Sternal Wound Salvage in Post-Transplant Adolescents: Omental Flap Reconstruction in Patients With Prior Abdominal Surgery.

Sternal wound infections remain a significant cause of morbidity and mortality in patients undergoing complex cardiothoracic surgery. Heart and lung transplant patients presumably face additional risk secondary to their underlying morbidity, postoperative immunosuppression, and difficulty with primary wound closure over large graft size. These patients present a unique challenge to the reconstructive surgeon, as many have a significant past surgical history, which can limit or alter treatment options. This study reports 2 pediatric transplant patients who underwent use of omental flap for sternal wound reconstruction in the context of significant past abdominal surgery. One patient underwent prior heart transplantation and the other patient underwent previous bilateral lung transplantation. Both had significant abdominal surgery prior to transplantation and suffered from sternal wound complications post-transplantation. Each patient was successfully treated with omental flap reconstruction.

Management of traumatic duodenal hematomas in children.

BACKGROUND: Duodenal hematomas from blunt abdominal trauma are uncommon in children and treatment strategies vary. We reviewed our experience with this injury at a large-volume children's hospital. MATERIALS AND METHODS: A retrospective case series was assembled from January 2003-July 2014. Data collected included demographics, clinical and radiographic characteristics, and hospital course. Patients with grade I injuries based on the American Association for the Surgery of Trauma Duodenum Injury Scale were compared with those with grade II injuries. RESULTS: Nineteen patients met inclusion criteria at a median age of 8.91 y (range, 1.7-17.2 y). Mechanisms of injury included direct abdominal blow or handle bar injury (n = 9), nonaccidental trauma (n = 5), falls (n = 3), and motor vehicle accident (n = 2). Ten patients had grade I hematomas and nine had grade II. Hematomas were most frequently seen in the second portion of the duodenum (n = 9). Five patients underwent a laparotomy for concerns for hollow viscus injury. No patients required operative drainage of the hematoma; however, one patient underwent percutaneous drainage. Twelve patients received parenteral nutrition (PN) for a median duration of 9 d (range, 5-14 d). Median duration of PN for grade I was 6.5 d (range, 5-8 d) versus 12 d for grade II (range, 9-14 d; P = 0.016). Complications included one readmission for concern of bowel obstruction requiring bowel rest. CONCLUSIONS: This study suggests that duodenal hematomas can be successfully managed nonoperatively. Grade II hematomas are associated with longer duration of PN therapy and consequently longer hospital stays. These data can assist in care management planning and parental counseling for patients with traumatic duodenal hematomas.

Overuse of fluoroscopic gastrostomy studies in a children's hospital.

BACKGROUND: Gastrostomy tubes are often dislodged or exchanged in children. Indications for fluoroscopic examination of gastrostomy location include concern for malposition, dislodgement, leak, or gastric outlet obstruction. We hypothesized that most of the studies obtained at our institution were not ordered for one of the aforementioned indications and do not ultimately affect patient management. METHODS: All fluoroscopic gastrostomy studies performed from January 2011 to December 2012 were reviewed. Transgastric jejunostomy studies were excluded. Patient demographics, indications for the study, elapsed time since placement, imaging findings, and short-term outcomes were recorded. Chi-square analysis was used to evaluate relationships between categorical variables. RESULTS: During the study period, 337 patients who underwent fluoroscopic gastrostomy studies were identified; median age was 2.5 y (0.05-23.8). Sixty-two percent (208/337) of the studies were ordered in asymptomatic patients to confirm tube placement location after routine exchange or replacement. Symptomatic patients accounted for 38% of the studies. Ordering physicians were primarily nonsurgeons (72%, 242/337). Abnormal findings were observed in 4.8% (16/337) of patients, six (1.7%) of whom required an operative intervention. The 2.9% (6/208) abnormal study rate for asymptomatic patients was significantly lower than the 7.9% (10/129) rate in the patients who were evaluated for symptomatic indications (P = 0.03). CONCLUSIONS: Most of the fluoroscopic gastrostomy studies ordered at a tertiary care center did not appear to alter patient care. Development of a standardized management algorithm based on clinical indications is necessary to decrease the number of extraneous gastrostomy studies.

Needle decompression to avoid tension pneumoperitoneum and hemodynamic compromise after pneumatic reduction of pediatric intussusception.

BACKGROUND: The contemporary management of children with ileocolic intussusception often includes pneumatic reduction. While failure of the procedure or recurrence after reduction can result in the need for surgical treatment, more serious adverse sequelae can occur including perforation and, rarely, tension pneumoperitoneum. During the last year, four cases of perforation during attempted pneumatic reductions complicated by tense pneumoperitoneum have occurred in our center. OBJECTIVE: We have elected to report our patient experience, describe methods of management and review available literature on this uncommon but serious complication. MATERIALS AND METHODS: Using ICD-9 diagnosis codes, we reviewed the records of children with intussusception during 2011. Demographic and therapeutic clinical data were collected and summarized. RESULTS: During the study period, 101 children with intussusception were treated at our institution, with 19% (19/101) of them requiring surgical intervention. Four children (4%) experienced a tense pneumoperitoneum during air enema reduction, prompting urgent needle decompression in the fluoroscopy suite. These children required bowel resection during subsequent laparotomy. No deaths occurred. CONCLUSION: Pneumoperitoneum is a real and life-threatening complication of pneumatic enemas. It requires immediate intervention and definitive surgical management. Caution should be exercised by practitioners performing this procedure at institutions where pediatric radiology experience is limited and immediate pediatric surgical support is not available.

Diagnostic delay and colectomy risk in pediatric ulcerative colitis.

BACKGROUND/PURPOSE: Diagnostic delay or time to diagnosis, and its relationship with colectomy risk has been studied in adult Inflammatory Bowel Disease (IBD), but rarely in pediatric IBD (PIBD), especially pediatric ulcerative colitis (P-UC), which often has a more severe course than adult UC. This study compared the relationship between diagnostic delay and colectomy in P-UC. METHODS: The medical records of P-UC patients, ages <18 years, diagnosed at Texas Children's Hospital from 2012 to 2018 were examined. We identified 106 P-UC patients, where the onset of symptoms of IBD (i.e. fever, diarrhea, blood in stool, weight loss, abdominal pain) could be clearly identified. RESULTS: Twenty (20 = 18.9%) patients progressed to colectomy, and 86 did not. There was no significant difference in diagnostic delay between the patients undergoing colectomy with UC (C-UC) and those with no colectomy (NC-UC) (p = 0.2192). The median (C-UC = 7.1 weeks; NC-UC = 11.9 weeks) and mean (C-UC = 16.5 weeks±4.7; NC-UC = 20.1 ±â€¯2.6) diagnostic delay actually tended to be shorter in C-UC compared to NC-UC. Fecal calprotectin levels were significantly higher (p = 0.0228) in C-UC than NC-UC patients at diagnosis. CONCLUSIONS: Shorter time to diagnosis may reflect disease severity at the time of disease onset and also a more aggressive subsequent course of P-UC. The significantly higher level of fecal calprotectin in the C-UC patients at diagnosis provided biologic/biochemical support for our conclusion. LEVELS OF EVIDENCE: Prognosis study, Level III evidence.