Does Surgical Volume Influence the Need for Second Surgery? A Pilot Study.

OBJECTIVE: To examine outcomes of pediatric thyroidectomy in the context of training background, institution, and experience of the surgeon. STUDY DESIGN: Case series with chart review. SETTING: A tertiary academic medical center and a pediatric hospital. SUBJECTS AND METHODS: Eighty-one thyroidectomy patients younger than 18 years. Outcomes were major complications (recurrent laryngeal nerve injury, permanent hypocalcemia, and wound infection), length of stay (LOS), and need for repeat surgery. RESULTS: Eighty-one patients, 39 from the University of Nebraska Medical Center and 42 from the Children's Hospital and Medical Center-Omaha, were identified over a 12-year time period. No difference was found in surgeon training (otolaryngology/head and neck surgery vs general/pediatric surgery) for complications (1 vs 1, odds ratio [OR] = 0.76, 95% confidence interval [CI] = [0.05, 13.1]), LOS >1 day (5 vs 13, OR = 0.39, 95% CI = [0.13, 1.24]), or need for second surgery (4 vs 7, OR = 1.47, 95% CI = [0.39, 5.49]). Higher surgeon volume (≥12 surgeries) was found to be significant for decreased need for second surgery (3 vs 8, OR = 6.67, 95% CI = [1.57, 27.17]). Patients of higher-volume surgeons were 4.2 times more likely to stay in the hospital 1 day or less compared with those patients operated on by surgeons with less experience (7 vs 11, 95% CI = [1.59, 15.0]). CONCLUSIONS: Need for second surgery in pediatric thyroidectomy may be predicted by surgical volume.

Chronic cervical esophageal foreign bodies in children: surgical approach after unsuccessful endoscopic management.

OBJECTIVES: We reviewed the surgical management of chronic cervical esophageal foreign bodies (CCEFBs) in a pediatric population after failed endoscopic retrieval. METHODS: A descriptive analysis via a retrospective chart review of patients with CCEFBs who failed initial endoscopic management was performed between 2008 and 2013. Details were recorded regarding presenting symptoms, time from symptom onset to diagnosis of the CCEFB, surgical approach, and complications. RESULTS: Three patients with CCEFBs unsuccessfully managed with endoscopy were identified. The range of ages at diagnosis was 14 months to 4.5 years. The foreign bodies (FBs) were present for at least 1 month before diagnosis (range, 1 to 10 months). Respiratory symptoms were predominant in all cases. Neck exploration with removal of the FB was performed in each case. Complications included esophageal stricture necessitating serial dilations (patient 1), left true vocal fold paresis that resolved spontaneously (patient 3), and tracheoesophageal fistula with successful endoscopic closure (patient 3). No long-term sequelae were experienced. CONCLUSIONS: A high index of suspicion is required to recognize CCEFBs in children with respiratory distress. Although endoscopic management remains the first-line treatment, it may fail or may not be possible because of transmural FB migration. In this setting, neck exploration with FB removal is a safe and effective alternative.

Retropharyngeal thymus and parathyroid gland: a case report.

Cervical ectopic thymus occurs when thymic tissue arrests during its embryologic descent through the neck to the upper mediastinum. Most often it presents as an asymptomatic neck mass. Rarely does it present with airway compromise, particularly in neonates. A neonate presented with a retropharyngeal mass causing dynamic upper airway obstruction, mimicking a venolymphatic malformation. Ultimately this proved to be aberrant ectopic thymus with an associated parathyroid gland. While there have been isolated reports of thymus or parathyroid in the retropharyngeal space, none of the prior reports found both within the same patient.

Identifying a window of vulnerability during fetal development in a maternal iron restriction model.

It is well acknowledged from observations in humans that iron deficiency during pregnancy can be associated with a number of developmental problems in the newborn and developing child. Due to the obvious limitations of human studies, the stage during gestation at which maternal iron deficiency causes an apparent impairment in the offspring remains elusive. In order to begin to understand the time window(s) during pregnancy that is/are especially susceptible to suboptimal iron levels, which may result in negative effects on the development of the fetus, we developed a rat model in which we were able to manipulate and monitor the dietary iron intake during specific stages of pregnancy and analyzed the developing fetuses. We established four different dietary-feeding protocols that were designed to render the fetuses iron deficient at different gestational stages. Based on a functional analysis that employed Auditory Brainstem Response measurements, we found that maternal iron restriction initiated prior to conception and during the first trimester were associated with profound changes in the developing fetus compared to iron restriction initiated later in pregnancy. We also showed that the presence of iron deficiency anemia, low body weight, and changes in core body temperature were not defining factors in the establishment of neural impairment in the rodent offspring.Our data may have significant relevance for understanding the impact of suboptimal iron levels during pregnancy not only on the mother but also on the developing fetus and hence might lead to a more informed timing of iron supplementation during pregnancy.

Microvascular changes in the diabetic foot.

Impairment of the microcirculation of diabetic patients may contribute to secondary complications in the lower extremity, such as foot infections and ulcerations. These microcirculatory changes, which are mainly functional rather than structural, are responsible for the impaired ability of the microvasculature to vasodilate in response to injury. Dysfunction of vascular endothelial cells and vascular smooth muscle cells both contribute to the reduction in vasodilation that is observed in diabetic patients. Nerve-axon reflex related microvascular vasodilation is also impaired in the diabetic population, and there is a growing belief that both the failure of the vessels to dilate and the impairment of the nerve axon reflex are major causes for impaired wound healing in diabetic patients. Further studies are necessary to clarify the precise etiology of endothelial and smooth muscle dysfunction in diabetic patients so that potential therapeutic interventions may be identified.