Early use of an implantable diaphragm pacing stimulator for a child with severe acute flaccid myelitis-a case report.

Introduction: Acute Flaccid Myelitis (AFM) is a recently recognized, polio-like illness of children that can be functionally devastating. Severe cases can lead to ventilatory failure. Incomplete phrenic nerve injuries in other populations has been shown to respond to diaphragmatic stimulation. We therefore proposed an early assessment for incomplete denervation by laparoscopic direct stimulation of the diaphragm and placement of a diaphragmatic pacing system to enhance diaphragm function. Case presentation: A 3 year-old girl presented with AFM with clinically and electrodiagnostically severe involvement of all four limbs and muscles of respiration. Direct stimulation of the diaphragm demonstrated contraction and a diaphragmatic stimulator was placed at 3 weeks post presentation. The patient was immediately able to tolerate short bouts of reduced ventilation settings. Electromyography via the pacing wires demonstrated intact motor units consistent with partial denervation/reinnervation in the left hemidiaphragm, and no motor units in the right hemidiaphragm. At three months, she tolerated 6 h of pacing on pressure support setting. At 5 months she demonstrated larger tidal volumes with active pacing than without. Discussion: In our experience, AFM patients who require chronic ventilator support are rarely able to be weaned. Despite clinical and surface electrodiagnostic evidence of complete phrenic nerve involvement, the patient's diaphragm responded to direct stimulation. The patient preferred pacing over non-pacing times and showed improved ventilatory ability with pacing as opposed to without, though remains ventilator-dependent. These findings support augmentation of diaphragm function and possible enhanced recovery of spontaneous function.

Magnamosis II: Magnetic compression anastomosis for minimally invasive gastrojejunostomy and jejunojejunostomy.

BACKGROUND: Previously we demonstrated the safety and patency of a magnetic compression anastomosis (magnamosis). We present the further development of this technique, with specific focus on optimizing device design for minimally invasive magnamosis. STUDY DESIGN: The magnamosis device was designed to incorporate 3 features: 2 convex-concave radially symmetric halves that magnetically self-align, a central channel for immediate patency, and specially engineered radial topography of the mating surfaces to promote gradual remodeling. Each symmetrical half consists of a ring-shaped neodymium-iron-boron magnet encased in polycarbonate casing. Twenty-one young adult pigs underwent either magnetic gastrojejunostomy (n = 13) or jejunojejunostomy (n = 8). Animals were euthanized at 1, 2, 4, and 6 weeks after operation. Anastomoses were studied with contrast radiography, burst pressure, and histology. RESULTS: Gastrojejunostomy: In all animals with successful placement of magnets, anastomoses were patent by contrast fluoroscopy, well healed by histologic examination, and showed excellent burst strength. Jejunojejunostomy: All animals had uneventful clinical courses, indicating that the magnamosis with immediate patency functioned properly without device dislodgement. At sacrifice, all magnamoses were patent, well healed by histology, and had burst strengths that equaled or exceeded that of traditional stapled anastomoses. CONCLUSIONS: Minimally invasive placement of a custom magnetic device in the stomach and jejunum allows intraluminal self-alignment and subsequent compression anastomosis over 3 to 10 days. The magnamosis is immediately patent and develops strength equal to or greater than that of hand-sewn or stapled anastomoses. Magnamosis is effective in the pig model, and may be a safe, effective, and minimally invasive alternative to current anastomotic strategies in humans.