Fetal lung apparent diffusion coefficient measurement using diffusion-weighted MRI at 3 Tesla: Correlation with gestational age.

PURPOSE: To evaluate the feasibility of using diffusion-weighted magnetic resonance imaging (DW-MRI) to assess the fetal lung apparent diffusion coefficient (ADC) at 3 Tesla (T). MATERIALS AND METHODS: Seventy-one pregnant women (32 second trimester, 39 third trimester) were scanned with a twice-refocused Echo-planar diffusion-weighted imaging sequence with 6 different b-values in 3 orthogonal diffusion orientations at 3T. After each scan, a region-of-interest (ROI) mask was drawn to select a region in the fetal lung and an automated robust maximum likelihood estimation algorithm was used to compute the ADC parameter. The amount of motion in each scan was visually rated. RESULTS: When scans with unacceptable levels of motion were eliminated, the lung ADC values showed a strong association with gestational age (P < 0.01), increasing dramatically between 16 and 27 weeks and then achieving a plateau around 27 weeks. CONCLUSION: We show that to get reliable estimates of ADC values of fetal lungs, a multiple b-value acquisition, where motion is either corrected or considered, can be performed. J. Magn. Reson. Imaging 2016;44:1650-1655.

Esophageal duplication cysts and closure of the muscle layer.

BACKGROUND: Foregut duplication cysts are rare congenital anomalies that require surgical intervention with approximately 10%-15% of all gastrointestinal duplication cysts originating from the esophagus. Consensus is lacking among surgeons regarding closure of the esophageal muscle layer after resection of an esophageal duplication cyst and long-term outcomes are poorly documented. Therefore, we conducted the first study comparing complication rates in patients undergoing closure versus nonclosure of the esophageal muscle layer after esophageal duplication cyst resection. MATERIALS AND METHODS: A retrospective cohort study at Boston Children's Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and the Floating Hospital for Children at Tufts Medical Center was conducted. Patients undergoing resection of esophageal duplication cysts between 1990 and 2012 were classified according to whether the esophageal muscle layer was closed or left open. Demographic data, surgical technique, preoperative symptoms, and both short-term (<30 d) and long-term (≥30 d) complication rates were abstracted from patient medical records. RESULTS: Twenty-five patients were identified with a median age of 15-y old (range, 2 mo to 68-y old) and an average follow-up of 1 y. Eleven patients had the esophageal muscle layer closed after surgical resection (44%). Of those 11 patients, one developed a short-term complication, dysphagia (9%, 95% CI: 2%, 38%). Only one patient returned to the operating room, after 30 d, for an upper endoscopy after developing symptoms of gastroesophageal reflux disease. Of the 14 patients who had their muscle layer left open, three patients (21%, 95% CI: 8%, 48%) developed short-term complications, two of whom required surgical intervention within 30 d. Furthermore, two additional patients required surgical intervention after 30 d for a long-term complication (diverticulum and cyst recurrence). CONCLUSIONS: Surgical complications occurred more frequently in patients who had the muscle layer left open after resection of an esophageal duplication cyst. In addition, most patients requiring reoperation for both short-term and long-term complications occurred in this group. Though small, this study is the first to evaluate the complications after resecting esophageal duplication cysts. Our results suggest that closing the esophageal muscle layer after removal of an esophageal duplication cyst may be indicated to prevent both complications and the need for reoperations.

Postoperative Complications in Children With Crohn Disease Treated With Infliximab.

OBJECTIVES: Infliximab (IFX) has become a mainstay of therapy for children with Crohn disease (CD). Despite medical advances, many children with CD, however, still require operative interventions. The risk of complications following resection in children treated with IFX remains largely unknown. We compare surgical outcomes stratified by IFX therapy in a cohort of children with CD who require bowel resection. METHODS: We reviewed the postoperative complications in 123 children with CD who underwent bowel resection with primary anastomosis at our institution between 1977 and 2011. Demographics, medications, types of operations, and inpatient courses were analyzed. Complications and length of stay were compared based on medical therapy. RESULTS: Overall, the postoperative complication rate was 13%. Of the 123 surgical cases, 24 children had received IFX before their operation. In the children treated with IFX, we identified 3 major complications, including anastomotic leak, acute renal failure, and intraabdominal abscess. There were 9 major complications in the non-IFX group, including infections (2), intraabdominal abscesses (2), bowel obstruction, shock, supraventricular tachycardia, phlegmon, and anastomotic stricture. No significant differences in complication rates or postoperative lengths of stay were identified between those who did or did not receive IFX. CONCLUSIONS: In this cohort, surgical procedures in children and young adults treated with IFX were not associated with an increased number of complications or prolonged length of stay. Given that postoperative complications are infrequent in children, larger multicenter studies may be required to determine whether IFX therapy increases the risk of surgical complications in pediatric CD.

Surgical Treatment of Tracheobronchomalacia: A novel approach.

Tracheobronchomalacia, as a whole, is likely misdiagnosed and underestimated as a cause of respiratory compromise in pediatric patients. Currently, there is no standardized approach for the overall evaluation of pediatric tracheobronchomalacia (TBM) and the concept of excessive dynamic airway collapse (EDAC); no grading score for the evaluation of severity; nor a standardized means to successfully approach TBM and EDAC. This paper describes our experience standardizing the approach to these complex patients whose backgrounds include different disease etiologies, as well as a variety of comorbid conditions. Preoperative and postoperative evaluation of patients with severe TBM and EDAC, as well as concurrent development of a prospective grading scale, has allowed us to ascertain correlation between surgery, symptoms, and effectiveness on particular tracheal-bronchial segments. Long-term, continued collection of patient characteristics, surgical technique, complications, and outcomes must be collected given the overall heterogeneity of this particular population.

Quality improvement program reduces venous thromboembolism in infants and children with long-gap esophageal atresia (LGEA).

PURPOSE: Patients with long-gap esophageal atresia (LGEA) treated with the Foker process are at increased risk of venous thromboembolism (VTE). An institutional quality improvement program to decrease VTE risk factor exposure and utilize prophylactic anticoagulation was implemented. We aim to evaluate the efficacy and safety of a VTE risk-reduction program in patients with LGEA. METHODS: Implementation and evaluation of a VTE risk-reduction program in patients with LGEA from 2012 to 2015 was performed. Symptomatic VTE with radiographic confirmation were defined as events. Post-program characteristics were evaluated and compared to a historical cohort. RESULTS: Sixty-seven patients were identified. Two developed VTE (7 %) post-program implementation; compared to 13/40 (33 %) VTE incidence in the historical cohort (p = 0.018). Baseline demographics were similar, including age, esophageal atresia type and gap length. Post-protocol patients had fewer paralysis episodes (p = 0.004), paralysis days (p = 0.003), central venous catheters (p = 0.003), thoracotomies (p < 0.001), ventilator hours (p = 0.02), and decreased hospital (p < 0.001) and ICU stay (p < 0.001). All patients in the VTE risk-reduction program were exposed to prophylactic anticoagulation. No bleeding complications and/or thrombosis-related mortality occurred. CONCLUSION: VTE risk-reduction program implementation decreased symptomatic VTE incidence with associated decreases in ICU and hospital length of stay. Prophylactic anticoagulation can be utilized safely in a complicated pediatric surgical population.

Paravertebral nerve block catheters using chloroprocaine in infants with prolonged mechanical ventilation for treatment of long-gap esophageal atresia.

BACKGROUND: Infants with long-gap esophageal atresia (LGEA) undergo repeated thoracotomies for staged surgical repair known as the Foker process (FP). Associated prolonged mechanical ventilation results in exposure to high doses of opioids and benzodiazepines, and prolonged weaning times and ICU stays. AIM: The aim of this study was to determine the effectiveness of short-term paravertebral nerve block (PVNB) catheters in reducing opioid/benzodiazepine exposure and effects on clinical variables. METHODS: The medical records of seventeen infants were retrospectively reviewed; 11 with PVNB and six without (CG). PVNB were placed using ultrasound-guidance and chloroprocaine infusions implemented in the ICU. Opioids and benzodiazepines were administered via the protocol for 5 days following thoracotomies for Foker-I and Foker-II. RESULTS: Foker-I: Average reduction in morphine and midazolam consumption was 36% (2.18 vs 3.40 mg·kg(-1) ·day(-1) ; P < 0.001) and 31% (2.25 vs 3.25 mg·kg(-1) ·day(-1) ; P = 0.033), respectively, in the PVNB compared with CG. Foker-II: Average reduction in morphine and midazolam consumption was 39% (3.19 vs 5.27 mg·kg(-1) ·day(-1) ) and 38% (3.46 mg·kg(-1) ·day(-1) vs 5.62; P < 0.001), respectively in the PVNB compared with CG. 24-h prior to extubation: Average reduction in morphine and midazolam consumption was 50% (2.91 vs 5.85 mg·kg(-1) ·24 h(-1) ; p = 0.023) and 61% (2.27 vs 5.83 mg·kg(-1) ·24 h(-1) ; P = 0.004), respectively, in the PVNB compared with CG. Infusion wean time, (independence from opioid/midazolam infusions) following extubation was 5 days in the PVNB group and 15 days in CG (P = 0.005). Median ICU stay (IQR) was 40 days (34-45 days) in PVNB patients and 71 days (42-106 days) in controls (P = 0.02). PVNB catheters were left an average of 7 days and there were no complications associated with the nerve blocks. CONCLUSION: Short-term PVNB placement decreases opioid and benzodiazepine exposure, weaning days and ICU stay in infants undergoing prolonged mechanical ventilation for LGEA repair in this small pilot study. Larger studies are warranted to confirm results.

Successful percutaneous management of traumatic abdominal compartment syndrome in a child.

Posttraumatic abdominal compartment syndrome (ACS) is an unusual and potentially lethal entity in pediatric patients. Early recognition and/or prevention of the syndrome, as well as prompt treatment of ACS, can reduce its associated morbidity and mortality but has traditionally required a laparotomy. Herein, we describe a case of posttraumatic ACS successfully treated percutaneously.

Imaging of long gap esophageal atresia and the Foker process: expected findings and complications.

Long gap esophageal atresia (EA) is characterized by esophageal segments that are too far apart for primary anastomosis. Surgical repair utilizing interposition grafts or gastric transposition are often employed. The Foker staged lengthening procedure is an alternative surgical method that utilizes continuous traction on the esophagus to induce esophageal growth and allow for primary esophageal anastomosis. This pictorial review presents the step-by-step radiographic evaluation of the Foker procedure and illustrates the radiographic findings in the most commonly encountered complications in our cohort of 38 patients managed with this procedure from January 2000 to June 2012.

Cost-Effectiveness Analysis of Bariatric Surgery for Morbid Obesity.

BACKGROUND: In the USA, three types of bariatric surgeries are widely performed, including laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic adjustable gastric banding (LAGB). However, few economic evaluations of bariatric surgery are published. There is also scarcity of studies focusing on the LSG alone. Therefore, this study is evaluating the cost-effectiveness of bariatric surgery using LRYGB, LAGB, and LSG as treatment for morbid obesity. METHODS: A microsimulation model was developed over a lifetime horizon to simulate weight change, health consequences, and costs of bariatric surgery for morbid obesity. US health care prospective was used. A model was propagated based on a report from the first report of the American College of Surgeons. Incremental cost-effectiveness ratios (ICERs) in terms of cost per quality-adjusted life-year (QALY) gained were used in the model. Model parameters were estimated from publicly available databases and published literature. RESULTS: LRYGB was cost-effective with higher QALYs (17.07) and cost ($138,632) than LSG (16.56 QALYs; $138,925), LAGB (16.10 QALYs; $135,923), and no surgery (15.17 QALYs; $128,284). Sensitivity analysis showed initial cost of surgery and weight regain assumption were very sensitive to the variation in overall model parameters. Across patient groups, LRYGB remained the optimal bariatric technique, except that with morbid obesity 1 (BMI 35-39.9 kg/m2) patients, LSG was the optimal choice. CONCLUSION: LRYGB is the optimal bariatric technique, being the most cost-effective compared to LSG, LAGB, and no surgery options for most subgroups. However, LSG was the most cost-effective choice when initial BMI ranged between 35 and 39.9 kg/m2.

The impact of bariatric surgery on pulmonary function: a meta-analysis.

Morbid obesity may affect several body systems and cause ill effects to the cardiovascular, hepatobiliary, endocrine, and mental health systems. However, the impact on the pulmonary system and pulmonary function has been debated in the literature. A systematic review and meta-analysis for studies that have evaluated the impact of bariatric surgery on pulmonary function were pooled for this analysis. PubMed, Cochrane, and Embase databases were evaluated through September 31, 2016. They were used as the primary search engine for studies evaluating the impact pre- and post-bariatric surgery on pulmonary function. Pooled effect estimates were calculated using random-effects model. Twenty-three studies with 1013 participants were included in the final meta-analysis. Only 8 studies had intervention and control groups with different time points, but 15 studies had matched groups with different time points. Overall, pulmonary function score was significantly improved after bariatric surgery, with a pooled standardized mean difference of .59 (95% confidence interval: .46-.73). Heterogeneity test was performed by using Cochran's Q test (I2 = 46%; P heterogeneity = .10). Subgroup analysis and univariate meta-regression based on study quality, age, presurgery body mass index, postsurgery body mass index, study design, female patients only, study continent, asthmatic patients in the study, and the type of bariatric surgery confirmed no statistically significant difference among these groups (P value>.05 for all). A multivariate meta-regression model, which adjusted simultaneously for these same covariates, did not change the results (P value > .05 overall). Assessment of publication bias was done visually and by Begg's rank correlation test and indicated the absence of publication bias (asymmetric shape was observed and P = .34). This meta-analysis shows that bariatric surgery significantly improved overall pulmonary functions score for morbid obesity.

Primary laparoscopic gastrojejunostomy tubes as a feeding modality in the pediatric population.

PURPOSE: Outcomes associated with primary laparoscopic gastrojejunal (GJ) tube placement in the pediatric population were evaluated. METHODS: A single-institution, retrospective review examined patients undergoing laparoscopic GJ tube placement between June 2011 and December 2014. Outcomes included gastric feeding tolerance, subsequent fundoplication, complications, and mortality. RESULTS: Ninety laparoscopic GJ tubes were placed. Median follow-up was 342days (interquartile range [IQR]=141-561days). Median patient age was 5months (IQR=3-11months) and weight was 5.2kg (IQR=4-8.4kg). The most common indications for placement were gastroesophageal reflux (n=85, 94.4%) and/or aspiration (n=40, 44.4%). Most common comorbidities included cardiac (n=34, 37.8%) and respiratory (n=29, 32.2%) diseases. The complication rate was 17.8%, including one case of intestinal perforation. Thirty-four (37.7%) patients transitioned to gastric feeding within 1year; time to conversion was 156days (IQR=117-210days); of those, 18.9% patients transitioned to oral feedings. A fundoplication was later performed in 4 children for persistent reflux. Mortality was 23.3% with no procedural-related deaths. CONCLUSION: Primary laparoscopically placed GJ tubes are a reliable means of enteral access for pediatric patients with gastric feeding intolerance. Many of these children are successfully transitioned to gastric and/or oral feedings over time. Further studies are needed to characterize which patients are best served with a GJ tube versus alternatives such as fundoplication. LEVEL OF EVIDENCE: III (treatment) TYPE OF STUDY: Retrospective.

Long-Gap Esophageal Atresia Is a Unique Entity within the Esophageal Atresia Defect Spectrum.

BACKGROUND: Long-gap esophageal atresia (LGEA) may have clinical and syndromic presentations different from those of esophageal atresia (EA) that affects shorter segments of the esophagus (non-LGEA). This may suggest unique underlying developmental mechanisms. OBJECTIVES: We sought to characterize clinical differences between LGEA and non-LGEA by carefully phenotyping a cohort of EA patients, and furthermore to assess molecular genetic findings in a subset of them. METHODS: This is a retrospective cohort study to systematically evaluate clinical and genetic findings in EA infants who presented at our institution over a period of 10 years (2005-2015). RESULTS: Two hundred twenty-nine EA patients were identified, 69 (30%) of whom had LGEA. Tracheoesophageal fistula was present in most non-LGEA patients (158 of 160) but in only 30% of LGEA patients. The VACTERL association was more commonly seen with non-LGEA compared to LGEA (70 vs. 25%; p < 0.001). Further, trisomy 21 was more common in LGEA than in non-LGEA. 25% of LGEA patients had an isolated EA diagnosis without other anomalies, compared to <1% for non-LGEA. Chromosomal microarray analysis showed copy number variations (CNV) in 4 of 39 non-LGEA patients and 0 of 3 LGEA patients. A review of the ClinGen database showed that none of those CNV have been previously described with EA. CONCLUSIONS: LGEA represents a unique type of EA. Compared to non-LGEA, it is more likely to be an isolated defect and associated with trisomy 21. Further, it is less commonly seen with VACTERL anomalies. Our findings suggest the involvement of unique pathways that may be distinct from those causing non-LGEA.

Characteristics of Hospitalized Children With a Diagnosis of Malnutrition: United States, 2010.

INTRODUCTION: Malnutrition is common in hospitalized patients in the United States. In 2010, 80,710 of 6,280,710 hospitalized children <17 years old had a coded diagnosis of malnutrition (CDM). This report summarizes nationally representative, person-level characteristics of hospitalized children with a CDM. METHODS: Data are from the 2010 Healthcare Cost and Utilization Project, which contains patient-level data on hospital inpatient stays. When weighted appropriately, estimates from the project represent all U.S. hospitalizations. The data set contains up to 25 ICD-9-CM diagnostic codes for each patient. Children with a CDM listed during hospitalization were identified. RESULTS: In 2010, 1.3% of hospitalized patients <17 years had a CDM. Since the data include only those with a CDM, malnutrition's true prevalence may be underrepresented. Length of stay among children with a CDM was almost 2.5 times longer than those without a CDM. Hospital costs for children with a CDM were >3 times higher than those without a CDM. Hospitalized children with a CDM were less likely to have routine discharge and almost 3.5 times more likely to require postdischarge home care. Children with a CDM were more likely to have multiple comorbidities. CONCLUSIONS: Hospitalized children with a CDM are associated with more comorbidities, longer hospital stay, and higher healthcare costs than those without this diagnosis. These undernourished children may utilize more healthcare resources in the hospital and community. Clinicians and policymakers should factor this into healthcare resource utilization planning. Recognizing and accurately coding malnutrition in hospitalized children may reveal the true prevalence of malnutrition.

Jejunal Interposition after Failed Esophageal Atresia Repair.

BACKGROUND: The early outcomes of using jejunal interpositions to establish esophageal continuity in patients who have had a failed repair of esophageal atresia (EA) were determined. STUDY DESIGN: This was a retrospective review of all patients treated at our institution with a jejunal interposition after a failed EA repair from 2010 to 2015. Demographics, anatomy encountered, operative techniques, requirement for microvascular support, and length of stay were analyzed. Outcomes measures included conduit survival, as well as feeding status at last follow-up. RESULTS: Ten patients were reviewed. Median age at time of interposition operation was 48 months (range 8 to 276 months) and median weight was 14.2 kg (range 7.2 to 49.7 kg). Preoperative anatomy, operative techniques, and outcomes are presented. Four patients had microvascular "supercharging" for a long jejunal graft. Median follow-up was 1.5 years (range 0.5 to 5 years) with no long-term loss of graft or deaths. Six patients are eating by mouth completely, 1 by mouth primarily with supplemental night-time feeds, 1 is transitioning from tube to oral feeds, and 2 with functional grafts are fed mostly enterally due to severe oral aversion in 1 and aspiration in 1. CONCLUSIONS: Jejunal interpositions have been used for the past 5 years to establish esophageal continuity after a failed EA repair. All jejunal conduits survived and were joined to the upper esophageal segment. For shorter gaps with a longer upper esophageal pouch, a thoracic esophageal anastomosis was possible without additional vascular support. For longer interpositions into the neck, upper conduit survival might benefit from additional vascular anastomoses (ie, supercharging). To provide adequate space in the mediastinum, the first rib can be removed, as well as a portion of the manubrium to enlarge the pathway into the neck.

Cost-effectiveness of Adolescent Bariatric Surgery.

BACKGROUND:  The current estimates of the prevalence of adolescent morbid obesity and severe morbid obesity are about 21% and 6.6%, respectively. Obesity, if left untreated, may result in a variety of comorbid conditions and earlier mortality. Adolescent bariatric surgery is an effective, but expensive means to ameliorate these conditions and the risk of earlier mortality. We aimed to develop a model to evaluate the long-term cost-effectiveness of bariatric surgery. METHODS: All adolescents who participated in our bariatric surgery multidisciplinary program from January 2010 to December 2013 were included if they had at least 12 months follow-up after their surgery. Intervention costs included all operative as well as preoperative and 12-month postoperative care. We used the US Medical Expenditures Panel Survey (MEPS) to estimate the association between reductions in BMI after surgery with future savings from reduced medical care use and with increased health-related quality of life (HRQL). We linked BMI with life expectancy using data from the Centers for Disease Control and Prevention. A Markov cohort model was then used to project health care-related costs (2013 US$), and quality-adjusted life years (QALYs) over time starting at age 18. Incremental costs per QALY of surgery vs. no surgery from a health care system perspective were then estimated. RESULTS:  At one year follow-up, mean weight loss was 37.5 (std. = 13.5) kg and the corresponding BMI was 35.4 (reduction of 13.2, p<0.01). Mean total intervention costs/person were $25,854 (std. = 2,044). A unit change in BMI was associated with future medical care savings of $157/year (p<0.01) and with an increase in HRQL of 0.004 (p<0.01) and life expectancy. At a threshold of a 100,000/QALY, bariatric surgery was not cost-effective in the first three years, but became cost-effective after that ($80,065/QALY in year four and $36,570/QALY in year seven).  CONCLUSION:  Our results suggest that bariatric surgery among adolescents may be cost-effective when evaluated over a long period of time. Future studies on a large scale are needed to show a continued improvement in QALYs and to evaluate earlier cost-effectiveness of the procedure.

Anterior Cutaneous Nerve Entrapment Syndrome in Children.

PURPOSE: The purpose of this manuscript is to report on an entity known as Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) and its relevance to chronic abdominal pain encountered in children. METHODS: Following institutional review board approval, we retrospectively reviewed patients who underwent operation for presumed ACNES from 2011-2014. Variables reviewed included age, gender, age at surgery, time from onset of pain to surgery, additional medical treatments, and surgery performed. The main outcome measure was amelioration of pain. RESULTS: Nine patients met the study criteria whereby 7 were female and 2 were male patients. Median age at time of surgery was 14 years (range: 10-19 years) and time from onset of symptoms to surgery was 10 months (range: 0.5-60 months). Eight reported complete resolution of the original symptoms in follow-up appointments. One patient reported new, yet similar symptoms on her opposite trunk. CONCLUSION: ACNES is a reported cause of chronic abdominal pain that can be managed surgically in the pediatric patient once medical management has been optimized. Close collaboration between surgeons and pain specialists helps identify patients who will benefit from surgical interventions and consideration of this condition could result in more timely pain relief in children. Further studies on a larger scale are needed to determine the long-term outcomes of this procedure.

High incidence of fracture events in patients with Long-Gap Esophageal Atresia (LGEA): A retrospective review prompting implementation of standardized protocol.

PURPOSE: To identify factors associated with an increased risk of fractures in Long-Gap Esophageal Atresia (LGEA) patients. Following implementation of a risk-stratified program, we hypothesized a reduction in fracture incidence within this potentially high-risk population. METHODS: A retrospective review of LGEA-patients admitted between 2005 and 2014 was conducted. Symptomatic fractures with radiographic confirmation were defined as events. Univariate and multivariable analysis evaluated factors including admission weight-for-age z-score, primary versus secondary Foker process (FP), weight at Foker Stage I, days and episodes of paralysis, number of parenteral nutrition (PN) days, cumulative dose of loop diuretics adjusted for body weight and days exposed, and exposure to non-loop diuretics. A fracture-prevention protocol was initiated in 2012; incidence was evaluated pre and post-intervention. RESULTS: Fifty-nine patients met inclusion criteria. Twenty-three (39%) patients in the entire cohort incurred at least one fracture during their hospitalization utilizing the Foker process. Given this high percentage, a targeted fracture-prevention protocol was initiated in 2012. Fracture incidence decreased from 48% prior to the protocol to 21% following the protocol (P = 0.046). Several variables that were associated with an increased risk of fractures on univariate analysis included prior esophageal anastomosis attempt (P = 0.008), number of separate episodes of paralysis (P = 0.002), exposure to non-loop diuretics (P = 0.006), cumulative loop diuretic dose (P < 0.001), as well as cumulative loop diuretic over days exposed (P < 0.001). Intensive care unit (ICU) stay (P = 0.002) and total length of hospitalization (P < 0.001) were also significantly longer among patients with a fracture. Number of separate episodes of paralysis was the only independent risk factor for the development of a fracture; patients having more than 3 episodes of paralysis had an estimated risk of fracture 15 times higher than those patients paralyzed only once or twice (O.R. 15.87, 95% C.I.: 1.47-171.23, P = 0.008). CONCLUSION: Episodes of paralysis appeared to be the most significant risk factor for fractures in patients with LGEA who underwent the Foker procedure. The incidence of symptomatic fractures decreased significantly following implementation of a standardized protocol in this series of LGEA patients with continued prospective evaluation.

Diverse Morbidity and Mortality Among Infants Treated with Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is utilized for cardiopulmonary failure. We aimed to qualify and quantify the predictors of morbidity and mortality in infants requiring VA-ECMO. METHODS: Data was collected from 170 centers participating in the extracorporeal life support organization (ELSO) registry. Relationships between in-hospital mortality and risk factors were assessed using logistic regression. Survival was defined as being discharged from the hospital. RESULTS: Six hundred and sixty-two eligible records were reviewed. Mortality occurred in 303 (46%) infants. Congenital diaphragmatic hernia patients (OR=3.83, 95% CI 1.96-7.49, p<0.001), cardiac failure with associated shock (OR= 2.90, 95% CI 1.46-5.77, p=0.002), and pulmonary failure including respiratory distress syndrome (OR=4.06, 95% CI 1.72-9.58, p=0.001) had the highest odds of mortality in this cohort. Birth weight (BW) < 3 kg (OR=1.83, 95% CI 1.21-2.78, p=0.004), E-CPR (OR=3.35, 95% CI 1.57-7.15, p=0.002), hemofiltration (OR=2.04, 95% CI 1.32-3.16, p=0.001), and dialysis (OR=6.13, 95% CI 1.70-22.1, p<0.001) were all independent predictors of mortality. CONCLUSION: Infants requiring VA-ECMO experience diverse sequelae and their mortality are high.

Twenty-years of splenic preservation at a level 1 pediatric trauma center.

BACKGROUND: Splenic preservation is the standard of care for hemodynamically stable children with splenic injuries. We report a 20-year single-institutional series of children with splenic injuries managed without a splenectomy. METHODS: Children evaluated and treated for blunt splenic injury at Boston Children's Hospital from 1994 to 2014 were extracted from the trauma registry. Demographics, clinical characteristics, complications, and outcomes were reviewed. Three time-periods were evaluated based upon the development and modification of splenic injury clinical pathway guidelines (CPGs). Survival was defined as being discharged from the hospital alive. RESULTS: 502 suffered isolated splenic injuries. The median AAST grade of splenic injury increased across the three CPG time periods (p<0.001). No splenic-injury related mortalities occurred. Hospital length of stay decreased significantly secondary to splenic injury CPGs (p<0.001). 99% of the patients were discharged home. CONCLUSION: In children managed over the last 20years for isolated splenic injury, no patient died or underwent splenectomy. Hospital length of stay decreased across time, despite an increase in the severity of splenic injuries encountered. Splenectomy has become so unusual in the management of hemodynamically stable children with a splenic injury that it may no longer be a legitimate outcome marker.

Restoring esophageal continuity following a failed colonic interposition for long-gap esophageal atresia.

The Foker process is a method of esophageal lengthening through axial tension-induced growth, allowing for subsequent primary reconstruction of the esophagus in esophageal atresia (EA). In this unique case, the Foker process was used to grow the remaining esophageal segment long enough to attain esophageal continuity following failed colonic interpositions for long-gap esophageal atresia (LGEA). Initially developed for the treatment of LGEA in neonates, this case demonstrates that (i) an active esophageal lengthening response may still be present beyond the neonate time-period; and, (ii) the Foker process can be used to restore esophageal continuity following a failed colonic interposition if the lower esophageal segment is still present.