Population Density and Triage of Pediatric Firearm Injuries in a Rural Trauma System.

BACKGROUND: Rural pediatric firearm injuries require regional pediatric and trauma expertise. We evaluated county-level population density associations with transport, hospital interventions, and patient outcomes at a Level I pediatric trauma center serving a rural, statewide catchment area. MATERIAL AND METHODS: The trauma registry of the only in-state pediatric trauma center was reviewed for firearm injuries in patients < 18 between 1/2013 and 3/2020. County-level population density was classified according to the United States Office of Management and Budget definitions for rural, micropolitan, and metropolitan areas. RESULTS: 364 patients were identified, including 7 patients who were re-injured. Mean age was 11.3 ± 4.5 y and patients were 79.4% male. 59.3% were transferred from a referring hospital. Median injury severity score was 5 (IQR 1-10); 88.0% required trauma center admission, and 48.2% required operative intervention. 7.4% were injured in a rural county, 46.4% in a micropolitan county, and 46.2% in a metropolitan county. Patients from rural counties were more likely to be unintentionally injured (72.0%) than those from micropolitan (54.4%) or metropolitan counties (44.0%, P = .04). While need for inpatient admission and length of stay were similar, those transported from rural counties had significantly longer transport times (P < .01) and less frequent need for operative intervention (P = .03), as well as trends toward lower injury severity (P = .08) and mortality (P = .06). CONCLUSION: Management of pediatric firearm injury is a unique challenge with significant regional variability. Opportunities exist for outreach, telehealth, and decision support to ensure equitable distribution of resources in rural trauma systems. LEVEL OF EVIDENCE: Epidemiological, Level III.

Wound complications after chemo-port placement in children: Does closure technique matter?

PURPOSE: Wound dehiscence after chemo-port placement is a rare but potentially significant complication. We hypothesize that by using a simple running skin closure technique during chemo-port placement the rate of wound dehiscence and overall wound complications can be significantly decreased. METHODS: IRB approval was obtained and patients <18years that received a tunneled central line with port from June 2012 to April 2016 were analyzed. Data collected on patients included patient demographics, skin closure type, and wound complications within 30days. Chi-square was performed to examine the univariate association with skin closure technique and wound dehiscence. Logistic regression was performed to examine the multivariable association between skin closure type and wound dehiscence and to compute odds ratios. RESULTS: There were 259 ports placed in this cohort: 125 used simple running skin closure technique, and 134 used the subcuticular skin closure. Patients were found to not have any difference in rate of dehiscence or overall wound complications based on gender, age, location of port, or use of steroids or chemotherapy within 1week of port placement. When compared, only 1 case (0.80%) in the simple running group vs 10 cases (7.46%) in the subcuticular group experienced a wound dehiscence [unadjusted OR=14.07 (1.69, 116.99) p=0.0144]. When comparing overall wound complications the simple running group had 3 (2.4%) versus 12 (8.96%) in the subcuticular group [unadjusted OR=4.78 (1.27, 17.94) p=0.0203]. When adjusting for port-number both dehiscence and overall wound complications remained statistically significant. CONCLUSION: We conclude that the simple running skin closure for chemo-port placement in children has superior outcomes in regards to prevention of dehiscence and overall wound related complications when compared to the subcuticular technique.

Stapled intestinal anastomoses with endoscopic staplers in premature infants.

PURPOSE: The safety and effectiveness of a stapled intestinal anastomosis in adults, children, and infants is well documented. However, in neonates it is not well validated. We hypothesized that premature infants who received a stapled bowel anastomosis utilizing endoscopic staplers had similar outcomes compared to patients with a handsewn anastomosis. METHODS: A retrospective study was performed reviewing premature infants who underwent an intestinal anastomosis over a 4-year period. Patients greater than 36weeks gestational age at birth or a weight greater than 5kg at surgery were excluded. Patient demographics, type of intestinal anastomosis, and anastomotic related complications within 3months were collected and analyzed. RESULTS: Sixty-five patients underwent 71 operations involving an intestinal anastomosis: 33 cases were handsewn, and 38 cases were stapled. Groups were noted to have differences in age, weight, and diagnosis. Complications including leak and anastomotic stricture did not differ between groups. Reports of blood per rectum after surgery were more common in the stapled group (24% versus 6%, p=0.0522), but this did not reach statistical significance. CONCLUSION: There were no significant differences in anastomotic complications when comparing the handsewn and stapled intestinal anastomosis techniques in premature infants weighting less than 5kg. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: III.

Resection of a giant hepatic adenoma in an eight-year-old girl.

Hepatic adenomas are benign tumors typically diagnosed in women of reproductive age, however, these tumors occur in the pediatric population although rare. We present the case of a giant hepatic adenoma in an 8-year-old female without established risk factors with progressive abdominal pain, and po intolerance, biliary obstruction, anemia, and fever. Right trisegmentectomy afforded extirpation of the 16 × 14.5 × 8.5 cm mass. The postoperative course was complicated by transient encephalopathy and a bile leak which resolved with appropriate care. The patient is well over 1 year from resection. She demonstrates age appropriate mental and physical function without disease recurrence or complication.

Defining hepatoblastoma responsiveness to induction therapy as measured by tumor volume and serum alpha-fetoprotein kinetics.

PURPOSE: Hepatoblastoma is commonly unresectable at presentation, necessitating induction chemotherapy before definitive resection. To refine the paradigm for timing of resection, we questioned whether a plateau in hepatoblastoma responsiveness to neoadjuvant therapy could be detected by calculating tumor volume (TV) and serum alpha-fetoprotein (sAFP) kinetics. METHODS: To calculate TV and sAFP as measures of treatment responsiveness over time, infants having initially unresectable epithelial-type hepatoblastomas were identified at a single institution (1996-2008). Effects of therapy type, therapy duration, and lobe of liver involvement on TV, sAFP, margin status, and toxicity were analyzed. RESULTS: Of 24 infants treated for epithelial-type hepatoblastoma during this interval, 5 were resected primarily, and 15 had complete digital films for kinetics analysis. Both TV and sAFP decreased dramatically over time (P < .0001). No statistically significant difference in mean TV or sAFP was detected after chemotherapy cycle 2. Left lobe tumors had greater presenting levels of and significantly slower decay in sAFP compared with right lobe tumors (P = .005), although no statistically significant differences in TV existed between liver lobes. Resection margins did not change with therapy duration. CONCLUSIONS: Measuring TV and sAFP kinetics accurately reflects hepatoblastoma responsiveness to induction therapy. Treatment toxicities may be reduced by earlier resection and tailoring of chemotherapeutic regimens.

Biomagnetic investigation of injury currents in rabbit intestinal smooth muscle during mesenteric ischemia and reperfusion.

A noninvasive, sensitive, and specific method of detecting mesenteric ischemia would be of great use in reducing the morbidity and mortality with which it is associated. Acute lesions in polarized electrically coupled tissues lead to injury currents driven by the transmembrane resting potential gradient. These injury currents are an effective indicator of pathophysiology. The presence of near-DC injury currents in rabbit intestinal smooth muscle has already been demonstrated using a Superconducting quantum interference device (SQUID), and the aim of this study was to evaluate the effect of arterial reperfusion upon these currents. We exteriorized the small bowel of 14 New Zealand white rabbits and placed a remotely operated vascular occluder around the distal most artery supplying a 3-in segment of the jejunum. Experiments were conducted in three groups, i.e., control (n=3), ischemia (n=6), and reperfusion following ischemia (n=5). The subject's position was modulated in and out of the biological field detection range of a SQUID magnetometer using a lift constructed of nonmagnetic material. The changes in magnetic field amplitude were 9.3 and 31.01% for the control and ischemia groups, respectively. The reperfusion group first exhibited a decrease of 17.35% from the pre-ischemic to the ischemic period, followed by an increase of 13.88% of the ischemic value after reestablishing perfusion. In conclusion, injury currents in GI smooth muscle that appear during ischemia are reduced to near-pre-ischemic levels during reperfusion.

Experience with the optical access trocar for safe and rapid entry in the performance of laparoscopic gastric bypass.

BACKGROUND: In laparoscopic surgery, serious complications caused by the blind insertion of trocars are well known. The open technique is compromised by the leakage of carbon dioxide and can also be time consuming, especially in morbidly obese patients. Our aim was to determine whether the optical access trocar can be used to establish a safe and rapid entry during laparoscopic gastric bypass. METHODS: The data on a single surgeon's experience with 370 laparoscopic gastric bypass procedures during a 4-year period were reviewed. The Optiview trocar was used for all except the initial 21 patients. The entry time for the optical trocar was measured in 10 patients. RESULTS: Of the 370 patients undergoing laparoscopic gastric bypass from November 2000 to September 2004, the initial 21 were treated using the standard Veress needle to create the pneumoperitoneum. The next 22 were treated using the Veress needle to create the pneumoperitoneum, followed by insertion of the optical access trocar in the left upper quadrant as the initial trocar. From this point to the present, the optical access trocar has been inserted without the use of a Veress needle. There have been no trocar-related bowel or vascular injuries in the entire series. The mean optical trocar insertion time was 28 +/- 1.2 s. CONCLUSIONS: This is the first laparoscopic gastric bypass series to report the results of its experience with the optical access trocar. This device provides a safe and rapid technique for placement of the initial trocar for laparoscopic gastric bypass. Insertion of the optical trocar with a 10-mm laparoscope into the left upper quadrant is our procedure of choice for obtaining the pneumoperitoneum in this patient population.

Myotomy: follow-up study of 50 patients.

Laparoscopic myotomy has become the standard treatment for definitive management of achalasia. This study was undertaken to assess the long-term results of the procedure. Perioperative data, including a symptom score questionnaire, were collected prospectively on all patients undergoing laparoscopic myotomy. The same questionnaire was readministered by phone to patients with follow-up greater than 3.75 years. The long-term success of myotomy was defined as a 50% or greater decrease in the dysphagia score and absence of further therapy (responders). Fifty of 95 patients (age = 57 years, 23 females) were successfully contacted. Average follow-up was 6.2 years. The overall long-term success rate was 64% (responders). Forty-two patients (84%) were able to gain or maintain their weight after the procedure. Five patients (10%) required one or more endoscopic dilations after the myotomy. The mean change in dysphagia score was higher in the responder group (7.8 +/- 1.9 vs. 1.9 +/- 2.1; P = 0.001). The two groups were similar in terms of age, gender distribution, and follow-up interval (P > .05). Dor fundoplication was performed in six patients (12%), and the outcome comparisons of these patients showed no significant differences from those patients undergoing Heller alone. Overall satisfaction was achieved in 94% of contacted patients. These results confirm that laparoscopic myotomy is an effective procedure with excellent long-term symptom resolution and overall satisfaction in patients with achalasia.