Yield and complications of kidney biopsy over two decades in a tertiary pediatric center.

BACKGROUND: Kidney biopsy serves as an adjunct for the diagnosis of renal disease, but it is not always productive. This study evaluated the yield and risks of kidney biopsies performed in 1995-2014 at a tertiary pediatric medical center. METHODS: The medical files of all patients who underwent closed percutaneous biopsy for various indications in native or transplanted kidneys were retrospectively reviewed for patient characteristics, technical and histopathologic findings, biopsy yield, and biopsy complications. Biopsy yield was considered positive if findings confirmed a probable diagnosis or led to a change in clinical diagnosis, disease severity/activity grade, treatment strategy, or prognosis; and negative, if findings were non-informative and in cases of technical failure. RESULTS: During the study period, 216 biopsies were performed on native kidneys and 84 on transplanted kidneys. In the transplanted kidney group, the most common indications for biopsy were decreased glomerular filtration rate and suspected rejection. Rates of positive biopsy yield were 86.6% in the native kidney group and 82.1% in the transplanted kidney group; the difference was not statistically significant. Significant between-group differences were found in various technical and histopathological parameters, patient age at biopsy, and sex distribution. In the native kidney group, positive biopsy yield was associated with the presence of nephrotic-range proteinuria. Post-procedural complications occurred in three patients (1.3%) with native kidneys, and in one patient (1.1%) with a transplanted kidney. CONCLUSIONS: Kidney biopsy is an efficient and safe procedure in both native and transplanted kidneys and provides helpful diagnostic information in most cases in which it is deemed necessary.

Primary gastric lymphoma in a soldier presenting as acute gastrointestinal bleeding.

Acute epigastric pain is commonly encountered among young adults undergoing military training. Gastric malignancy usually affects older individuals and may occasionally masquerade as peptic disease. We report a case of primary gastric lymphoma (PGL) in a young soldier, presenting as an acute upper gastrointestinal tract bleeding. The case is presented along with a review of the relevant literature. Primary care physicians should bear in mind that although highly unusual in this age group, primary gastric lymphoma may occasionally afflict young adults and military recruits as demonstrated by the case under discussion. Nevertheless, referral for investigation of suspected peptic disease should follow standard guidelines.

Pediatric scoliosis surgery--is postoperative intensive care unit admission really necessary?

BACKGROUND: It is common practice for patients to be admitted to the intensive care unit following scoliosis surgery, because of the prolonged anesthesia, the need for efficient pain control and the known immediate postoperative complications. However, this may be unnecessary in many patients. PURPOSE: We aimed to establish possible associations between pre- and perioperative parameters and early postoperative complication rates, in particular the need for prolonged mechanical ventilation (>1 day), and the presence of major complications in children undergoing primary spinal fusion by thoracolumbar spine instrumentation. METHODS: We conducted a retrospective review of children undergoing primary scoliosis surgery at a university-affiliated general hospital from 1998 to 2008. RESULTS: Surgical approaches were as follows: anterior spinal fusion, posterior spinal fusion, and combined anterior and posterior fusion. Prior to mid-2005, anesthesia included morphine; thereafter, remifentanil was used. Major complications correlated significantly with neuromuscular scoliosis (NMS) (OR, 4.94; 95% CI, 1.02-24.05), comorbidity conditions (OR, 3.47; 95% CI, 1.16-10.42), and anterior or combined fusion (OR, 7.81; 95% CI, 2.12-28.57). Late extubation correlated significantly with NMS (OR, 31.25; 95% CI, 1.06-100.00) and morphine use during anesthesia (OR, 17.91; 95% CI, 1.44-222.9). CONCLUSIONS: Relatively young, healthy idiopathic scoliosis children receiving intraoperative remifentanil sedation and undergoing posterior fusion can be successfully managed in regular wards in the immediate postoperative period. However, intensive care unit admission should be considered in NMS patients, patients with comorbidity conditions, those undergoing anterior or combined spinal fusion, and patients whose anesthesia involves long-acting opioids.

Remifentanil use in pediatric scoliosis surgery-an effective alternative to morphine (a retrospective study).

PURPOSE: The unique properties of remifentanil make it ideal for pediatric use despite a lack of wide randomized clinical trials and fear of adverse events due to its high potency. We aimed to consolidate preliminary conclusions regarding the efficacy of remifentanil use in pediatric scoliosis surgery. MATERIALS AND METHODS: The medical charts of children with idiopathic scoliosis who underwent primary spinal fusion between 1998 and 2007 at a large tertiary university-affiliated hospital were retrospectively reviewed and divided into two groups according to anesthetic regime (remifentanil vs. morphine). Demographic, surgery-related details and immediate postoperative course were recorded and compared. RESULTS: All 36 remifentanil children were extubated shortly after termination of surgery, compared to 2 of the 84 patients in the morphine group. The remaining patients in the morphine group were extubated hours after surgery [5.4 hours; standard deviation (SD) 1.7 hours]. Six remifentanil children were spared routine intensive care hospitalization (vs. 2 morphine children-significant difference). Shorter surgeries [5.6 hours (SD 1.82 hours) vs. 7.14 hours (SD 2.15 hours); p=0.0004] were logged for the remifentanil group. To achieve controlled hypotension during surgery, vasodilator agents were used in the morphine group only. A comparison of early postoperative major or minor complication rates (including neurological and pulmonary complications) between the two groups yielded no significant differences. CONCLUSION: Remifentanil use can shorten operating time and facilitate earlier spontaneous ventilation and extubation, with less of a need for intensive care hospitalization and no increase in significant complications.

Risk factors affecting the immediate postoperative course in pediatric scoliosis surgery.

STUDY DESIGN: A retrospective analysis of pediatric records of idiopathic scoliosis (IS) and neuromuscular scoliosis (NMS) etiology, in a search for complications and their risk factors immediately following surgical repair. OBJECTIVE: To evaluate the influence of pre- and intraoperative parameters on the postoperative course and lay the cornerstone for a course-prediction model. SUMMARY OF BACKGROUND DATA: Only a few studies have addressed the immediate postoperative complications of pediatric scoliosis surgery. METHODS: Our study included all children who underwent spinal fusion for scoliosis in our hospital between 1998 and 2006. The following data were collected: curve etiology, Cobb angle, number of fused vertebrae, fusion approach, and the addition of thoracoplasty. We evaluated the influence of this data on the rate of delayed extubations, length of intensive care unit (ICU) hospitalization, and the presence of major and minor immediate postoperative complications. RESULTS: The study included 126 children (95 IS and 31 NMS). Delayed extubations were recorded in 17 children (3% of IS vs. 45% of NMS). The most common major and minor complications were pulmonary and hematological-biochemical, respectively. Overall pulmonary complications (major and minor) were recorded in 38 children. Major complications (of any category) were recorded in 19 children. Average length of ICU hospitalization was 3.8 days. The rate of complications in the NMS group was significantly higher than in the idiopathic group. Posterior fusions were associated with a significantly lower rate of pulmonary complications and shorter ICU hospitalizations, in comparison to anterior and combined fusions. Cobb angle, number of fused vertebrae, and the addition of thoracoplasty did not correlate with any postoperative parameters. CONCLUSION: While NMS etiology, anterior and combined fusions correlated with a worse course, the Cobb angle, number of fused vertebrae, and the addition of thoracoplasty did not. Optimization of postoperative care should be carried out accordingly. Scoliosis surgery is safe even in extreme curves and long fusions. Thoracoplasty can be added whenever indicated, in order to improve the overall outcome.

Superior mesenteric artery syndrome after scoliosis repair surgery: a case study and reassessment of the syndrome's pathogenesis.

We carried out a retrospective analysis to investigate the prevalence of superior mesentery artery syndrome (SMAS) in children who underwent scoliosis surgical repair at our hospital between 1998 and 2006 and to reassess the syndrome's pathogenesis. Among 133 consecutive pediatric patients, two cases were identified, both 13-year-old girls with idiopathic scoliosis, undergoing surgery using third-generation instrumentation systems. Conservative management achieved resolution of the symptoms without recurrence. SMAS prevalence in our series was 1.6%. SMAS might occur after derotation and translation forces application, and even with nonextreme corrections. Low BMI and significant weight loss at presentation are not mandatory.

Avoiding neurologic complications following ligation of the segmental vessels during anterior instrumentation of the thoracolumbar spine.

STUDY DESIGN: A retrospective evaluation of anterior instrumentation of the vertebral bodies in the thoracolumbar spine. OBJECTIVE: To evaluate the possibility of preserving the segmental vessels following anterior instrumentation. SUMMARY OF BACKGROUND DATA: Occlusion of the segmental vessels, routinely performed during anterior spine instrumentation, might cause neurologic injury secondary to cord ischemia. METHODS: The medical data of 29 patients following anterior instrumentation of the vertebral bodies at the thoracolumbar spine were reviewed. All underwent surgery recently when we decided to preserve the segmental vessels whenever possible. We sought the reasons that enabled us to do so regarding age, gender, underlying pathology, surgical technique, operation duration, instrumentation type and size, and location in the vertebral body. RESULTS: In only 7 patients, fused between T10 and L5, were we able to preserve the segmental vessels. All were instrumented with one 6.25-7-mm wide screw in each vertebral body connected by one rod, approximately half the screws above and half below the segmental vessels. In 22 patients, we were unable to preserve the vessels due to the need to insert 2 screws or a large threaded wide vertebral cage into each vertebra. CONCLUSIONS: There is adequate space anteriorly in the vertebral body, above and below the segmental vessels, for the insertion of one screw, even with staples.