14), falls (1), and assault (1), with a mean Injury Severity Score of 36 (16-59); PTS, 3 (0-7); and Revised Trauma Score, 5.5 (4-11). Eleven patients (70%) had low Do(2) (Pbto(2), <20 mm Hg) on admission despite undergoing standard resuscitation affected by fraction of inspired oxygen, Pao(2), and cerebral perfusion pressure (P = .001). Eubaric hyperoxia improved cerebral oxygenation in the low-Do(2) group (P = .044). The Revised Trauma Score (r = 0.65) showed moderate correlation with Pbto(2) and was a significant predictor for low Do(2) (P = .001). In patients with Pbto(2) of less than 20 mm Hg, PTS correlated with cerebral oxygenation (r = 0.671, P = .033). The mean 2-hour Pbto(2) and the final Pbto(2) in survivors were significantly higher than deaths (21.6 vs 7.2 mm Hg [P = .009] and 25 vs 11 mm Hg [P = .01]). Although 4 of 6 deaths were from uncontrolled high ICP, PTS and 2-hour low Do(2) were significant for roots for mortality. CONCLUSIONS: Pbto(2) monitoring allows for early recognition of low-Do(2) situations, enabling appropriate therapeutic intervention.

Mediastinoscopy in the treatment of mediastinal cysts.

OBJECTIVE: Primary cysts constitute 25% of all masses in the mediastinum. Because radiological investigations are often inconclusive, many adults require mediastinoscopy, thoracotomy, video-assisted thoracic surgery, or computed tomography-guided transbronchial, transesophageal, or transcutaneous aspiration to confirm the cystic nature of these lesions. Minimally invasive procedures fail when the cyst contents are gelatinous and mucoid (failure to aspirate) or when the cyst wall continues to secrete fluid. Though Pursel reported mediastinoscopic extirpation of benign cysts 35 years ago, it remains a "therapeutic curiosity" with sporadic reports of its usage. We report 2 successful mediastinal cyst extirpations performed as outpatient procedures and review the literature with regards to its management. METHODS: A rigid, 8-mm mediastinoscope was inserted into the anterior mediastinum following the creation of a 2-cm suprasternal incision and dissection along the anterior surface of the trachea. After aspiration, cytology of the contents revealed their benign nature. Right paratracheal cysts in 2 adult males were successfully removed mediastinoscopically by blunt and sharp dissection. RESULTS: Histopathology revealed benign mesothelial cysts in both instances. Both patients had an uncomplicated procedure and were discharged within 23 hours. No other pathology was detected on mediastinoscopy, and follow-up at 3 months and 6 months has revealed no recurrence. CONCLUSION: Mediastinoscopic cyst removal is a minimally invasive procedure with a very low morbidity and mortality rate. Morbidity, recovery, and discharge times are much less than those of more invasive procedures (video-assisted thoracic surgery / thoracotomy). We suggest that it should be the first-choice procedure for the excision of appropriately located benign mediastinal cysts.

Thyroglossal duct infections and surgical outcomes.

PURPOSE: Thyroglossal duct cysts (TGDC) are the most common head and neck congenital anomalies in children and often present as infected neck masses. The authors reviewed their experience with TGDC to determine if preoperative infection was related to postoperative complications, including recurrence and postoperative infection. METHODS: The medical records of 99 patients undergoing excision of TGDC from January 1991 to July 2002 were reviewed. Factors thought to be associated with recurrence (age, history of infection, drainage, abscess, and operative procedure) were analyzed. RESULTS: Ninety-nine patients made up the study group. The mean age at operation was 5.0 years (range, 6 months to 16 years) with a male to female ratio of 1.6:1. TGDC recurred in 12.1% (12 of 99) of these patients. There was no gender difference for those with and without recurrence. The presence of an abscess or cellulitis preoperatively (22 of 99 patients) did not correlate with recurrence (NS). In addition, postoperative infection occurred in 13 of 99 patients and also was independent of preoperative infection. However, postoperative infection clearly was associated with an increased risk of TGDC recurrence. Seven of 87 patients without recurrence had a postoperative infection, whereas 6 of 12 of those who had a recurrence had a postoperative infection (P <.001). The mean follow-up was 3.7 years and was comparable for the 2 groups (recurrence v. resolution). Twelve patients successfully underwent a second procedure for recurrence. CONCLUSIONS: In this large series of TGDC, preoperative infection occurred in approximately 1 of 5 patients and was not predictive of recurrence. Although postoperative infection did not correlate with the presence of preoperative infection, it was clearly associated with a statistically significant incidence of recurrent disease.

Rapid communication: laparoscopic Anderson-Hynes dismembered pyeloplasty using the da Vinci robot: technical considerations.

PURPOSE: To present our initial experience with laparoscopic pyeloplasty utilizing the da Vinci robot for upper tract reconstruction. CASE REPORT: A four-port transperitoneal approach was used in a 73-year-old man. The ureteropelvic (UPJ) obstruction was identified with a crossing vessel. After dismemberment of the UPJ, the renal pelvis was trimmed and reconstructed using the da Vinci robot. The total operative time was 5 hours; the time spent for reconstruction was 45 minutes. Blood loss was <150 mL. The postoperative analgesic requirement was 8 mg of morphine and 25 mg of hydrocodone. There were no intraoperative or postoperative complications. CONCLUSION: The da Vinci robot can serve as a vital surgical tool during pyeloplasty with extensive reconstruction.