Abdominal wall closure in neonates after congenital diaphragmatic hernia repair.

PURPOSE: Repair of Congenital Diaphragmatic Hernia (CDH) abruptly increases intra-abdominal pressure. This study sought to characterize the incidence and significance of ACS and delayed fascial closure (DFC) after CDH repair. METHODS: We reviewed the CAPSNet database from 2006 to 2011, identifying the subset of patients that developed ACS or required DFC. Prenatal and demographic information, operative and physiologic details, and outcomes were investigated. RESULTS: Of 349 patients with CDH, 3 (0.8%) were diagnosed with ACS, while 43 patients (12%) had DFC at the time of CDH repair. Patients more often had right-sided defects (26% vs 13%, p=0.04) and trended toward requiring a patch repair (41% vs 31.2%, p=0.23) and having a liver lobe above the diaphragmatic rim (47% vs 32.7, p=0.09). Patients with ACS or DFC had increased length of stay (47.5 vs 33.9, p=0.01), days fasting (8.2 vs 5.8, p=0.01), days on parenteral nutrition (23.6 vs 15.5, p=0.003), and days on mechanical ventilation (16.3 vs 9.0, p=0.001). CONCLUSIONS: While ACS in neonates after CDH repair is rare (<1%), DFC is required relatively commonly (>10%) and is associated with right-sided diaphragmatic hernias. Inability to close abdominal fascia is associated with increased morbidity. Clinicians caring for neonates with CDH should be facile with strategies to manage delayed abdominal fascia closure.

Quality of life after laparoscopic cholecystectomy for biliary dyskinesia in the pediatric population: a pilot study.

This pilot study examined symptom relief and quality of life in pediatric patients who received laparoscopic cholecystectomy surgery at our institution for biliary dyskinesia. We used two validated questionnaires: the Child Health Questionnaire (CHQ-PF28), to assess general well-being, and the Gastrointestinal Quality of Life Index (GIQLI), to measure gastrointestinal-related health. After Institutional Review Board approval, all patients under the age of 18 years who underwent laparoscopic cholecystectomy for biliary dyskinesia between November 2006 and May 2010 received mailed questionnaires. Preoperative and postoperative data were retrospectively collected from respondents and included age, race, symptoms, gallbladder ejection fraction values, pathologic findings, and clinical course. Of 89 patients meeting inclusion criteria, 21 responded. Mean age at surgery was 13.08 years (range, 8 to 17 years). The most common preoperative symptoms consisted of nausea (100%), postprandial pain (90.5%), right upper quadrant pain (81.0%), and vomiting (66.7%). Mean long-term follow-up interval was 18.9 months (range, 7 to 40 months; SD 10.37). Patients with long-term symptom relief reported significantly higher GIQLI scores than those with enduring symptoms. Examination of the results from the CHQ-PF28 revealed significantly lower scores than a general U.S. pediatric sample in both the Physical and Psychosocial Summary Measures (P < 0.05). Children experiencing long-term symptom cessation after laparoscopic cholecystectomy reported higher quality of life than those who had incomplete or only short-term relief. However, regardless of the degree of symptom relief, the degree of quality of life experienced by our study sample of patients with biliary dyskinesia is lower than that of a comparable U.S. pediatric sample.

Laparoscopic cholecystectomy for treatment of biliary dyskinesia is safe and effective in the pediatric population.

Experience with laparoscopic cholecystectomy for biliary dyskinesia in children remains limited. The aim of this study was to examine the results of a single institution's experience with laparoscopic cholecystectomy for the treatment biliary dyskinesia in the pediatric population. Medical records were reviewed on all patients younger than age 18 who underwent laparoscopic cholecystectomy at our institution from July 2004 to December 2006. Patients undergoing surgery for biliary dyskinesia, as evidenced by a preoperative gallbladder ejection fraction of 40 per cent or less, comprised the study group. Of the 51 pediatric laparoscopic cholecystectomies, 30 (58.8%) were performed for biliary dyskinesia. The patients' ages ranged from 7 to 17 (mean, 12.67 years; SD, 2.75). Symptoms consisted of chronic right upper quadrant pain (96.67%), nausea/vomiting (73.33%), back pain (30.0%), weight loss (13.33%), and a history of pancreatitis (6.66%). The amount of time between onset of symptoms and surgery was as follows: 1 to 3 months (34.62%), 4 to 6 months (30.77%), 7 to 12 months (7.69%), and greater than 1 year (26.92%). Gallbladder ejection fraction ranged from 1 to 36 per cent (mean, 14.7%). Seven of the 30 (26.67%) underwent endoscopic evaluation as part of their preoperative workup (six upper endoscopy, one colonoscopy), all of which were noncontributory. Pathology revealed chronic cholecystitis in 26 of 30 (93.3%), no abnormalities in three of 30 (10.0%), and unexpected cholelithiasis in one of 30 (3.33%). No perioperative complications were encountered. Twenty-nine of the 30 patients were available for follow up and all but one reported relief of symptoms (96.55%). This study supports the use of laparoscopic cholecystectomy as a safe and effective treatment for biliary dyskinesia in the pediatric population. The success rate in our study was substantially higher than that reported in previous series. Routine preoperative endoscopy was not used and was reserved for investigation of ambiguous or unrelated complaints.

Percutaneous transfemoral endovascular repair of popliteal artery aneurysms.

Popliteal artery aneurysms are the hallmark of peripheral aneurysms, accounting for 70%, and are commonly bilateral in 50% to 75% of patients. The prevalence and incidence of popliteal artery aneurysms are not precisely known. The presence of a popliteal aneurysm is a marker of risk to limb and life because 33% to 43% are associated with an abdominal aortic aneurysm. Ligation and bypass reconstruction has long been the "gold standard" for the treatment of popliteal aneurysms. Recently, endoluminal repair with a percutaneously delivered stent-graft has become a valid alternative to open repair. In this study, we illustrate two cases of a total of four patients with popliteal artery aneurysms treated with percutaneous stent graft placement and discuss overall management of these aneurysms. The other two patients had a successful early outcome (30 days), but long-term follow-up is still lacking.

Obstructing phytobezoar arising from proximal jejunal diverticulum.

The following report illustrates a rare case of small bowel obstruction which occurred when a large phytobezoar, which had formed in a proximal jejunal diverticulum, dislodged and migrated distally. Obstruction and subsequent perforation resulted when the phytobezoar passed into the narrow terminal ileum and lodged just proximal to the ileocecal valve. The images are presented for educational purposes.

Carotid duplex velocity criteria revisited for the diagnosis of carotid in-stent restenosis.

Carotid percutaneous transluminal angioplasty/stenting has become an accepted treatment modality for carotid artery stenosis in high-risk patients. There has been an ongoing debate regarding which duplex ultrasound (DUS) criteria to use to determine the rate of in-stent restenosis. This prospective study revisits DUS criteria for determining the rate of in-stent restenosis. In analyzing a subset of 12 patients (pilot study) who had both completion carotid angiography and DUS within 30 days, 10 patients with normal post-stenting carotid angiography (< 30% residual stenosis) had peak systolic velocities (PSVs) of the stented internal carotid artery (ICA) of < or = 155 cm/s and two patients with > or = 30% residual stenosis had internal carotid artery (ICA) PSVs of > 155 cm/s. Eighty-three patients who underwent carotid stenting as part of clinical trials were analyzed. All patients underwent post-stenting carotid DUS that was done at 1 month and every 6 months thereafter. PSVs and end-diastolic velocities of the ICA and common carotid artery were recorded. Patients with PSVs of the ICA of > 140 cm/s underwent carotid computed tomographic (CT) angiography. The perioperative stroke rate was 1.2%. When the old DUS velocity criteria for nonstented carotid arteries were applied, 54% of patients had > or = 30% restenosis (PSV of > 120 cm/s), but when our new proposed DUS velocity criteria for stented arteries were applied (PSV of > 155 cm/s), 33% had > or = 30% restenosis at a mean follow-up of 18 months (p = .007). The mean PSVs for patients with normal stented carotid arteries based on CT angiography, were 122 cm/s versus 243 cm/s for > or = 30% restenosis and 113 cm/s versus 230 cm/s for > or = 30% restenosis based on our new criteria. The mean PSVs of in-stent restenosis of 30 to < 50%, 50 to < 70%, and 70 to 99%, based on CT angiography, were 205 cm/s, 264 cm/s, and 435 cm/s, respectively. Receiver operating curve analysis demonstrated that an ICA PSV of > 155 cm/s was optimal for detecting > or = 30% in-stent restenosis, with a sensitivity of 100%, a specificity of 90%, a positive predictive value of 74%, and a negative predictive value of 100%. The currently used carotid DUS velocity criteria overestimated the incidence of in-stent restenosis. We propose new velocity criteria for the ICA PSV of > 155 cm/s to define > or = 30% in-stent restenosis.

Injuries associated with pediatric liver trauma.

Injury remains the leading cause of childhood mortality for children younger than 14 years of age, with the liver being particularly susceptible to blunt trauma in children. This study reviews the authors' institutions' experience with pediatric liver injuries in an attempt to establish current patterns of injury, management and outcomes. A single-center, retrospective review was conducted of 105 consecutive pediatric patients who presented with a traumatic liver injury from January 1996 through February 2004. Average patient age was 13.1+/-4.9 years and 58 per cent were male. Perihospital mortality was 8.6 per cent, with 67 per cent of mortality being attributed to head injury. The majority of patients were managed nonoperatively (81%). Liver injury was most often grade II (35%) by CT scan. Liver injury grade did not affect survival, but did affect injury management, with grade I and grade IV liver injuries more likely to be managed surgically (P < 0.001). Grade I liver injuries were associated with concomitant spleen injuries, whereas grade IV injuries were associated with pancreatic injuries. Surgical management was associated with a higher injury severity score (P = 0.005), higher mortality (P = 0.01), and with other associated injuries as well. Children experiencing blunt abdominal trauma are at risk of significant morbidity and mortality; however, these risks stem more likely from associated injuries than injury to the liver proper. Clinicians should maintain a high index of suspicion for potentially catastrophic associated injuries to the pancreas with high-grade liver injury.