Staged surgical approach of neonates with esophageal atresia and tracheoesophageal fistula from low- and middle-income countries.

BACKGROUND: Neonates born in low- and middle-income countries (LMICs) with esophageal atresia (EA) and tracheoesophageal fistula (TEF) often do not have access to adequate surgical care. We have partnered with the non-profit organization World Pediatric Project (WPP) to facilitate care for such patients. METHODS: Our protocol included placement of a gastrostomy tube by local surgeons before definitive repair at the Children's Hospital of Richmond at VCU (CHoR). The outcomes of WPP-sponsored patients with EA and TEF in this program (n = 9) were compared to patients born in the U.S. with the same condition at CHoR (n = 9). RESULTS: The baseline characteristics of the groups aside from the age at admission to CHoR and at day of surgery were comparable (0.5 ± 1.3 days vs. 15.3 ± 11.1 days, p < 0.0001; 1.1 ± 3.9 days vs. 37.3 ± 8.3 days, p < 0.0001, respectively). All patients received definitive repair without mortality; the average length of stay after surgery was lower in the WPP group. There were 4 surgical complications in the U.S. group and 1 in WPP group. All patients were weaned off of TPN and all WPP patients are now on a regular PO diet. Every WPP patient has been seen in follow-up in the U.S. and in their home country. CONCLUSION: We provided successful multidisciplinary care for neonates with EA and TEF from LMICs with outcomes similar to the neonates with the same abnormality in the U.S. The partnership with WPP has been invaluable as it has provided essential support to identify and manage these patients. LEVEL OF EVIDENCE: IV.

The effects of irrigation on outcomes in cases of perforated appendicitis in children.

INTRODUCTION: Appendicitis is the most common indication for urgent abdominal operation in children. Approximately 20%-30% of patients will have a perforation at operation. Intra-abdominal abscess after appendectomy is reported in 3%-20% of patients and adds significantly to hospital stay with increased morbidity and overall cost. Surgical dogma has long advocated for irrigation in the setting of gross pus to prevent abscess formation. METHODS: Following IRB approval, data were retrospectively collected for children who had undergone appendectomy for perforated appendicitis at one of two children's hospitals over the course of 5 y. Perforation was determined by review of operative notes. All patients had free fluid in their peritoneal cavity evacuated by suction, whereas some of the patients also had their peritoneal cavity irrigated with normal saline. Postoperative intra-abdominal abscess rates were determined based on clinical symptoms and confirmatory radiologic studies. RESULTS: There were 99 patients in the suction-only group and 139 in the irrigation group. Standard demographics were relatively similar between the two groups. There were significantly lower rates of intra-abdominal abscess formation (4.0% versus 17.2%, P = 0.002) and wound infection (1.0% versus 8.6%, P = 0.003) in the suction-only group compared with the irrigation group. We further analyzed abscess rates by surgical treatment, either laparoscopic or open appendectomy. There were 85 patients in the laparoscopic group and 152 patients in the open appendectomy group. In this subgroup analysis, there were also significantly lower rates of abscess formation in patients treated with suction only compared with irrigation in the laparoscopic (3.5% versus 18.8%, P = 0.012) and open appendectomy groups (4.2% versus 16.3%, P = 0.036). CONCLUSIONS: Results of this retrospective review indicate that a suction-only approach significantly decreased rates of abscess formation and wound infections compared to irrigation in cases of perforated appendicitis in children.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma.

BACKGROUND: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Utilization of a handheld telemedicine device in postoperative pediatric surgical care.

PURPOSE: The purpose of this study was to assess the utilization of a handheld telemedicine (TM) device in the postoperative care of pediatric surgical patients. METHODS: We performed postoperative TM evaluations using an advanced medical tablet immediately prior to seeing the patients in clinic as well as at two different time points from their home. The caregivers and physicians were surveyed about their overall satisfaction. RESULTS: Twenty-four postoperative patients who underwent a variety of general surgical operations were included. There were no changes to the TM plan of care following "in person" evaluations (n = 12) and no complications, missed diagnoses, emergency department visits, or additional clinic visits in those who only had TM postoperative evaluations (n = 12). Caregiver satisfaction ratings were 3.92 ±â€¯0.28 out of 4 (4 = very satisfied). Ninety-two percent of caregivers responded that they would be comfortable with a TM-only postoperative evaluation in the future. The physician was able to formulate an accurate assessment and plan using the device. The average travel distance saved was 44.7 ±â€¯45.5 miles (range = 10-150 miles). CONCLUSIONS: These preliminary data suggest safe and effective care with high caregiver and physician satisfaction can be provided by utilizing TM in the postoperative care of pediatric surgical patients. LEVEL OF EVIDENCE: IV.

Laparoscopic gastroesophageal dissociation in neurologically impaired children with gastroesophageal reflux disease.

PURPOSE: Neurologically impaired children with severe gastroesophageal reflux disease (GERD) are a challenging group of patients. We theorized that a laparoscopic gastroesophageal dissociation (LGED) may decrease reflux-related readmissions and healthcare visits, and improve quality of life (QOL) for them and their caregivers. METHODS: A retrospective review was performed on our pediatric patients that underwent an LGED along with a caregiver survey from 2013 to 2017. RESULTS: Twenty-two neurologically impaired patients (14months-17years) with severe GERD underwent an LGED. Patients weighed 7.9-57kg (avg=23.8kg), length of stay ranged from 5 to 20days (avg=12days), estimated blood loss ranged from <5cm3 to 450cm3 (avg=66cm3, median=25cm3), and duration of operation ranged from 299 to 641min (avg=462min). One death occurred on postoperative day 19 from gram negative sepsis (30-day perioperative mortality of 4.5%). There were a modest number of minor and major complications (follow-up avg.=13.7months, range=2-40months). There was a decrease in healthcare visits for respiratory illnesses (rated 5/5 from all 13/19 survey respondents) as well as improvements in perceived QOL of the patient (avg=4.3/5) and caregiver (avg=4.6/5). CONCLUSIONS: Our cohort of patients had a reduction in readmissions and healthcare visits, and improved QOL after undergoing an LGED based on the perceptions of their caregivers. In neurologically impaired patients with severe GERD, an LGED may be a viable alternative to traditional treatments. TYPE OF STUDY: Retrospective case series review. LEVEL OF EVIDENCE: Level IV evidence: case series without comparison.

Laparoscopic gastric plication in the morbidly obese adolescent patient.

Childhood obesity is a significant problem. Due in part to suboptimal weight loss with lifestyle intervention alone, bariatric surgery, combined with ongoing lifestyle changes, has become a favorable approach in adolescents with severe obesity and weight-related comorbidities and is associated with effective weight loss and reducing weight-related comorbidities. Laparoscopic greater curvature plication is a promising new bariatric surgical procedure that has been shown to be effective in adults with severe obesity but has not been evaluated in the adolescent population. Gastric plication may be a particularly attractive approach for the adolescent patient as it is potentially reversible, does not involve the surgical removal of tissue, and is without a significant malabsorptive component. Our team has obtained approval from our Institutional Review Board to perform a laparoscopic greater curvature plication on 30 adolescent patients with severe obesity and study its effect on weight loss, metabolic effects, and psychological functioning in the setting of a multidisciplinary program. Results of this study, including comprehensive clinical and psychological data collected over a 3.5-year span, will inform larger prospective investigations comparing the laparoscopic greater curvature plication and other bariatric operations in the adolescent population.

Robotic-assisted laparoscopic Nissen fundoplication with gastrostomy preservation in neurologically impaired children.

Robotic fundoplication has equivalent safety profiles, hospital stay, and time to alimentation, compared to laparoscopic fundoplication, but is not indicated for routine repair due to higher cost, decreased availability, and longer procedure time. Robotic surgery does offer key advantages over standard laparoscopy by employing internally articulating arms, a stable camera platform, and three dimensional imaging. Children presenting for initial or redo fundoplication after feeding gastrostomy are a subset of patients that may benefit from the robotic approach. Minimal dissection of the phrenoesophageal ligament, in combination with four anchoring sutures from the esophagus to the crura, has been shown to lead to less wrap herniation in children. This technique is particularly difficult in standard laparoscopy without dislodgement of the gastrostomy, particularly if there are abundant adhesions or a replaced left hepatic artery to preserve. In this article, we present 15 children with neurologic impairment and previous gastrostomy who underwent Nissen fundoplication, using the da Vinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA). All patients underwent a floppy Nissen fundoplication after crural closure and placement of four anchoring stitches to the crura. Six patients (40%) had redo Nissens and 5 (33.3%) had replaced left hepatic or accessory arteries that were preserved. Seven patients underwent repair of a hiatal hernia and 2 had biologic mesh placed. There were no conversions to open or intraoperative complications. One child had a revision of the gastrostomy site, because the prior percutaneous endoscopic gastrostomy had been placed through the transverse mesocolon. There were only a few minor postoperative complications. All children were doing well at latest follow-up (average, 32 months). The da Vinci surgical robot can be used to safely perform fundoplications in patients with gastrostomy tubes. The articulating instruments allow for the optimal placement of four crural tacking sutures, while preserving the gastrostomy, even in the presence of a replaced left hepatic artery.

Differential use of Erk1/2 and transforming growth factor beta pathways by mid- and late-gestational murine fibroblasts.

BACKGROUND: Previously, we demonstrated the rapid closure of mid-gestational excisional murine wounds at 32 hours. In this study, we theorized that mid-gestational wounds would be completely regenerated, whereas late-gestational wounds would heal with scar formation at 48 hours. Furthermore, we theorized that mid- and late-gestational fibroblasts differentially use the transforming growth factor beta and mitogen-activated protein kinase pathways. METHODS: Three-millimeter excisional cutaneous wounds were made on murine mid- (embryonic day 15 [E15]) and late-gestational (E18) fetuses and harvested at 48 hours for histology. Percent wound closure was calculated. E15 and E18 fibroblasts were cultured overnight for in vitro scratch wound assay in the presence of the activin receptor-like kinase 4-5-7, Erk1/2, and p38 inhibitors. RESULTS: E15 wounds healed in a regenerative manner, whereas E18 wounds exhibited scar formation. In vitro scratch closure was similar in the E15 and E18 groups at 8 hours; yet, it increased in E15 compared with E18 groups with activin receptor-like kinase 4-5-7 and Erk1/2 inhibitors. p38 inhibition resulted in reduced scratch closure in both groups. CONCLUSION: The scarless mid-gestational excisional wounds compared with the scar-forming late-gestational wounds provides a model to study scar formation. This study also suggests that variable transforming growth factor beta and Erk1/2 signaling may influence differences in wound closure between mid- and late-gestational wounds.

Successful treatment of a bowel perforation after chemotherapy for Burkitt lymphoma.

Chemotherapy-induced intestinal perforation after treatment for Burkitt lymphoma is a known potential complication. However, there are very few reports in the pediatric literature that discuss this complication in any detail, and most incidents are secondary to surgical complications such as anastomotic leaks. Furthermore, there are no reports of children that have survived chemotherapy-induced perforation, and thus, guidelines for the diagnosis and treatment of this complication or for the continuation of chemotherapy are lacking. We present a case of a 5-year-old boy who survived jejunal perforation after treatment for his Burkitt lymphoma, and the critical aspects of his care are discussed.

Rapid closure of midgestational excisional wounds in a fetal mouse model is associated with altered transforming growth factor-beta isoform and receptor expression.

BACKGROUND: Many pediatric diseases are characterized by excessive tissue contraction. Because of a poor understanding of contraction, few therapies exist. We developed a murine fetal excisional wound model of contraction and theorize that wound closure is associated with changes in transforming growth factor-beta (TGF-beta) expression. METHODS: Pregnant FVB mice underwent hysterotomy at midgestational (E15) or late-gestational (E18) ages. Three-millimeter excisional wounds were made in fetuses and harvested at 32 hours. Real-time polymerase chain reaction was performed for TGF-beta1, TGF-beta2, TGF-beta3, TbetaR-1, and TbetaR-2 in wounds and normal skin and normalized to glyceraldehyde-3-phosphate dehydrogenase. Data were analyzed by paired t test (P < .05). H&E staining of wounds was performed. RESULTS: E15 wounds (80.5% +/- 4.4%) were smaller than E18 wounds (10.4% +/- 10.5%; P < .001) at 32 hours. E15 wounds expressed higher levels of TGF-beta1 compared with normal skin (P = .001). TbetaR-2 levels were elevated in E15 and E18 wounds compared with their respective normal skin (P = .02, P = .01) and in E18 normal skin compared with E15 normal skin (P = .002). CONCLUSION: This study demonstrates that rapid midgestational wound closure in a murine model is associated with increased TGF-beta1 and TbetaR-2 expression. Elucidating the role of the TGF-beta pathways may lead to an improved understanding of wound contraction.

Regulation of fibroblast functions by lysophospholipid mediators: potential roles in wound healing.

The bioactive lysophospholipids, primarily lysophosphatidic acid (LPA) and sphingosine-1-phosphate (S1P), are recent additions to the list of potent mediators of tissue repair and wound healing. In this review, we highlight the diverse actions of LPA and S1P on many types of cells involved in the wound healing process, with special emphasis on their regulation of fibroblasts. The effects of LPA and S1P are principally mediated via specific cell surface receptors. Important signaling pathways downstream of these receptors and the importance of TGFbeta and S1P cross-talk for wound healing are also discussed. Moreover, specific agonists and antagonists of the lysophospholipid receptors may be useful for the treatment of wounds and abnormal wound healing.

Altered procollagen gene expression in mid-gestational mouse excisional wounds.

INTRODUCTION: Many pathologic conditions are characterized by excessive tissue contraction and scar formation. Previously, we developed a murine model of excisional wound healing in which mid-gestational wounds heal scarlessly compared with late-gestational wounds. We theorized that variations in procollagen gene expression may contribute to the scarless and rapid closure. METHODS: Time-dated pregnant FVB strain mice underwent laparotomy and hysterotomy on embryonic days 15 (E15) and 18 (E18). Full-thickness, excisional wounds (3 mm) were made on each of 4 fetuses per doe and then harvested at 32, 48, or 72 h. Control tissue consisted of age-matched normal fetal skin. Procollagen types 1alpha1, 1alpha2, and 3 gene expressions were measured by real-time polymerase chain reaction and normalized to glyceraldehyde-3-phosphate dehydrogenase. Trichrome staining was also performed. RESULTS: Procollagen 1alpha1 expression was decreased in E15 wounds at 32 h compared with their normal skin groups. Procollagen types 1alpha2 and 3 expressions were both increased in the E15 groups compared with the E18 groups at 48 h. At 72 h, the E15 wounds had a collagen density similar to the surrounding normal skin while E18 wounds exhibited increased collagen deposition in a disorganized pattern. CONCLUSIONS: This study demonstrates that the pattern of gene expression for types 1 and 3 collagen varies between mid- and late-gestational mouse excisional wounds. These alterations in procollagen expression may contribute to a pattern of collagen deposition in the mid-gestational fetuses that is more favorable for scarless healing with less type 1 and more type 3 collagen.

Using quantitative methods to improve the diagnostic workup for abdominal pain in children.

INTRODUCTION: The differential diagnosis of abdominal pain in children can be challenging. We applied quantitative decision-making methods to this process and sought to determine if their use provided measurable benefit. METHODS: After obtaining institutional review board approval, we recorded key elements of the history, physical examination, laboratory, and imaging evaluations along with the cost and the time spent in the emergency department (ED) for children presenting with abdominal pain. Initially, data were collected (group 1, n = 1366 patients) and then presented to the ED pediatricians. For subsequent patients, ED physicians received a sheet specific to that patient's age and sex reporting the most common diagnoses and the elements of the evaluation that had proven most useful (group 2, n = 624 patients). We compared the difference in length of stay and costs before and after intervention, between study groups, by age groups, and separately by sex using a 2-factor analysis of variance. RESULTS: The diagnostic workup cost less in boys aged 2 to 12 years after the intervention. In boys and girls older than 12 years, the cost trended lower. DISCUSSION: This study demonstrates that ED physicians equipped with specific information were able to complete their diagnostic evaluation of children presenting with abdominal pain at a lower cost.