Percutaneous endoscopic gastrostomy tube placement via the introducer technique is safe and effective in children when compared to the laparoscopic technique.

PURPOSE: We compare our experience of percutaneous endoscopic gastrostomy, introducer technique (PEG) and laparoscopic technique (LapGT) at a tertiary care pediatric hospital. METHODS: Isolated PEGs and LapGTs placements were reviewed at our institution from August 2016 through January 2018. Demographics, procedure time, operative charges, and 30-day complications were reviewed. Means of quantitative values were compared using the student's t test. Categorical values were compared using the X2 test. RESULTS: Ninety-three isolated gastrostomy tubes were placed in children aged 2 weeks to 19 years. There were 56 PEGs (60%) and 37 LapGTs (40%), based on surgeon preference. There was no significant difference in demographics between the two groups. Mean operative time for PEG was 59% shorter (14 vs. 33 min, p < 0.001). Operating room charges averaged $4500 less in the PEG group ($11,400 vs. $15,900, p < 0.001). Neither group had complications that required a return to the operating room within 30 days postoperatively. There was no difference in the rate of fundoplication after gastrostomy tube placement. In two cases PEGs were converted to LapGTs after safety criteria for PEG were not met. CONCLUSION: The PEG introducer technique, when used with clearly defined safety criteria, decreased operative time and cost without compromising safety. LEVEL OF EVIDENCE: III.

A case report of spontaneous gastric perforation in a premature and low-birth weight neonate.

INTRODUCTION: Spontaneous gastric perforation of the neonate is a rare phenomenon with a high risk of mortality. Despite an uncertain etiology, an association with prematurity and low-birth weight has been demonstrated. Prompt surgical repair and intensive care remain imperative to survival. PRESENTATION OF CASE: A premature, low-birth weight male was born at 32 weeks and admitted to the NICU for respiratory distress syndrome. Forty-eight hours after birth he developed abdominal distention and an abdominal radiograph demonstrated pneumoperitoneum. Antibiotics were initiated and he was taken for emergent operative exploration. A 3 cm longitudinal perforation was identified in the greater curvature of the stomach. A two-layered repair was performed and a protective Stamm gastrostomy created. On postoperative day 10, an upper gastrointestinal contrast study demonstrated no evidence of leakage. After sustained clinical improvement, the initiation of oral feeding, and continued weight gain, the neonate was successfully discharged home. DISCUSSION: The etiology of spontaneous gastric perforation remains a debate with several proposed mechanisms. In most cases, the neonate will present with abdominal distention and emesis. Although presentation and evidence of pneumoperitoneum on abdominal radiograph are suspicious for this pathology, definitive diagnosis is confirmed during operative exploration. Dedicated intensive care and prompt surgical repair are paramount to survival. Despite decreasing mortality rates, premature and low-birth weight neonates continue to have the lowest rates of survival. CONCLUSION: We present a rare case of a premature, low-birth weight neonate who developed spontaneous gastric perforation and was successfully rescued using a coordinated multidisciplinary approach enabling prompt diagnosis and surgical repair.

Rapid Adoption of an Interdisciplinary Care Team Model for Surgical Residents Managing Coronavirus Disease-19.

Introduction: Patients infected with SARS-Cov-2, the causative virus behind the coronavirus disease-19 (COVID-19) pandemic, have been increasing rapidly in New York City. New York City has the highest incidence in the United States and fully 45% of all deaths from COVID-19. Our medical center is located within a high-density region of cases in south Brooklyn and, in fact, three of our neighborhood zip codes are in the top seven in New York in incidence. As a result, our center has experienced a dramatic increase in hospitalizations, particularly respiratory distress secondary to COVID-19, which rapidly exceeded the capacity of our internal medicine service. This necessitated the formation of new COVID-19 units throughout the hospital, replacing all former service lines. These units employed management teams composed of residents from many medical and surgical disciplines, including general surgery residents. Methods: Our general surgery residency program established a surgical COVID-19 (SCOVID) management team. Initially, 4 surgical residents (2 senior and 2 junior), 1 attending surgeon, and 1 attending internal medicine physician were allocated to the initial SCOVID team. On day 3 of implementation, to achieve more rapid competence in the complex management of these patients, a senior medicine resident with direct experience in the care of COVID-19 patients was added in an advisory capacity. Results: The addition of an experienced senior medical resident and attending allowed for the quick adoption of uniform management protocols by surgical residents and attendings. Discussion: We describe a protocol for the establishment of COVID-19 management teams staffed with general surgical residents, as well as a strategy for the achievement of rapid increases in competency. The addition of a senior internal medicine resident and attending to our SCOVID team allowed for rapid achievement of competency in the care of COVID-19 patients in our large institution at the epicenter of the COVID-19 pandemic.

Successful cardiopulmonary resuscitation following minimally invasive pectus excavatum repair: A case report.

INTRODUCTION: Pectus excavatum is the most common congenital chest wall deformity. The minimally invasive repair of pectus excavatum (MIRPE) is the most commonly practiced method of surgical treatment and there is concern that the pectus bar will prevent effective CPR. There are no recorded cases of successful cardiopulmonary resuscitation with pectus bars in place. PRESENTATION OF CASE: A 17-year-old male with pectus excavatum underwent MIRPE. Two years later, he experienced out-of-hospital cardiac arrest and underwent successful cardiopulmonary resuscitation (CPR) in the field with a pectus bar in place. DISCUSSION: Successful CPR is possible after MIRPE. Clear identification of patients who have undergone MIRPE and education of CPR providers in providing effective chest compressions and defibrillation for this patient population is necessary. CONCLUSION: This is the first documented case of successful CPR in a patient with a pectus bar in place who experienced out-of-hospital cardiac arrest.

NOTCH3 regulates stem-to-mural cell differentiation in infantile hemangioma.

Infantile hemangioma (IH) is a vascular tumor that begins with rapid vascular proliferation shortly after birth, followed by vascular involution in early childhood. We have found that NOTCH3, a critical regulator of mural cell differentiation and maturation, is expressed in hemangioma stem cells (HemSCs), suggesting that NOTCH3 may function in HemSC-to-mural cell differentiation and pathological vessel stabilization. Here, we demonstrate that NOTCH3 is expressed in NG2+PDGFRß+ perivascular HemSCs and CD31+GLUT1+ hemangioma endothelial cells (HemECs) in proliferating IHs and becomes mostly restricted to the αSMA+NG2loPDGFRßlo mural cells in involuting IHs. NOTCH3 knockdown in HemSCs inhibited in vitro mural cell differentiation and perturbed αSMA expression. In a mouse model of IH, NOTCH3 knockdown or systemic expression of the NOTCH3 inhibitor, NOTCH3 Decoy, significantly decreased IH blood flow, vessel caliber, and αSMA+ perivascular cell coverage. Thus, NOTCH3 is necessary for HemSC-to-mural cell differentiation, and adequate perivascular cell coverage of IH vessels is required for IH vessel stability.