Routine use of chest radiographs in the post-operative management of pectus bar removal: necessity or futility.

BACKGROUND: While there is literature on techniques for pectus bar removal, there are limited reports on post-operative management. This can include obtaining a postoperative chest radiograph (CXR) despite the minimal risk of associated intra-thoracic complications. This is a review of our experience with bar removal and lack of routine post-operative CXR. METHODS: A single institution retrospective chart review was performed from 2000 to 2015. Patients who underwent a pectus bar removal procedure were included. We assessed operative timing of bar placement and removal, procedure length, intra-operative and post-operative complications and post-operative CXR findings, specifically the rate of pneumothoraces. RESULTS: 450 patients were identified in this study. Median duration of bar placement prior to removal was 35 months (interquartile range 30 and 36 months). Sixtey-four patients obtained a post-operative CXR. Of these, only one (58%) film revealed a pneumothorax; this was not drained. A CXR was not obtained in 386 (86%) patients with no immediate or delayed complications from this practice. Median follow-up time for all patients was 11 months (interquartile range 7.5-17 months). DISCUSSION: The risk for a clinically relevant pneumothorax is minimal following bar removal. This suggests that not obtaining routine imaging following bar removal may be a safe practice.

Epidural versus Patient-Controlled Analgesia after Pediatric Thoracotomy for Malignancy: A Preliminary Review.

Introduction The use of thoracic epidural is standard in adult thoracotomy patients facilitating earlier mobilization, deep breathing, and minimizing narcotic effects. However, a recent randomized trial in pediatric patients who undergo repair of pectus excavatum suggests patient-controlled analgesia (PCA) produces a less costly, minimally invasive postoperative course compared with epidural. Given that thoracotomy is typically less painful than pectus bar placement, we compared the outcomes of epidural to PCA for pain management after pediatric thoracotomy. Methods A retrospective review of 17 oncologic thoracotomies was performed at a children's hospital from 2004 to 2013. Data points included operative details, epidural or PCA use, urinary catheterization, days to regular diet, days to oral pain regimen, postoperative pain scores, length of stay, and anesthesia charges. Patients were excluded if they did not have epidural or PCA following thoracotomy. Results Six thoracotomies were managed with an epidural and 11 with a PCA. Three epidural patients were opiate naïve compared with two with a PCA. The most common indication for thoracotomy was metastatic osteosarcoma (n = 13). When comparing epidural to PCA, there was no significant difference in days to removal of Foley catheter, regular diet, oral pain control, length of stay, or total operating room time. Postoperative pain scores were also comparable. The mean anesthesia charges were significantly higher in patients with an epidural than with a PCA. Conclusion Epidural catheter and PCA provided comparable pain relief and objective recovery course in children who underwent thoracotomy for oncologic disease; however, epidural catheter placement was associated with increased anesthesia charges, suggesting that PCA is a noninvasive, cost-effective alternative.

Pediatric Crohn disease presenting as appendicitis: differentiating features from typical appendicitis.

BACKGROUND: The initial presentation of Crohn disease (CD) may mimic acute appendicitis, and preoperative clues may aid in recognizing patients at risk for CD. METHODS: A retrospective case control study of patients presenting over 10 years compared control patients with appendicitis versus patients presenting with appendicitis who ultimately developed CD. We matched 10 patients of the same age, gender, and perforated versus nonperforated appendicitis status for each of the CD patients. Demographic, laboratory, and clinical data were compared. Additionally, appendectomy specimens of CD patients were genotyped for common NOD2 (nucleotide-binding oligomerization domain-containing protein 2) mutations. RESULTS: Of 2718 patients treated for appendicitis, 8 subsequently developed CD. Compared to the matched controls, CD patients were found to have lower hemoglobin (10.4 + 1.0 vs. 13.3 + 0.2, p < 0.0001) and mean corpuscular volume (MCV) (72.5 + 3.4 vs. 84.1 + 0.5, p < 0.0001) values, and higher platelets values (444.8 + 42.2 vs. 275.6 + 8.0, p < 0.0001) at initial presentation. Anthropometric z-scores, length of stay, and antibiotic therapy duration did not significantly differ between groups. The NOD2 mutation frequency (25%) was consistent with the currently described CD population. CONCLUSIONS: Preoperative findings of a low hemoglobin level and MCV count, and a high platelet count in a child presenting with appendicitis warrant further evaluation for CD, as prompt diagnosis allows for optimal treatment and quality of life for these patients.