Blood Transfusion is Associated With Adverse Outcomes in Pediatric Solid Tumor Oncology Patients Following Tumor Resection.

BACKGROUND: Packed red blood cell (PRBC) transfusion is a lifesaving intervention that also has proinflammatory and immunosuppressive effects. Adults with a malignancy who receive PRBC transfusion have increased rates of infection, tumor recurrence, and decreased survival. The effect of PRBC transfusion among children with solid tumors is unknown. METHODS: We performed a retrospective review of all children who underwent operative resection of a solid tumor malignancy. Data collected included demographic information, location of operation, nadir hemoglobin, and any PRBC transfusion within 30 days of tumor resection. RESULTS: Three hundred sixty children underwent tumor resection at our institution between 2002 and 2013; 194 (54%) received a perioperative blood transfusion. After adjusting for stage at diagnosis, tumor location, preoperative chemotherapy and nadir hemoglobin, blood transfusion was associated with a higher rate of postoperative infectious complications, shorter disease-free interval, and a higher rate of tumor recurrence. Each additional transfused unit increased the risk of postoperative infection (odds ratio 3.83; 95% confidence interval 1.21, 14.22, P =0.031). CONCLUSIONS: Among children with solid tumor malignancies, PRBC transfusion within 30 days of operation is associated with higher rates of postoperative infection. If transfusion becomes necessary, single unit increments should be transfused. LEVEL OF EVIDENCE: Level III.

Pediatric ulcerative colitis: three- versus two-stage colectomy with ileal pouch-anal anastomosis.

BACKGROUND: Despite advancements in medical therapy for ulcerative colitis (UC), a significant proportion of children progress to colectomy with ileal pouch-anal anastomosis (IPAA). Procedural related complications between two- and three-stage operations in children have not been well described. METHODS: We performed a retrospective review of patients who underwent a colectomy for UC or inflammatory bowel disease unclassified between 2008 and 2018. RESULTS: Forty-nine children underwent an IPAA at the time of colectomy (two stage) or during a subsequent operation (three stage). Preoperative hemoglobin and albumin concentrations were lower among those undergoing three-stage procedures. The rate of early complications (≤30 days) was similar between the two groups (p = 0.46); however, late complications (>30 days) were more commonly associated with three-stage procedures (p = 0.03). Time with a stoma was 3.2 months longer among those who underwent a three-stage procedure. While three-stage procedures were more often performed during the first half of the study period (2008-2012), two-stage procedures became more common during the second half (2013-2018). During this transition to favor two-stage procedures, complication rates did not significantly change. CONCLUSION: Although three-stage procedures were thought to be associated with fewer complications, we found comparable complication rates as we transition to two-stage procedures.

Concomitant Fundoplication With Gastrostomy: A Two-State Comparison Showing Continued Use of Reflux Medications.

OBJECTIVES: We sought to determine whether practice differences for fundoplication exist between 2 geographically distinct states, and to determine the reflux medication use pattern associated with concomitant fundoplication. METHODS: A retrospective observational cohort study of children in Colorado (CO) and North Carolina (NC) insured by Medicaid from 2006 to 2008. Children who received a surgical gastrostomy during the study period were included, and our primary outcome measure was the performance of a concomitant gastric fundoplication. Thirty-day prescription fills for reflux medications were examined before and after gastrostomy procedure. RESULTS: We examined 969 surgical gastrostomy admission in both states over the 3-year study period (CO, n = 341 and NC, n = 628). Patients in each state had similar age (median age, 6 months, P = 0.97). Use of pH probe (CO: 15%, NC: 11%) and diagnosis of reflux (CO: 84%, NC: 72%) differed in each state. Concomitant fundoplication was performed in 60% of patients in CO and 43% in NC (P < 0.01). Age less than 6 months was associated with an increased adjusted odds of fundoplication in CO (OR 9.77, CI, 3.91, 24.43), but less so in NC (OR 2.73, CI, 1.48, 5.04). Among patients undergoing gastrostomy, the proportion of patients on reflux medication 4 to 6 months post-discharge did not differ between those receiving fundoplication and those that did not in either state. CONCLUSIONS: Rates of concomitant fundoplication varied in the 2 states despite patients having similar demographic and clinical characteristics. Antireflux surgery was not associated with a reduction in reflux medications in either state.

Altered pulmonary artery endothelial-smooth muscle cell interactions in experimental congenital diaphragmatic hernia.

BACKGROUND: Pulmonary hypertension (PH) secondary to vascular remodeling contributes to poor outcomes in congenital diaphragmatic hernia (CDH), however mechanisms responsible are unknown. We hypothesized that pulmonary artery endothelial cell (PAEC) dysfunction contributes to smooth muscle cell (SMC) hyperplasia in experimental CDH. METHODS: PAEC and SMC were isolated from fetal sheep with experimental CDH and controls. SMC growth was assessed alone and with SOD plus catalase and during coculture with control or CDH PAEC with and without ET-1 siRNA transfection. ET-1 protein was measured in PAEC and SMC lysates and supernatant. ROS production was measured in normal and CDH PAECs with and without ET-1 siRNA. PAEC growth and tube formation were measured with SOD plus catalase. RESULTS: CDH SMC growth was decreased and increased with coculture with CDH PAEC more than control PAEC. Treatment of CDH PAEC with SOD plus catalase or ET-1 siRNA prevented the increase in SMC growth seen with coculture. ET-1 protein was increased in CDH PAEC and SMC. ROS production was increased in CDH PAEC and decreased with ET-1 SiRNA. SOD plus catalase restored CDH PAEC growth and tube formation. CONCLUSION: PAEC dysfunction in experimental CDH increases SMC proliferation via ET-1 induced ROS production by PAEC.

Pyloric stenosis--postoperative care on a nonsurgical ward.

BACKGROUND: Recent progress has been made in the care of infants with hypertrophic pyloric stenosis (HPS), including earlier operative intervention and shorter hospital length of stay (LOS), which is attributable to expedited postoperative feeding protocols developed and implemented by surgeons. We hypothesized that patients with HPS admitted to a unit that is co-managed by nonsurgeon providers postoperatively have a longer LOS than those on the surgical ward. MATERIALS AND METHODS: We reviewed the medical records of infants who underwent pyloromyotomy for HPS at a single institution from April, 2009-July, 2013. RESULTS: A total of 259 patients underwent pyloromyotomy (35 female; 13.5%), 205 (79%) were admitted to the surgical ward; 46 had a planned neonatal intensive care unit (NICU) admission (18%) and were co-managed with the neonatology team. Eight (3%) had an unplanned NICU admission and were excluded from the analysis. The groups did not differ in terms of sex, age, serum electrolytes at presentation, or time between surgeon evaluation and operative intervention. Surgical ward patients had longer preoperative symptom duration. Operative time was longer in the NICU patients. Comparing the two groups, there was no difference in postoperative apnea, hypoxic, or bradycardic episodes. NICU patients achieved ad libitum feeds later than floor patients (2.0 versus 1.4 d; P = 0001) and had a longer postoperative LOS (2.2 versus 1.6 d; P = 0.0012). CONCLUSIONS: Patients with HPS admitted to the NICU postoperatively had a longer time to full feeds and hospital LOS. The reduction in LOS between hospital wards may be improved with implementation of a hospital-wide postoperative protocol for patients with HPS.

Minimally invasive surgical techniques are safe in the diagnosis and treatment of pediatric malignancies.

BACKGROUND: Minimally invasive surgical (MIS) techniques have become an established part of the care of the adult oncology patient. As surgeons have become more experienced with these advances in technique, MIS has recently seen an expanding role in the diagnosis and treatment of pediatric malignancies. We hypothesize that MIS techniques can be used to provide reliable diagnosis and safe therapeutic resection of many pediatric malignancies. PROCEDURE: We performed a retrospective review of all patients who underwent a minimally invasive operation for diagnosis or treatment of a malignant solid tumor at the Children's Hospital Colorado over a ten-year period. RESULTS: A total of 105 minimally invasive procedures were performed in 98 patients, 61% of which were male. The majority of cases, 78 (74%) were thoracoscopic procedures and the remaining 27 (26%) were laparoscopic procedures. Twenty-one (27%) thoracoscopic procedures were performed for complete resection of primary tumor or metastases, with only three cases (14%) converted to open thoracotomy. Tumors that were successfully removed thoracoscopically include neuroblastomas (n = 8), metastatic disease (n = 7), and a schwannoma. Of the 28 laparoscopic procedures, nine were performed for tumor resection with one case converted to open. Tumors that were successfully removed laparoscopically include 6 adrenal neuroblastomas and one pseudopapillary pancreatic tumor. There were no major surgical complications. No port site or surgical site recurrences were reported. CONCLUSIONS: MIS techniques can be used safely and effectively for the diagnosis and resection of pediatric malignancies and treatment decisions can be made accurately based on tissue obtained.

A pediatric specific shock index in combination with GMS identifies children with life threatening or severe traumatic brain injury.

PURPOSE: We have previously demonstrated that a shock index, pediatric age adjusted (SIPA) accurately identifies severely blunt injured children. We aimed to determine if SIPA could more accurately identify children with severe traumatic brain injury (TBI) than hypotension alone. METHODS: We performed subset analysis of those children with TBI among a cohort of children age 4-16 years with blunt trauma and injury severity score ≥15 from 1/07 to 6/13. We evaluated the ability of four markers to identify the most severely brain injured children. Markers included hypotension, elevated SIPA, abnormal GCS motor score (GMS), and elevated SIPA or abnormal GMS. We aimed to determine which of these four markers had the highest sensitivity in identifying severely injured children. RESULTS: Three hundred and ninety-two (392) children were included. Hypotension was present in 24 patients (6%); elevated SIPA in 106 (27 %), abnormal GMS in 172 (44%), and elevated SIPA or abnormal GMS in 206 (53%). All markers were able to accurately identify severely injured children with TBI. Elevated SIPA or abnormal GMS identified a greater percentage of patients with each of seven complications with higher sensitivity than each of the three other markers. CONCLUSION: Among blunt injured children with TBI, elevated SIPA or abnormal GMS identifies severely brain injured children.

Stearoyl-CoA desaturase plays an important role in proliferation and chemoresistance in human hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is often diagnosed at an advanced stage, when it is not amenable for aggressive therapies such as surgical resection or liver transplantation. Current therapeutic options achieve clinical responses in only a small percentage of cases. As a consequence, effective approaches for prevention and treatment are greatly needed. Altered lipid metabolism has been recently linked to HCC pathogenesis. The aims of this study were to define the cellular and molecular mechanisms linking stearoyl-CoA desaturase (SCD), the rate-limiting enzyme and an essential regulator of lipid homeostasis in liver cells, to carcinogenesis in HCC. MATERIAL AND METHODS: HCC and normal liver specimens were collected. Human HCC cell lines: HepG2, Hep3B, and PLC/PLF/5 were used for immunoblot, cell viability, proliferation, and apoptosis assays. Small interfering RNAs were used for genetic inhibition, and 10, 12 conjugated linoleic acid was used for pharmacologic SCD inhibition. RESULTS: SCD was strongly expressed in surgically resected HCC (n = 64) and various human HCC cell lines (HepG2, Hep3B, and PLC/PLF/5). The levels of SCD negatively correlated with degree of tumor differentiation (P < 0.01). Treatment of these HCC cell lines with a panel of chemotherapeutic drugs resulted in a time-dependent, phosphatidylinositol 3 kinase- and c-Jun N-terminal kinases1/2-mediated upregulation of SCD expression, which paralleled the degree of resistance to drug-induced apoptosis. Specific genetic or pharmacologic SCD suppression resulted in inhibition of cell proliferation (P < 0.001) and significantly increased sensitivity to chemotherapy-induced apoptosis. CONCLUSIONS: Our data suggest that increased SCD expression plays an important role in HCC development and resistance to chemotherapy-induced apoptosis, and this is in part mediated by phosphatidylinositol 3 kinase/c-Jun N-terminal kinases activation. Specific targeted interruption of this pathway in HCC could be a desirable approach in designing novel therapeutic strategies.

National trends and outcomes of pediatric gastrostomy tube placement.

OBJECTIVES: National outcomes data regarding surgical gastrostomy tube (G-tube) and percutaneous endoscopic gastrostomy (PEG) tube procedures are lacking. Our objectives were to describe trends in G-tube and PEG procedures, examine regional variation, and compare outcomes. METHODS: This was a retrospective study using pediatric admissions during 1997, 2000, 2003, 2006, and 2009 from the Kids' Inpatient Database. Length of stay and cost were adjusted for demographics, complexity, setting, year, and infection or surgical complication. RESULTS: G-tubes were placed during 64,412 admissions, increasing from 16.6 procedures/100,000 US children in 1997 to 18.5 in 2009. Surgical gastrostomy rates increased by 19% (0.17 procedures/100,000/year, P < 0.002) and, among children <1 year, they increased by 32% (2.56 procedures/100,000/year, P < 0.01). PEG rates did not increase (0.02 procedures/100,000/year, P = 0.47) in the study years. The West had an 18% higher rate than the national average for surgical G-tubes and a 10% higher rate for PEGs. When the sole procedure during the admission was gastrostomy, the G-tube was associated with a 19% (confidence interval 9.7-57.5) longer length of stay, and a 25% higher cost (confidence interval 16.4-34.5) compared with PEG. CONCLUSIONS: Surgical gastrostomy insertion rates have increased whereas PEG rates have not, despite evidence of better severity-adjusted outcome measures for PEG tubes. Surgical gastrostomy insertion in children <1 year of age yielded the greatest increase, which may relate to a changing patient population; however, regional variation suggests that provider preference also plays a role. Our data underline the need for more robust collection and analysis of surgical outcomes to guide decision making.

Head injury pattern in children can help differentiate accidental from non-accidental trauma.

OBJECTIVES: Our aim was to define the radiographic findings that help differentiate abusive head trauma (AHT) from accidental head injury. METHODS: Our trauma registry was queried for all children ≤5 years of age presenting with traumatic brain injury (TBI) from 1996-2011. RESULTS: Of 2,015 children with TBI, 71% had accidental injury and 29% had AHT. Children with AHT were more severely injured (ISS 22.1 vs 14.4; p < 0.0001) and had a higher mortality rate (15 vs 5%; p < 0.0001). Patients with AHT had higher rates of diffuse axonal injury (14 vs 8%; p < 0.0001) and subdural hemorrhage (76 vs 23%; p < 0.0001). Children with accidental injury had higher rates of skull fractures (52 vs 21%; p < 0.0001) and epidural hemorrhages (11 vs 3%). CONCLUSIONS: AHT occurred in 29% of children and resulted in increased mortality rates. These children had higher rates of subdural hemorrhages and diffuse axonal injury. Physicians initially evaluating injured children must maintain a high index of suspicion for abuse in those who present with subdural hematoma or diffuse axonal injury.

Pulmonary artery endothelial cell dysfunction and decreased populations of highly proliferative endothelial cells in experimental congenital diaphragmatic hernia.

Decreased lung vascular growth and pulmonary hypertension contribute to poor outcomes in congenital diaphragmatic hernia (CDH). Mechanisms that impair angiogenesis in CDH are poorly understood. We hypothesize that decreased vessel growth in CDH is caused by pulmonary artery endothelial cell (PAEC) dysfunction with loss of a highly proliferative population of PAECs (HP-PAEC). PAECs were harvested from near-term fetal sheep that underwent surgical disruption of the diaphragm at 60-70 days gestational age. Highly proliferative potential was measured via single cell assay. PAEC function was assessed by assays of growth and tube formation and response to known proangiogenic stimuli, vascular endothelial growth factor (VEGF), and nitric oxide (NO). Western blot analysis was used to measure content of angiogenic proteins, and superoxide production was assessed. By single cell assay, the proportion of HP-PAEC with growth of >1,000 cells was markedly reduced in the CDH PAEC, from 29% (controls) to 1% (CDH) (P < 0.0001). Compared with controls, CDH PAEC growth and tube formation were decreased by 31% (P = 0.012) and 54% (P < 0.001), respectively. VEGF and NO treatments increased CDH PAEC growth and tube formation. VEGF and VEGF-R2 proteins were increased in CDH PAEC; however, eNOS and extracellular superoxide dismutase proteins were decreased by 29 and 88%, respectively. We conclude that surgically induced CDH in fetal sheep causes endothelial dysfunction and marked reduction of the HP-PAEC population. We speculate that this CDH PAEC phenotype contributes to impaired vascular growth in CDH.

Torsed ectopic intra-abdominal liver rest within an adolescent female.

Extrahepatic liver (EL) rests are rare, with a reported annual incidence of 0.24-0.47. While reports often note EL incidentally found on pathologic specimens of aberrant tissue, there has been a case report of hepatocellular carcinoma arising from one of these rests, highlighting the importance of surgical resection. EL has been reported to cause symptoms such as abdominal pain, intraperitoneal bleeding and compression of adjacent organs. Most commonly, it has been identified in the gallbladder, likely due to proximity of the gallbladder to the native liver. The paucity of diagnostic tests makes the preoperative diagnosis challenging. We present a case of a 12-year-old female presenting with severe epigastric pain secondary to incapsulated EL tissue attached to the stomach via a narrow stalk. By describing this case, we hope to improve the diagnosis and management of abdominal masses with unclear etiology.

Adolescent blunt solid organ injury: Differences in management strategies and outcomes between pediatric and adult trauma centers.

BACKGROUND: Adolescents with blunt solid organ injuries (BSOI) are cared for at both pediatric trauma centers (PTC) and adult trauma centers (ATC). Over the past decade, treatment strategies have shifted towards non-operative management with reported favorable outcomes. The aim of this study was to compare management strategies and outcomes between PTC and ATC. METHODS: We queried the 2016-2018 Trauma Quality Improvement Program (TQIP) datasets to identify adolescents between the ages of 16 and 19 with BSOI. Characteristics were stratified by center type (pediatric or adult) for comparative analyses. Separate logistic regressions were used to assess the association of hospital type, location of injury, age, gender, weight, Glascow Coma Score (GCS), Injury Severity Score (ISS), and intensive care unit (ICU) admissions for outcomes of interest. RESULTS: Among the 3,011,310 patients enrolled in the 2016-2018 TQIP datasets, 106,892 (3.5%) had a BSOI ICD9/10 code. Of those, 9,193 (8.6%) were between 16 and 19 years of age and included in this analysis. Within this cohort, 6,073 (66.1%) were managed at an ATC and 3,120 (33.9%) were managed at a PTC. While statistically different, there were no clinically relevant differences for age, weight, and sex between groups. A significantly higher ISS and lower GCS score were observed among those admitted to ATC compared to PTC. ICU admissions were more frequent at ATC. Number of blood transfusions by 4 h after presentation were also higher among those admitted to an ATC. Despite a lower ISS and higher GCS at presentation, mortality was higher among those treated at a PTC with an odds ratio (95% confidence interval) of 2.42 (1.31-4.53). After excluding adolescents with a traumatic brain injury, a common cause of mortality among adolescent trauma patients, these differences in outcomes persisted. CONCLUSIONS: Our data suggest that adolescents with BSOI managed at a PTC are less likely to receive blood transfusions by 4 h of admission or be admitted to the ICU than those managed at an ATC. However, this more conservative approach may come at the expense of higher overall mortality. Further work is needed to understand these differences and determine if PTC need to be more aggressive in managing BSOI.

Ultrasound-guided erector spinae plane block versus thoracic epidural analgesia: Postoperative pain management after Nuss repair for pectus excavatum.

AIM OF THE STUDY: Postoperative pain management is a significant challenge in patients undergoing Nuss repair for pectus excavatum chest wall deformity. Therapeutic anesthetic options primarily include patient-controlled intravenous analgesia, thoracic epidural analgesia (TEA), and cryoanalgesia. However, TEA is limited to inpatient use and both TEA and cryoanalgesia can result in neurologic injury. The novel technique of ultrasound-guided erector spinae plane regional analgesia has been used recently in our patients undergoing the Nuss repair and has shown impressive pain relief, but without the potential complications of other modalities. Erector spinae plane block (ESPB) postoperative pain management outcomes were studied as compared to TEA. METHODS: Thirty consecutive patients with severe pectus excavatum undergoing Nuss repair and placement of ultrasound-guided ESPB were each paired to a historical cohort control patient with TEA postoperative pain management. The cohort patient match was defined by age (± 2 years), gender, and CT pectus index (± 15%). Study variables included hospital length of stay (LOS), pain scores, and pain medication usage. RESULTS: Pain scores as measured by area under the curve per hour (Day 1: 2.72 (SD = 1.37) vs. 3.90 (SD = 1.81), P = 0.006; Day 2: 2.83 (SD = 1.32) vs. 3.97 (SD = 1.82), P = 0.007) and oral morphine equivalent (OME) pain medication usage (Day 1: 11.9 (SD = 4.9) vs 56.0 (SD = 32.2), P < 0.001; Day 2: 14.7 (SD = 7.1) vs. 38.0 (SD = 21.7), P < 0.001) were higher for the first two postoperative days in the ESPB group. However, mean hospital LOS was nearly one day shorter for ESPB patients (3.78 (SD = 0.82) vs. 2.90 (SD = 0.87), P < 0.001) who were discharged home with the catheter in place until removal, typically at 5-7 days postoperatively. CONCLUSION: Ultrasound-guided ESPB is thus a feasible, safe, and effective alternative to TEA in postoperative pain management after Nuss repair and results in decreased hospital stay. LEVEL OF EVIDENCE: III.

Contemporary pediatric splenectomy: continuing controversies.

PURPOSE: We undertook the current study to update the literature on pediatric splenectomy in the age of minimally invasive proficiency among pediatric surgeons. The study is designed to address specific concerns among surgeons about the suitability of the laparoscopic approach in specific situations and among hematologists about the relative benefits and risks of splenectomy in children. METHODS: Retrospective analysis of clinicopathologic data for 118 children who underwent open (OS) or laparoscopic (LS) splenectomy at an urban tertiary children's hospital from January 2000 to July 2008. RESULTS: One hundred and three cases (87%) were started as LS. Operative times were equivalent for LS and OS (P = 0.8). In the LS group, there were four conversions (3.9%) from LS to OS and five early post-operative complications (4.9%). Median length of stay was 2 days for LS and 4 days for both OS and LS converted to OS (P < 0.0001). The ten largest spleens removed by LS had greater mass (P = 0.02) and tended to have greater volume (P = 0.1) than those removed by OS. Children with hereditary spherocytosis, ITP, and hemoglobinopathy had favorable clinical outcomes, regardless of operative approach. There were no cases of overwhelming post-splenectomy sepsis in this series. CONCLUSIONS: Laparoscopic splenectomy is the preferred approach for splenectomy in children with hematological diseases, with or without splenomegaly. Compared to open splenectomy, laparoscopic splenectomy has equivalent operative time and improved length of stay. Both approaches have excellent therapeutic outcomes for appropriate indications.

Failure of resolution of portal fibrosis during omega-3 fatty acid lipid emulsion therapy in two patients with irreversible intestinal failure.

Parenteral omega-3 fatty acid lipid emulsions have been evaluated for their potential role in reversing intestinal failure-associated liver disease. We report our experience using Omegaven in 2 patients with irreversible intestinal failure and intestinal failure-associated liver disease. Despite biochemical and histologic improvement in cholestasis, both patients had persisting, significant portal fibrosis on liver biopsy.

The inflammatory response to injury in children.

PURPOSE OF REVIEW: Severely injured children have a decreased incidence and different pattern of multiple organ failure when compared with adults. This article reviews recent advances in understanding the mechanisms leading to this discrepancy. RECENT FINDINGS: Post injury, inflammation-related outcomes are age-related, as demonstrated by epidemiological and laboratory investigations that confirm a relative protection from acute lung injury and multiple organ failure in children. The importance of the innate immune system in initiating and regulating the inflammatory response to injury is also increasingly well understood, but relatively little research has focused on the implications of a maturing innate immune system for the inflammatory response to injury in children. The development of age-appropriate immunomodulatory interventions for the prevention and treatment of postinjury inflammatory dysregulation depends on continued investigation of mechanisms responsible for the unique pediatric inflammatory response to trauma. SUMMARY: The inflammatory response to injury in children is functionally and mechanistically unique, as suggested by age-related differences in the incidence and pattern of systemic inflammation and multiple organ failure after major trauma. We review the current clinical and basic science literature related to postinjury inflammation in childhood, focusing on the developmental biology of innate immunity and the implications of a maturing immune system for trauma-related interventions and outcomes.

Open versus thoracoscopic thymectomy for juvenile myasthenia gravis.

BACKGROUND: Juvenile myasthenia gravis (JMG) is an antibody mediated autoimmune disorder that manifests as progressive voluntary muscle weakness and fatigue. In medically refractory cases, thymectomy has been shown to abrogate symptoms and reduce glucocorticoid dependence. While transcervical or transsternal incisions have been the traditional approach, adult trends now favor thoracoscopic thymectomy. Little data exist to support this approach in children. METHODS: A retrospective review of all patients younger than 20 years of age who underwent a thymectomy for JMG at two pediatric institutions between 2001 and 2018 was performed. Children were divided into either an open (transcervical or transsternal) or thoracoscopic group and baseline characteristics, perioperative, and postoperative outcomes were compared. RESULTS: Thirty-four thymectomies were performed during the 18-year study period; 18 via an open and 16 via a thoracoscopic approach. The operative time was shorter for open procedures compared thoracoscopic ones (108 ±â€¯49 and 145 ±â€¯43 min, respectively, p = 0.025). Thoracoscopic thymectomy was associated with less intraoperative blood loss (5.5 ±â€¯6.0 vs 55 ±â€¯67 ml, p = 0.007), decreased duration of postoperative intravenous narcotic use (5.0 ±â€¯1.5 vs 20 ±â€¯23 h, p = 0.018), and a shorter length of hospitalization (1.7 ±â€¯1.0 vs 2.7 ±â€¯1.1 days, p = 0.009). No perioperative complication occurred in either group. Clinical improvement was reported in 94% of children in both groups. CONCLUSIONS: Thoracoscopic thymectomy in children is a safe and effective surgical technique for the treatment of JMG. Increased acceptance of this minimally invasive approach by children, families, and referring neurologists may enable earlier surgical intervention. TYPE OF STUDY: Clinical research paper. LEVEL OF EVIDENCE: III.

Pediatric empyemas - Has the pendulum swung too far?

BACKGROUND: The management of childhood empyemas has transformed over the past decade, with current trends favoring chest tube placement and intrapleural fibrinolytic therapy. Although this strategy often avoids the need for video-assisted thoracoscopic surgery (VATS), hospital length of stay can be long. METHODS: To characterize national trends and outcomes associated with empyema management, the Pediatric Health Information System (PHIS) database was queried to identify children (2 months-18 years) treated for an empyema between January 2010 and December 2017. The cohort was divided into those treated with primary VATS and those treated with chest tube and intrapleural fibrinolysis. Number of chest radiographic studies obtained, frequency of pediatric intensive care unit (PICU) admission, mechanical ventilation requirements, and length of hospitalization were compared between groups. RESULTS: A total of 3,365 otherwise healthy children met inclusion criteria. Among them, 523 (16%) were managed with primary VATS and 2,842 (84%) were managed with chest tube and fibrinolytic therapy. Of those who were treated with chest tube and fibrinolysis, 193 (6.8%) subsequently underwent VATS. The percentage of children treated with chest tube and fibrinolysis increased from 65% in 2010 to 95% in 2017 (p<0.001). After adjusting for age, race, ethnicity, payer, and region, children who underwent primary VATS received fewer chest radiographic studies, were less likely to be admitted to the PICU or require mechanical ventilation and had a shorter PICU and hospital length of stay compared to those who were treated with chest tube and fibrinolytic therapy (p<0.001 for all analyses). DISCUSSION: Although national trends favor chest tube and fibrinolysis, primary VATS are associated with a shorter hospital and PICU length of stay and a lower requirement for mechanical ventilation. Future studies should aim to risk stratify children who may suffer from a protracted course with the goal to offer primary VATS to this subset of children and return them to normal life more expeditiously. LEVEL OF EVIDENCE: III.