Electrocautery smoke exposure and efficacy of smoke evacuation systems in minimally invasive and open surgery: a prospective randomized study.

Worldwide, health care professionals working in operating rooms (ORs) are exposed to electrocautery smoke on a daily basis. Aims of this study were to determine composition and concentrations of electrocautery smoke in the OR using mass spectrometry. Prospective observational study at a tertiary care academic center, involving 122 surgical procedures of which 84 were 1:1 computer randomized to smoke evacuation system (SES) versus no SES use. Irritating, toxic, carcinogenic and mutagenic VOCs were observed in OR air, with some exceeding permissible exposure limits (OSHA/NIOSH). Mean total concentration of harmful compounds was 272.69 ppb (± 189 ppb) with a maximum total concentration of harmful substances of 8991 ppb (at surgeon level, no SES). Maximum total VOC concentrations were 1.6 ± 1.2 ppm (minimally-invasive surgery) and 2.1 ± 1.5 ppm (open surgery), and total maximum VOC concentrations were 1.8 ± 1.3 ppm at the OR table 'at surgeon level' and 1.4 ± 1.0 ppm 'in OR room air' away from the operating table. Neither difference was statistically significant. In open surgery, SES significantly reduced maximum concentrations of specific VOCs at surgeon level, including aromatics and aldehydes. Our data indicate relevant exposure of health care professionals to volatile organic compounds in the OR. Surgical technique and distance to cautery devices did not significantly reduce exposure. SES reduced exposure to specific harmful VOC's during open surgery.Trial Registration Number: NCT03924206 (clinicaltrials.gov).

Conservative treatment and outcome of upper cervical spine fractures in young children: A STROBE-compliant case series.

ABSTRACT: Cervical spine (C-spine) fractures in young children are very rare, and little information on treatment modalities and functional, radiographic, and patient-reported outcome exists. In this 2-center, retrospective case series, we assessed subjective and functional mid-term outcomes in children aged ≤5 years whose C-spine fractures were treated nonoperatively.Between 2000 and 2018, 6 children (median age at injury: 23.5 months; range: 16-31 months) with C1 or C2 injuries were treated with Minerva cast/brace or soft collar brace at 1 of the 2 study centers. Two patients suffered C1 fractures, and 4 patients had lysis of the odontoid synchondrosis. Overall, 3 children had sustained polytrauma. One child died due to the consequences of massive head injury.For the primary outcome parameter, we recorded subjective symptoms such as pain and functional restrictions due to the sequelae of C-spine injuries at follow-up.Based on medical records, we also assessed the causes of injury, diagnostic procedures, treatments and complications, and time to fracture consolidation.Median follow-up of the 5 surviving children was 51 months (range: 36-160 months). At the latest follow-up, 4 of 5 children did not complain of any pain. One child who sustained an open head injury in combination with a subluxation of the odontoid and undisplaced fracture of the massa lateralis reported occasional headache. All patients experienced complete fracture healing and normal range of motion of the cervical spine.Median duration of cast/brace treatment was 8.5 weeks. Fracture healing was confirmed by computed tomography in all patients.All C-spine injuries were managed with either Minerva cast/Halo brace or soft collar brace without complications.In our retrospective case series, nonoperative treatment of atlas fractures and dislocations or subluxations of the odontoid in young children using Minerva casts or prefabricated Halo braces resulted in good subjective and functional outcomes at mid-term. We observed no complications of conservative treatment of C1 and C2 injuries in young children.

Sternal elevation techniques during the minimally invasive repair of pectus excavatum.

The aim of the review was to evaluate the routine use of sternal elevation techniques (SETs) during minimally invasive repair of pectus excavatum (MIRPE, the Nuss procedure). We performed a review of the literature between January 1998 and September 2018 with focus on different methods of SET during MIRPE. Reported effects and side effects were evaluated and compared with our own experience concerning the routine use of the vacuum bell for sternal elevation during MIRPE during the last 13 years. SET is more often used in adult patients than in adolescents. SET improves visualization and safety of MIRPE. Advancement of the pectus introducer, retrosternal dissection and placement of the pectus bar are easier. The risk of cardial and/or pericardial lesion is reduced significantly. Different types of retractors, a crane combined with a wire and/or customized hooks are reported to be used as SET. Furthermore, routine use of a subxiphoid incision is reported. However, more technical equipment, and in some SETs additional incisions are necessary. In contrast, no additional skin incision is necessary for the vacuum bell. The routine intraoperative use of the vacuum bell was safe and effective in 131 patients. It facilitates the retrosternal dissection and the insertion of the pectus bar like other SETs. Besides a temporary mild hematoma, no relevant side effect was observed. In conclusion, an increasing number of authors report on the routine use of SET during MIRPE to improve safety of the procedure. We recommend the routine intraoperative use of the vacuum bell during MIRPE.

Standardized Haller and Asymmetry Index Combined for a More Accurate Assessment of Pectus Excavatum.

BACKGROUND: The measurement of the Haller index (HI) is not standardized, and HI does not consider the asymmetry of pectus excavatum. The aim of this study was to determine the most appropriate level for measuring the HI and to introduce the asymmetry index (AI) in order to respect the aspect of asymmetry. METHODS: Preoperative computer tomography scans of 43 patients with pectus excavatum were retrospectively analyzed by measuring both the HI and the AI at 3 different levels: (I) sternomanubrial junction; (II) caudal end of corpus sterni; and (III) tip of the xiphoid. The control group comprised 33 patients without chest wall deformity and a HI < 3.25. For each patient HI and AI were calculated according to a standardized protocol. A McNemar test was used for statistical analyses. RESULTS: The sensitivity of the HI was highest when measured at level II (p < 0.388), and the AI exhibited the highest sensitivity at level I. When combining both indices, the sensitivity of assessing pectus excavatum significantly increased compared with the use of HI at level II alone (p < 0.002). CONCLUSIONS: The measurement of the HI at level II represents the most valid standardized parameter for assessment of the severity of pectus excavatum. Asymmetry, on the other hand, is best assessed by the AI measured at level I. The combination of the standardized HI and AI not only provides a much more accurate description of pectus excavatum, but also improves the comparability of pectus excavatum patients in general.

Surgical smoke: still an underestimated health hazard in the operating theatre.

OBJECTIVES: Smoke generated from electrocautery dissection contains irritating and/or carcinogenic components. The aim of this study was to investigate the effectiveness of a mobile smoke evacuation system (SES) in protecting surgical personnel from these hazardous fumes. METHODS: Standardized cuts with an electrocautery device were performed on fresh porcine tissue, and the generated surgical fume was analysed with and without the additional use of a mobile SES using a real-time proton-transfer-reaction time-of-flight mass spectrometer. Furthermore, 2 different surgical masks were tested to investigate their filter capacity. RESULTS: Several toxic and/or carcinogenic volatile organic compounds including 1,3-butadiene, benzene and furfural were found in concentrations clearly above the limits that were set by the National Institute of Occupational Safety and Health: 1,3-butadiene at 19.06 ± 1.54 ppm (limit: 5 ppm), benzene at 6.21 ± 1.33 ppm (limit: 0.5 ppm) and furfural at 14.34 ± 2.97 ppm (limit: 2 ppm). Although the mobile SES was able to reduce these substances to a certain degree, butadiene and benzene still remained above the permissible exposure limits with concentrations of 14.21 ± 0.07 and 1.16 ± 0.05, respectively. Both surgical masks were unable to reduce the 'inhaled' concentrations of volatile organic compounds. CONCLUSIONS: Although the SES reduced the concentrations of most of the detected volatile organic compounds to a certain amount, especially the carcinogenic substances, butadiene and benzene remained high above exposure limits. According to the abovementioned significant data, further investigation on this topic is imperative, especially when considering that surgical masks were absolutely ineffective in protecting individuals from the toxic smoke and that the cautery was only used for 10 s in this experiment.

Treatment of isolated sternal fracture with a vacuum bell in an 8-year-old boy.

Isolated sternal fractures are very rare in children. Pain management is the method of choice, but surgery may be indicated in selected cases with dislocated fractures. However, the indication for open reduction of sternal fractures is discussed controversially. To the best of our knowledge, we present the first report of a child with displaced isolated sternal fracture who was successfully treated by conservative means using a vacuum bell.

Evaluating interest in narrative therapy for decision making about pectus excavatum treatment.

OBJECTIVES: The decision to proceed with surgical treatment for pectus excavatum (PE) is rarely clear-cut. Patients interested in treatment are referred for evaluation by numerous different specialists, but psychosocial counselling is currently not included in this process. Our objective was to assess whether PE patients would be interested in formal assistance with the decision-making process surrounding PE surgery using narrative therapy principles. METHODS: Ninety-seven untreated PE patients at 5 different institutions in 4 countries completed a questionnaire consisting of 13 questions, with 3 questions specifically evaluating interest in narrative therapy. RESULTS: Eighty-two percent of participants were interested in narrative therapy to assist with the decision-making process surrounding PE surgery. Individuals most interested in narrative therapy tend to be more interested in correction (P < 0.05) to improve the way they feel about their body (P < 0.05). CONCLUSIONS: The majority of PE patients are interested in narrative therapy to aid the decision-making process about treatment. We propose that narrative therapy should be offered to PE patients during the treatment evaluation process to address the psychosocial difficulties associated with PE and the surgical decision-making process overall. Future studies should assess the effectiveness of this interdisciplinary model.

Monitoring the effectiveness of the vacuum bell during pectus excavatum treatment: Technical innovation.

BACKGROUND: The vacuum bell (VB) is a valid and the only non-invasive treatment for pectus excavatum (PE). To elevate the sternum the patient himself creates a differential negative pressure inside the VB using a hand pump. A distance and differential pressure measuring device (DPMD) enables us for the first time to assess objectively those parameters. METHODS: After approval by the institutional review board, 53 patients recruited from our outpatient clinic were included in this retrospective study and distributed into three groups (group 1 aged 6 to 10years; group 2 aged 11 to 15years; group 3 aged 16 to 20years). Sternum elevation and differential negative pressure inside the VB compared to atmospheric pressure were assessed with the DPMD, a device developed by engineers at the University of Applied Sciences, Northwestern Switzerland. Pressure-elevation curves were recorded during VB therapy. For statistical comparison of the groups, analysis of variance was used. Post-hoc analysis was performed using the Tukey-Kramer test. A p-value of less than 0.05 was considered to be statistically significant. RESULTS: The VB therapy was monitored in 53 children (39 males, 14 females) aged from 6 to 20years (average, 14years). Relationships were established between the differential negative pressure inside the vacuum bell, the elevation of the sternum, and the patient's age. The younger the patient, the lower is the differential negative pressure difference required to obtain a complete elevation of the sternum. Patient's age, weight, the pectus depth, the differential negative pressure inside the VB, and the elevation of the sternum were correlated. When comparing the depth 25 of the pectus excavatum to the patient's age, a statistically significant difference was verified between the groups 3 and 1 (p=0.0291) and 3 and 2 (p=0.0489). The older the patient, the deeper is the pectus excavatum. However, no statistically significant difference between the groups was found when comparing the sternum elevation to the patient's age (p=0.4574) and the elevation to pressure ratio to the patient's age (p=0.8048). The sternum elevation and the elevation to pressure ratio are independent of the patient's age. CONCLUSIONS: DPMD supplies objective data of the elevation of the sternum and the related pressure inside the VB during its application. Correlation between the patient's age, the elevation of the sternum and the pressure inside the VB were demonstrated, but additional data are needed to better understand their relationship and their impact in the treatment of PE by VB. STUDY TYPE: Diagnostic Study. LEVEL OF EVIDENCE: IV.

Sternal Fracture in Children: Diagnosis by Ultrasonography.

Because of its subcutaneous location, the sternum can be examined sonographically using a linear scanner. We report about two children who experienced blunt chest trauma. Anterior-posterior chest X-rays were normal. Ultrasonic imaging confirmed a fracture of the sternum with dorsal displacement of the distal fragment (by 0.97 cm) in the first child and a transverse fracture of the body of the sternum without displacement in the second child. In both children, pericardial effusion was excluded by sonography. The displaced fracture of the sternum was confirmed by magnetic resonance imaging (MRI), which ruled out concomitant injuries of the soft tissues adjacent to the sternum. Both sternum fractures were managed nonoperatively. These cases serve to emphasize the importance of sonography that represents an ionizing radiation free, noninvasive, efficient, and safe imaging modality to diagnose fractures of the sternum in children while also enabling the assessment of the pericardium.

Replaceable Jejunal Feeding Tubes in Severely Ill Children.

Long-term enteral nutrition in chronically ill, malnourished children represents a clinical challenge if adequate feeding via nasogastric or gastrostomy tubes fails. We evaluated the usefulness and complications of a new type of surgical jejunostomy that allows for easier positioning and replacement of the jejunal feeding tube in children. We surgically inserted replaceable jejunal feeding tubes (RJFT) connected to a guide thread which exited through a separate tiny opening of the abdominal wall. In a retrospective case series, we assessed the effectiveness and complications of this technique in severely ill children suffering from malnutrition and complex disorders. Three surgical complications occurred, and these were addressed by reoperation. Four children died from their severe chronic disorders within the study period. The RJFT permitted continuous enteral feeding and facilitated easy replacement of the tube. After the postoperative period, jejunal feeding by RJFT resulted in adequate weight gain. This feeding access represents an option for children in whom sufficient enteral nutrition by nasogastric tubes or gastrostomy proved impossible. Further studies are required to investigate the safety and effectiveness of this surgical technique in a larger case series.

Delayed diagnosis of fractured anterior arch of the atlas in a young child.

A 2-year-old girl fell off a bunk bed onto a parquet floor. She immediately reported neck pain and presented with muscle spasm and limited motion of the cervical spine (C-spine). Plain X-rays of the C-spine showed no osseous lesion. Owing to persisting pain and limited motion in the neck, MRI of the C-spine was obtained which revealed intact ligaments and cervical spinal cord, as well as soft tissue swelling in front of the anterior arch of the atlas. Subsequent CT of the C-spine confirmed a complete, undisplaced fracture of the anterior arch of the atlas (Gehweiler type I fracture). A Minerva cast was applied for 2 months, followed by a soft cervical collar. Persistent neck pain and limited range of motion of the neck after a fall may be indicative of atlas fracture that should be ruled out by CT.

Pulmonary function in pectus excavatum patients before repair with the Nuss procedure.

OBJECTIVES: Whether the origin of symptoms in pectus excavatum patients (Pex) is related to reduced pulmonary function or impaired cardiovascular performance is debatable. However, pulmonary function testing (PFT) is still part of the evaluation prior to surgical repair in Pex. The purpose of this study was to corroborate our hypothesis that the majority of Pex that qualified for surgery present preoperatively with normal or close to normal PFT. METHODS: After institutional review board approval, preoperative PFT data of Pex who underwent surgical repair were analyzed retrospectively: total lung capacity (TLC), vital capacity (VC), functional residual capacity, forced expiratory volume in 1 second (FEV1) and maximal expiratory flow at 25% of FVC (MEF25). RESULTS: 82 patients aged from 9 to 27 years (average, 15 years) underwent PFT. A restrictive pattern (VC<80%) was observed in 45%, an obstructive pattern (FEV1 < 75 %) in 35%, and a normal total lung capacity in 62% of the Pex. No significant correlation was noted between the increasing severity of the Haller index and the PFT. CONCLUSION: Adolescent Pex without relevant respiratory symptoms have nearly a normal lung function. We suggest to skip PFT from the routine preoperative assessment in asymptomatic Pex.

Dynamic Compression System: An Effective Nonoperative Treatment for Pectus Carinatum: A Single Center Experience in Basel, Switzerland.

Background Several nonoperative treatments are currently available for the correction of pectus carinatum (PC). Objective The objective of this study is to report our single center experience with the dynamic compression system (DCS). Materials and Methods The DCS is a rigid aluminum brace. PC is reshaped into a normal appearance through anterior-posterior pressure and lateral expansion of the chest. Patients with chondrogladiolar PC were considered suitable for the nonoperative treatment with DCS. Results In this study, 53 of 68 children (78%) with chondrogladiolar PC were assessed retrospectively: 2 children were corrected by surgery, 12/53 (23%) treated by a conventional orthesis, 11/53 (21%) remained without therapy because of minor PC, and 36/53 (68%) were treated using the DCS. Of these 36 patients, 17 (47%) are already cured with a good (7/17) to excellent (10/17) cosmetic result after a median treatment period of 9 months (range, 2.5-16 months). The mean daily time of wearing of the device for those 17 patients was 9 hours (range, 5-18). None abandoned the treatment and there were almost no complications. Conclusions Lateral expansion of the chest and the possibility to measure the applied pressure seemed to be the key to DCSs success. We propose the DCS as first choice in the treatment of chondrogladiolar PC in children.

Laparoscopy-Assisted Single-Port Appendectomy in Children: Safe Alternative also for Perforated Appendicitis?

Because of its low complication rate, favorable safety, cost-effectiveness, and technical ease, mono-instrumental, laparoscopy-assisted single-port appendectomy (SPA) has been the standard therapy for appendicitis in our department since its introduction 10 years ago. We report our experience with this technique and compare its outcome to open appendectomy (OA). The records of all children who underwent appendectomy at our institution over a period of 8 years were analyzed retrospectively. Patient baseline data, markers of inflammation, operative time, length of hospital stay, complication rate according to the classification of Clavien-Dindo, and histologic grading were assessed to compare the 2 surgical techniques (SPA and OA). The chi square test, the Student's t test and the Wilcoxon-Mann-Whitney test were used to analyze the data and the comparisons of the mean values. A P value < 0.05 was considered significant. Overall, 975 patients were included in the study. A total of 555 children had undergone SPA and 420 had been treated by OA. Median operative time of SPA was longer than that of OA (60.8  min vs 57.4  min; P < 0.05). Length of hospital stay after SPA was shorter than after OA (4.4 days and 5.9 days, respectively; P < 0.001). The overall complication rate was lower for SPA than that for OA (4.0% vs 5.7%), but the difference of complications for SPA and OA was not statistically significant (P < 0.22). SPA was successfully performed in 85.9% of children. In 53.8% of patients with perforated appendicitis, no conversion was required. In the group of children with perforated appendicitis, the complication rate of ∼20% was independent of the surgical technique applied. With respect to operative time, length of hospital stay, and postoperative complication rate, SPA is not inferior to OA. SPA is safe and efficient, even in the management of perforated appendicitis.

Anti-inflammatory/tissue repair macrophages enhance the cartilage-forming capacity of human bone marrow-derived mesenchymal stromal cells.

Macrophages are key players in healing processes. However, little is known on their capacity to modulate the differentiation potential of mesenchymal stem/stromal cells (MSC). Here we investigated whether macrophages (Mf) with, respectively, pro-inflammatory and tissue-remodeling traits differentially modulate chondrogenesis of bone marrow derived-MSC (BM-MSC). We demonstrated that coculture in collagen scaffolds of BM-MSC with Mf derived from monocytes polarized with M-CSF (M-Mf), but not with GM-CSF (GM-Mf) resulted in significantly higher glycosaminoglycan (GAG) content than what would be expected from an equal number of BM-MSC alone (defined as chondro-induction). Moreover, type II collagen was expressed at significantly higher levels in BM-MSC/M-Mf as compared to BM-MSC/GM-Mf constructs, while type X collagen expression was unaffected. In order to understand the possible cellular mechanism accounting for chondro-induction, developing monoculture and coculture tissues were digested and the properties of the isolated BM-MSC analysed. We observed that as compared to monocultures, in coculture with M-Mf, BM-MSC decreased less markedly in number and exhibited higher clonogenic and chondrogenic capacity. Despite their chondro-inductive effect in vitro, M-Mf did not modulate the cartilage tissue maturation in subcutaneous pockets of nude mice, as evidenced by similar accumulation of type X collagen and calcified tissue. Our results demonstrate that coculture of BM-MSC with M-Mf results in synergistic cartilage tissue formation in vitro. Such effect seems to result from the survival of BM-MSC with high chondrogenic capacity. Studies in an orthotopic in vivo model are necessary to assess the clinical relevance of our findings in the context of cartilage repair.

Neurogenic appendicopathy: clinical, macroscopic, and histopathological presentation in pediatric patients.

BACKGROUND: The proliferation of nerve fibers in the appendix, in association with an increase of the neuropeptides such as vasoactive intestinal peptide and substance P characterizes neurogenic appendicopathy (NA), which may mimic the symptoms of acute appendicitis (AA). It may be difficult to differentiate this little known distinct pathological entity clinically from AA. The aim of this study is to describe the epidemiology, clinical signs, and histological description of NA in pediatric patients. PATIENTS AND METHODS: After institutional review board approval, all appendiceal specimens from children who underwent appendectomy between February 2006 and December 2008 were analyzed. Analysis included age, gender, clinical symptoms, blood tests, intraoperative macroscopic assessment of the appendix, and the histopathological type of NA. NA was diagnosed by hematoxylin-eosin staining and /or S-100 immunochemistry and then classified into different histopathological groups. RESULTS: Of the 385 appendix specimens examined, 29 (7.5%) met the histopathological criteria of NA. The median duration of abdominal pain was 2 days (range, 1 to 7). The surgeon characterized the appendix as follows: not inflamed in 5 (17.2%), acute in 17 (58.6%), phlegmonous in 4 (13.8%), and perforated in 3 patients (10.4%). Histopathological diagnosis of NA classified the specimen as axial neuroma in 2 (7%), mucosal in 12 (41%), and submucosal in 15 cases (52%). CONCLUSION: NA is a relatively common diagnosis in children. NA must be considered in patients with recurrent right lower quadrant pain or signs of AA, even if intraoperative findings are normal. For these patients, we recommend appendectomy and consideration of a subsequent histopathological workup.

Laparoscopic-assisted single-port appendectomy in children: it is a safe and cost-effective alternative to conventional laparoscopic techniques?

Aim. Laparoscopic-assisted single-port appendectomy (SPA), although combining the advantages of open and conventional laparoscopic surgery, is still not widely used in childhood. The aim of this study was to evaluate the safety and the cost effectiveness of SPA in children. Methods. After institutional review board approval, we retrospectively evaluated 262 children who underwent SPA. The appendix was dissected outside the abdominal cavity as in open surgery. For stump closure, we used two 3/0 vicryl RB-1 sutures. Results. We identified 146 boys (55.7%) and 116 girls (44.3%). Median age at operation was 11.4 years (range, 1.1-15.9). Closure of the appendiceal stump using two sutures (cost: USD 15) was successful in all patients. Neither a stapler (cost: USD 276) nor endoloops (cost: USD 89) were used. During a follow-up of up to 69 months (range, 30-69), six obese children (2.3%, body mass index >95th percentile) developed an intra-abdominal abscess after perforated appendicitis. No insufficiency of the appendiceal stump was observed by ultrasound. Five of them were treated successfully by antibiotics, one child required drainage. Conclusion. The SPA technique with conventional extracorporal closure of the appendiceal stump is safe and cost effective. In our unit, SPA is the standard procedure for appendectomy in children.

Late-presenting diaphragmatic hernia associated with intrathoracic kidney: tachypnoea as unique clinical sign.

Intrathoracic renal ectopia associated with a congenital diaphragmatic hernia represents a very rare congenital malformation. The incidence of intrathoracic renal ectopia with congenital diaphragmatic hernia is reported to be less than 0.25%. The authors report on a 5-month-old female infant with late-presenting congenital diaphragmatic hernia associated with a left-sided intrathoracic ectopic kidney and adrenal gland. While prenatal ultrasound showed no pathology, the postnatal ultrasound assumed a left-sided renal agenesia. After recurrent episodes of tachypnoea, a chest x-ray confirmed the diagnosis of congenital diaphragmatic hernia which was repaired without complications. Intraoperatively, intrathoracic ectopic kidney was diagnosed. The authors discuss embryogenesis, the diagnostic algorithm and therapy as well as follow-up of this rare malformation.