'Short Bars Crossed' to Remodel the Entire Chest Wall in Children and Adolescents with Pectus Excavatum.

BACKGROUND: The cross-bar technique of minimally invasive pectus excavatum (PE) correction remains underreported, which is especially true of pediatric patients. We therefore reviewed the experience of a Turkish and an Austrian center. An additional novelty characterizing both pediatric cohorts was the use of short bars. METHODS: In a retrospective study, pediatric PE corrections involving 'short bars crossed' were analyzed for complications and intra-/postoperative outcomes. Cases with two or three bars were included, given that a horizontal third bar was placed whenever considered useful for upper-chest elevation. All bars were fitted with a single stabilizer near the surgical entry point. In the Austrian center, intercostal nerve cryoablation was used for pain management. Descriptive statistics are presented. RESULTS: Seventy-eight patients ≤18 years old were evaluable at the Turkish (n = 56) and Austrian (n = 22) centers. Total median values were 16.2 (IQR: 15.1-17.4) years for age and 4.60 (IQR: 3.50-6.11) for Haller index. Ten mild or moderate complications (12.8%) were observed, including just one revision requirement due to bar migration (1.28%). Intercostal nerve cryoablation (n = 13) was associated with longer surgical procedures at 150 (IQR: 137-171) versus 80 (IQR: 60-100) minutes but with shorter hospital stays, given an IQR of 3-4 days versus 4-5 days. CONCLUSION: 'Short bars crossed'-with a single stabilizer in a ventral position close to the surgical entry point-ensure a wide distribution of forces, protect against bar migration, are safe and effective, and offer stability at an age characterized by growth and physical activity. LEVEL OF EVIDENCE: IV.

Evaluation of cross-bar and parallel-bar techniques in MIRPE surgery in different countries: a multicenter study.

Parallel- and cross-bar techniques are surgical methods used in the pectus excavatum. While the parallel bar is used in many centers, the cross bar is a new technique. The aim of the study is to evaluate the data of centers using cross bar and parallel bar. The aim of this multicenter study is to retrospectively evaluate the data of centers have been using both cross-bar and parallel-bar techniques. 213 parallel bars and 205 cross bars were used. Parallel-bar advantages: the mean patient satisfaction score was 9.40 ± 0.95. Cross-bar advantages: the rate of patients with symmetric deformity was 75.6%, recurrence 0.5%. The mean patient satisfaction score was 9.40 ± 0.95 in operations performed with the parallel-bar technique and 9.13 ± 1.11 in operations performed with the cross-bar technique (p < 0.05). Recurrence was observed in 3.3% of patients undergoing surgery using the parallel-bar technique and 0.5% of patients undergoing surgery using the cross-bar technique (p < 0.04). The cross-bar technique is more advantageous in terms of the recurrence, while second, the parallel-bar technique is associated with greater patient satisfaction. Comparison of data from different countries reveals the differences between patients who have been treated with minimally invasive repair of pectus excavatum and the outcomes of surgery.

Management of hypertrophic pylorus stenosis with ultrasound guided single shot epidural anaesthesia--a retrospective analysis of 20 cases.

AIM: To retrospectively describe the performance of ultrasound guided thoracic epidural anaesthesia under sedation for anaesthesia management of open pyloromyotomy. BACKGROUND: Anaesthesia management for hypertrophic pylorus stenosis (HPS) is usually performed under general anaesthesia with tracheal intubation. Only a few publications describe avoidance of tracheal intubation in infants by using spinal or caudal anaesthesia. The present retrospective analysis describes the performance of ultrasound guided thoracic epidural anaesthesia under sedation for anaesthetic management of open pyloromyotomy. METHODS: Twenty consecutive infants scheduled for pyloromyotomy according to the Weber-Ramstedt technique were retrospectively analysed. After sedation with nalbuphine and propofol, an ultrasound guided single shot thoracic epidural anaesthesia was performed with 0.75 ml·kg(-1) ropivacaine 0.475%. Insufficient blockade was defined as increase of HR > 15% from initial value and/or any movements at skin incision. In those cases we were prepared for rapid sequence intubation according to the departmental standard. RESULTS: All pyloromyotomies could be performed under single shot thoracic epidural anaesthesia and sedation. One case of moderate oxygen desaturation was treated with intermittent ventilation via face mask. CONCLUSIONS: Thoracic epidural anaesthesia under sedation for pyloromyotomy has been a useful technique in this retrospective series of infants suffering from HPS. In 1/20 infants short term assisted ventilation via face mask was required. Undisturbed surgery was possible in all cases.

The plasma activities of lysosomal enzymes in infants with necrotizing enterocolitis: new promising class of biomarkers?

BACKGROUND: Intestinal ischemia plays a major role in the pathogenesis of necrotizing enterocolitis (NEC). The diagnosis of intestinal ischemia would be highly desirable, as it is impossible to achieve with the current diagnostic regimes. Preliminary data from an animal NEC model indicate a possible correlation between the plasma activity of the lysosomal enzyme beta-glucosidase and intestinal ischemia. METHODS: In this case-control study the plasma activities of six different lysosomal enzymes were detected by high-performance liquid-chromatography tandem mass-spectrometry in 15 infants with NEC and compared to 18 controls. RESULTS: The plasma activities of ß-glucosidase (ABG), α-glucosidase (GAA), and galactocerebrosidase (GALC) were significantly higher in the NEC group compared with controls (ABG, p=0.009; GAA, p<0.001; GALC, p<0.001). GAA and GALC showed the highest diagnostic value with areas under the curve of 0.91 and 0.87. CONCLUSIONS: We identified GAA and GALC as new promising biomarkers for gut wall integrity in infants with NEC, and report first results on the plasma activity of ABG. The present study supports the hypothesis that the plasma activity of ABG might serve as a marker of intestinal ischemia in NEC. The identification of intestinal ischemia could facilitate early discrimination of infants at risk for NEC from infants with benign gastrointestinal disorders.

Interleukin-8 predicts 60-day mortality in premature infants with necrotizing enterocolitis.

OBJECTIVE: The purpose of this study was to evaluate the predictiveness of circulating interleukin (IL)-8 for 60-day mortality in premature infants with necrotizing enterocolitis (NEC). BACKGROUND: NEC affects up to 5% of premature infants and remains a leading cause of mortality among neonates. METHODS: A total of 113 infants with surgically (n=50) or medically (n=63) treated NEC were retrospectively analyzed. Laboratory parameters including serum IL-8 were assessed at the diagnosis of NEC and during the preoperative workup. RESULTS: The 60-day mortality was 19% (22/113), 10% (6/63) in medical and 33% (16/50) in surgical NEC. IL-8 levels significantly correlated with 60-day mortality (odds ratio: 1.38; CI 1.14-1.67; p=0.001). Median IL-8 levels at diagnosis were significantly higher in neonates who were later treated surgically (median=2625 pg/ml; range: 27-7500) compared with those treated medically (median=156 pg/ml; range: 5-7500; p<0.001). The AUC to discriminate between medical and surgical NEC was 0.82 (CI, 0.74-0.90), and an exploratory IL-8 cutoff point could be established at 1783 pg/ml (sensitivity of 90.5%; specificity of 59.2%). CONCLUSIONS: Our findings that serum IL-8 (i) correlates directly with 60-day mortality and (ii) differs significantly between medically and surgically treated infants may change the process of therapeutic decision making in NEC.

Serum levels of interleukin-8 and gut-associated biomarkers in diagnosing necrotizing enterocolitis in preterm infants.

BACKGROUND: In recent years several potential biochemical markers have been evaluated to facilitate a reliable diagnosis of necrotizing enterocolitis (NEC), but none have made progress to clinical routine. We performed a comparative assessment in premature infants to evaluate the diagnostic value of the routinely available cytokine interleukin (IL)-8, and two promising experimental biomarkers, the gut barrier proteins liver fatty acid binding protein (L-FABP) and intestinal fatty acid binding protein (I-FABP), respectively, for the diagnosis of NEC. METHODS: IL-8, L-FABP, and I-FABP concentrations were analyzed in the serum of 15 infants with NEC and compared with 14 gestational age-matched infants serving as a control group. RESULTS: Serum concentrations of I-FABP, L-FABP and IL-8 were significantly higher in infants with NEC compared with controls. IL-8 showed the highest diagnostic value with an area under the curve of 0.99, followed by L-FABP and I-FABP. In addition we found a significant correlation between IL-8 and both FABPs in infants with NEC. CONCLUSION: Our results further advocate the possible role of IL-8 as a specific marker for NEC. The diagnostic value of IL-8 seems to be superior to I-FABP, and similar to L-FABP. The routinely availability facilitates IL-8 as a possible candidate for further clinical investigations.

Comprehensive evaluation of 11 cytokines in premature infants with surgical necrotizing enterocolitis.

OBJECTIVE: A prospective study to investigate the pattern of pro- and anti-inflammatory cytokine responses in neonates with surgical necrotizing enterocolitis (NEC) and identify those cytokines being the most promising for future research. METHODS: A panel of 11 different cytokines were measured in 9 infants with proven NEC and compared with 18 age-matched healthy neonates. RESULTS: The serum concentrations of the interleukins (IL)-6, IL-8, and IL-10 were significantly (32-fold to 56-fold) higher in NEC infants compared with controls. In contrast, IL-5, IFN gamma, IL-4 and IL-2 showed slightly (1.4-fold to 5.9-fold) lower levels in the NEC samples. However, these cytokines showed a very low absolute concentration in infants with NEC and in controls. The sum of the serum concentrations of IL-6, IL-8 and IL-10 was able to clearly separate infants with NEC from control samples. IL-1 beta and TNF-alpha showed no statistically different levels. The serum levels of TNF-beta and IL-12p70 were below the detection limit in more than 50% of all samples per group. CONCLUSION: In spite of strong local inflammation only three out of eleven cytokines (IL-6, IL-8, and IL-10) showed strongly increased serum levels indicating an important role of them in the pathogenesis of NEC. At least two of these three cytokines were elevated in every single NEC patient. Thus, longitudinal monitoring of combined IL-8, IL-6, and IL-10 levels could reveal their potency in being clinical relevant markers in NEC.

Interleukin 8 correlates with intestinal involvement in surgically treated infants with necrotizing enterocolitis.

PURPOSE: The aim of this study was to test the predictive value of interleukin (IL) 8 in the assessment of intestinal involvement in necrotizing enterocolitis (NEC). METHODS: Forty infants with surgically treated NEC were classified into 3 groups based on intestinal involvement during laparotomy: focal (n = 11), multifocal (n = 16), and panintestinal (n = 13). Preoperatively obtained serum levels of IL-8, C-reactive protein, white blood cell count, and platelet count were correlated with intestinal involvement using logistic regression models. RESULTS: Interleukin 8 correlated significantly with intestinal involvement in infants with surgically treated NEC (odds ratio, 1.74; confidence interval, 1.27-2.39; P < .001). An exploratory IL-8 cutoff value of 449 pg/mL provided a specificity of 81.8% and sensitivity of 82.8% to discriminate focal from multifocal and panintestinal disease. An IL-8 cutoff value of 1388 pg/mL provided a specificity of 77.8% and a sensitivity of 76.9% to discriminate panintestinal disease from focal and multifocal disease. CONCLUSIONS: To our knowledge, this is the first study to demonstrate a significant correlation of IL-8 with intestinal involvement in advanced NEC in a large patient population. Our results indicate that IL-8 may be a promising biomarker for assessing intestinal involvement in infants with advanced NEC.

US as a primary diagnostic tool in relation to negative appendectomy: six years experience.

PURPOSE: To evaluate the effect of ultrasonography (US) on the rate of appendectomy after false-positive diagnosis of acute appendicitis (negative appendectomy). MATERIALS AND METHODS: Data were analyzed in 736 pediatric patients (mean age, 13.2 years) who had undergone appendectomy between 1995 and 2000. Histologic data were compared in patients who underwent US with those who did not undergo imaging prior to surgery. US was performed by a radiologist or a pediatric surgeon or both. RESULTS: A total of 643 (87.4%) of the 736 pediatric patients underwent preoperative US, and 93 (12.6%) of the 736 did not undergo preoperative US. Of the 736 patients, 97 (13.2%) underwent negative appendectomy. Thirty-four (36.6%) of the 93 patients who underwent appendectomy with no preoperative US and 63 (9.8%) of the 643 patients who underwent preoperative US underwent negative appendectomy. There was a significant association between US and positive appendectomy (P <.001). CONCLUSION: US in pediatric patients suspected of having appendicitis can significantly lower the negative appendectomy rate.

Release of toxic metals from button batteries retained in the stomach: An in vitro study.

BACKGROUND: Ingestion of button batteries by children is a rapidly growing problem, and opinions differ on how button batteries distal to the gastroesophageal junction should be managed. The authors therefore performed an experimental study to determine the cumulative load of various toxic elements released from retained button cells in simulated gastric juice. METHODS: Eight different groups of button cells were immersed in simulated gastric juice. Analyzed elements included Al, Ba, Cd, Cr, Cu, Fe, Hg, Li, Mg, Mn, Ni, Pb, Sb, Sn, Sr, Te, TI, V, W; and Zn. Inductively coupled plasma mass spectrometry (ICP-MS) was used to evaluate the residual amounts of elements after 4, 24, 72, and 120 hours. RESULTS: At 4 hours, leakage was seen with almost all batteries, with the levels increasing in a time-dependent manner. The highest detected levels at 4 hours were 1.20 microgram for Cd, 280.51 ng for Hg, and 2.63 microgram for Pb. Dissolution, holes, and defragmentation were seen within 24 to 72 hours. Battery weight loss varied between 22 and 104 mg over the course of the study. CONCLUSIONS: Toxic elements contained in button cells are released quickly in gastric juice. This finding might change the current policy of watchful waiting or conservative management of batteries lodged in the stomach.

Posterior "Nutcracker" phenomenon in a patient with abdominal aortic aneurysm.

We report on a posterior "nutcracker" phenomenon due to an abdominal aortic aneurysm in a patient with a retro-aortic left renal vein. A 71-year-old man with a known abdominal aortic aneurysm presented in the emergency room with mild hematuria and flank pain. Computed tomography angiography revealed an aortic aneurysm, which compressed the left renal vein between the aorta and the vertebral column. Compression of the left renal vein, due to the aorta with consecutive congestion and hematuria as well as flank pain, was previously described as nutcracker phenomenon. In case of a retro-aortic left renal vein, increase of the aortic diameter can lead to compression of the renal vein and furthermore to the classical signs and symptoms of the "nutcracker" phenomenon, even though the aneurysm is not ruptured or there are no aorto-caval or aorto-left renal vein fistulas.