Outcomes of the Nuss procedure in children with pectus excavatum: 14 years of experience.

BACKGROUND: We aimed to assess the effectiveness of the Nuss procedure for pectus excavatum (PE) and explore the impacts of sex and age on outcomes. METHODS: We retrospectively reviewed 594 consecutive children ≤18 years of age who underwent the thoracoscopy-assisted Nuss technique between January 2006 and July 2019. The severity of pectus deformity was calculated according to the Haller index (HI). The classification of PE and clinical data including complications was analyzed. RESULTS: Of the 594 patients, 456 (76.8%) were boys and 138 (23.2%) were girls. The mean age at surgery was 10.0 ± 5.0 years. The most common types of PE were 1A and 2A2 according to Park classification. Intraoperative and postoperative complication rates were 2/594 (0.3%) and 74/594 (12.5%), respectively. The most common complication was bar displacement. The bar was removed in 414 patients 3.5 ± 0.8 years later. The mean preoperative HI, postoperative HI with bar, and HI after bar removal were 4.2 ± 1.7, 2.4 ± 0.3, and 2.7 ± 0.5, respectively. Compared to the preoperative HI, both the postoperative HI with bar and HI after bar removal were significantly lower ( p < 0.001). For preschool-age children, the preoperative HI was significantly higher ( p = 0.027) and the change in HI significantly improved compared to school-age children ( p = 0.004). Boys and adolescents needed significantly more bars and stabilizers. CONCLUSION: Surgical correction of PE using the Nuss procedure is a safe procedure and improves the HI in children of different ages, even in those younger than 6 years of age.

Late-onset vital complication after the Nuss procedure for pectus excavatum.

The Nuss procedure is the most popular technique for correction of pectus excavatum recently. Life-threatening complications associated with the procedure are very rare. We report a 13-year-old boy who developed late-onset bilateral hemothorax with hypovolemic shock 5 months after the Nuss procedure. In literature review, this is the first case of the late-onset life-threatening bilateral hemothorax with hypovolemic shock ever reported.

Cardiac injury protection from mouse bone marrow stromal cells with in utero transplantation followed by secondary postnatal boost.

Limited donor-cell engraftment to the injured tissue restricts therapeutic efficacy of stem cell transplantation. Herein, we proposed an alternative strategy by using in utero transplantation (IUT) to create mixed-chimerism environment in recipients and to facilitate donor-cell engraftment followed by postnatal secondary boost with the same cells. Mouse bone marrow stromal cells (BMSCs) were used as the xenogenic donor cells and given into rat fetus as an early exposure of IUT treatment. The engraftment potential was analyzed for the presence of BMSCs by flow cytometry or PCR in recipient tissues. The function of a second boost of mouse BMSCs, in terms of cardioprotection, was tested by given 1×106 cells to rat IUT hearts with ischemia/reperfusion (IR) injury that was induced by a 45 min of left coronary ligation and released for 72 h. Mouse BMSCs demonstrated an immunosuppressive effect when mixed with mouse or rat lymphocytes. IUT treatment only caused few BMSCs engrafted to fetal (embryonic day 20) and adult (4 weeks after birth) rat organs including heart, but engraftment was increased in hearts of the IUT rats after second boost. This was coincided with attenuation of cardiac injury caused by IR. Interestingly, an up-regulation of CXC chemokine receptor type 4 (CXCR4) was seen when BMSCs were exposed to hypoxia. This indicates that enhanced engraftment of mouse BMSCs to post-ischemic rat hearts possibly is dependent on CXCR4. Moreover, results of flow cytometry demonstrated that the presence of CD34⁺ cells in rat IUT hearts with IR injury was increased. These observations suggest that enhanced engraftment of donor BMSCs to rat IR hearts by CXCR4 may recruit endogenous CD34⁺ cells of recipients which in turn protects heart against IR. This also supports the notion of fetal preconditioning with BMSC enhances the efficiency of progenitor cell-mediated organ protection after a postnatal second boost in xeno-transplantation.

Malignant transformation of a well-organized sacrococcygeal fetiform teratoma in a newborn male.

We report herein a case of a male newborn with a sacrococcygeal fetiform teratoma (FT). The baby presented with a large coccygeal teratoma. The preoperative diagnosis of FT was made by plain radiography, ultrasonography and magnetic resonance imaging. The baby was successfully treated by complete excision and pelvic floor reconstruction. Postoperative follow-up was uneventful until the teratoma recurred 11 months later as a malignancy. After undergoing a second operative procedure accompanied by chemotherapy, he has been doing well for 18 months.

Pectus excavatum repair after sternotomy: the Chest Wall International Group experience with substernal Nuss bars.

OBJECTIVES: Patients with pectus excavatum (PE) after prior sternotomy for cardiac surgery present unique challenges for repair of PE. Open repairs have been recommended because of concerns about sternal adhesions and cardiac injury. We report a multi-institutional experience with repair utilizing substernal Nuss bars in this patient population. METHODS: Surgeons from the Chest Wall International Group were queried for experience and retrospective data on PE repair using sub-sternal Nuss bars in patients with a history of median sternotomy for cardiac surgery (November 2000 to August 2015). A descriptive analysis was performed. RESULTS: Data for 75 patients were available from 14 centres. The median age at PE repair was 9.5 years (interquartile range 10.9), and the median Haller index was 3.9 (interquartile range 1.43); 56% of the patients were men. The median time to PE repair was 6.4 years (interquartile range 7.886) after prior cardiac surgery. Twelve patients (16%) required resternotomy before support bar placement: 7 pre-emptively and 5 emergently. Sternal elevation before bar placement was used in 34 patients (45%) and thoracoscopy in 67 patients (89%). Standby with cardiopulmonary bypass was available at 9 centres (64%). Inadvertent cardiac injury occurred in 5 cases (7%) without mortality. CONCLUSIONS: Over a broad range of institutions, substernal Nuss bars were used in PE repair for patients with a history of sternotomy for cardiac surgery. Several technique modifications were reported and may have facilitated repair. Cardiac injury occurred in 7% of cases, and appropriate resources should be available in the event of complications. Prophylactic resternotomy was reported at a minority of centres.

Bacteriology and antibiotic susceptibility of community-acquired intra-abdominal infection in children.

BACKGROUND AND PURPOSE: Intra-abdominal infection can be a life-threatening condition in children, and aggressive treatment is usually needed. The treatment should include surgical correction and drainage, and administration of antimicrobials that are effective against both aerobic and anaerobic microorganisms. This study investigated the microbiological characteristics of intra-abdominal infection of children in Taiwan. METHODS: Data for bacterial specimens from 113 children (64 males), aged from 9 months to 18 years, who had community-acquired intra-abdominal infections at our hospital during a 10-year period were analyzed. RESULTS: In total, 113 specimens were collected, including those with only aerobes (62%), and those with mixed aerobic and anaerobic species (35%). A total of 239 aerobes and 86 anaerobes were isolated. Polymicrobial infection was found in 79% of specimens. The predominant aerobe was Escherichia coli (42%), and Bacteroides fragilis (36%) was the most frequently isolated anaerobic microorganism. Enterococcus was detected in about 14% of Gram-positive aerobic isolates. Review of the results of antibiotic susceptibility testing revealed that the Gram-positive aerobes, apart from staphylococci, had a high susceptibility rate to ampicillin, and 84% of Gram-negative aerobes were susceptible to gentamicin. In addition, B. fragilis showed a high resistance rate to clindamycin (52%) but all of these isolates were susceptible to metronidazole. CONCLUSION: Triple antibiotic combination therapy including ampicillin, gentamicin and metronidazole remains an alternative empirical antibiotic therapy for pediatric patients with mild to moderate community-acquired intra-abdominal infection.

Calmette-Guérin bacillus sternal osteomyelitis diagnosed by DNA sequencing analysis of PNC A.

Sternal osteomyelitis is an uncommon complication of Calmette-Guérin bacillus vaccination. Herein we describe a 4-month-old Taiwanese infant with a growing parasternal mass resulting from sternal osteomyelitis. By using DNA sequencing analysis, we identified the etiology as Calmette-Guérin bacillus vaccination.

A cross-sectional study of lung volume development in pectus excavatum patients: estimating the total lung volume from chest computed tomograph using 3-dimensional volumetric reconstruction.

BACKGROUND/PURPOSE: This study quantified the lung volume development of pectus excavatum (PE) patients using chest computed tomography (CT) 3-dimensional volumetric reconstructions. The technique permits current and retrospective analyses of data from different institutions. PATIENTS AND METHODS: We analyzed the records of PE patients who underwent chest CT preoperatively between 2005 and 2009 at 3 institutions. All patients were Chinese. A window of -992 to -198 Hounsfield units was chosen for calculating the CT total lung volume (TLV). The data were compared with the data for 73 microtia and other chest-wall tumor patients studied during the same period as a control group. RESULTS: In total, 377 PE patients with Haller pectus index (PI) of at least 3.2 were identified for this study. Compared with the reported TLV data for 1050 healthy children and our control group, we found little evidence of a decreased TLV in PE patients at any age for either sex. The mean PI did not change significantly between the ages of 3 and 27 years. The PI was inversely correlated with the TLV (P < .001). CONCLUSION: Our cross-sectional study provides evidence that the TLV of PE patients is within the reference range in children and adolescents.

A rare type of ileal atresia due to intrauterine intussusception.

Intrauterine intussusception is an extremely rare cause of intestinal atresia. We report on a full-term neonate with clinical manifestations of intestinal obstruction two days after birth. The prenatal sonography at the late stage of pregnancy did not show any abnormality. The barium enema suggested distal intestinal obstruction. At surgery, a visible ileo-ileal intussusception resulting in ileal atresia was found. According to our knowledge, this presentation of ileal atresia did not fit into the present classification and have not yet been reported on. We present this rare type of ileal atresia due to intrauterine intussusception with operative evidence, which is the first case reported in the medical literature so far.

Preputial flaps to correct buried penis.

The authors developed a preputial skin flap technique to correct the buried penis which was simple and practical. This simple procedure can be applied to most boys with buried penis. In the last 3 years, we have seen 12 boys with buried penis and have been treated by using preputial flaps. The mean age is about 5.1 (from 3 to 12). By making a longitudinal incision on the ventral side of penis, the tightness of the foreskin is released and leave a diamond-shaped skin defect. It allows the penile shaft to extend out. A circumferential incision is made about 5 mm proximal to the coronal sulcus. Pedicled preputial flaps are obtained leaving optimal penile skin on the dorsal side. The preputial skin flaps are rotated onto the ventral side and tailored to cover the defect. All patients are followed for at least 3 months. Edema and swelling on the flaps are common, but improves with time. None of our patients need a second operation. The preputial flaps technique is a simple technique which allows surgeons to deal with most cases of buried penis by tailoring the flaps providing good cosmetic and functional results.

Unusual epithelium in a subpubic sinus.

A 5-year-old male presented with the history of whitish discharge from a midline sinus opening just above the pubis for 2 months. Attempted radiography of the sinus revealed a blind fistula and voiding cystourethrography was normal. The fistula was excised deep to the subpubic space without any evidence of connection to the lower urinary tract. Pathologic evaluation of the lesion revealed a ciliated-columnar lining with stratified-squamous and transitional epithelium. To our knowledge, a subpubic sinus with this unique presentation of epithelium has not been reported previously.