Implementation of an evidence-based accelerated pathway: can hospital length of stay for children with blunt solid organ injury be safely decreased?

BACKGROUND: Recent work has demonstrated that an accelerated pathway for pediatric patients with blunt solid organ injuries is safe; however, this is not well-studied in a dual trauma center. We hypothesized that implementation of an accelerated pathway would decrease length of stay (LOS) and hospitalization cost without increased mortality. METHODS: Retrospective review of patients < 15 years presenting to a dual level 1 trauma center between 2015 and 2020 with traumatic blunt liver and splenic injuries. Patients presenting pre- and post-protocol implementation were compared. The primary outcome was total hospital LOS. Secondary outcomes were number of lab draws, intensive care unit (ICU) LOS, cost of hospitalization, readmissions within 30 days, and mortality. RESULTS: 103 patients were evaluated, 67 pre-protocol and 63 post-protocol. LOS was significantly shorter post-protocol (2 days vs. 4 days, p < 0.001). The ICU LOS was unchanged. There was a decrease in direct hospitalization cost per patient from $6,246 pre-protocol to $4,294 post-protocol (p = 0.001). There was one readmission post-protocol and none pre-protocol. There were no deaths. CONCLUSION: Implementation of an accelerated pathway for management of blunt solid organ injury at a dual trauma center was associated with decreased LOS and decreased costs with no increased morbidity or mortality.

Causes of early mortality in pediatric trauma patients.

BACKGROUND: Trauma is the leading cause of death in children, and most deaths occur within 24 hours of injury. A better understanding of the causes of death in the immediate period of hospital care is needed. METHODS: Trauma admissions younger than 18 years from 2009 to 2019 at a Level I pediatric trauma center were reviewed for deaths (n = 7,145). Patients were stratified into ages 0-6, 7-12, and 13-17 years old. The primary outcome was cause of death, with early death defined as less than 24 hours after trauma center arrival. RESULTS: There were 134 (2%) deaths with a median age of 7 years. The median time from arrival to death was 14.4 hours (interquartile range, 0.5-87.8 hours). Half (54%) occurred within 24 hours. However, most patients who survived initial resuscitation in the emergency department died longer than 24 hours after arrival (69%). Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%). Deaths from hemorrhage were most often in patients sustaining gunshot wounds (73% vs. 11% of all other deaths, p < 0.0001), more likely to occur early (100% vs. 50% of all other deaths, p = 0.0009), and all died within 6 hours of arrival. Death from hemorrhage was more common in adolescents (21.4% of children aged 13-17 vs. 6.3% of children aged 0-6, and 0% of children aged 7-12 p = 0.03). The highest case fatality rates were seen in hangings (38.5%) and gunshot wounds (9.6%). CONCLUSION: Half of pediatric trauma deaths occurred within 24 hours. Death from hemorrhage was rare, but all occurred within 6 hours of arrival. This is a critical time for interventions for bleeding control to prevent death from hemorrhage in children. Analysis of these deaths can focus efforts on the urgent need for development of new hemorrhage control adjuncts in children. LEVEL OF EVIDENCE: Epidemiological study, level IV.

Quantifying the need for pediatric REBOA: A gap analysis.

BACKGROUND: Trauma is the leading cause of death in children. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides temporary hemorrhage control, but its potential benefit has not been assessed in children. We hypothesized that there are pediatric patients who may benefit from REBOA. METHODS: Trauma patients <18 years old at a level 1 pediatric trauma center between 2009 and 2019 were queried for deaths, pre-hospital cardiac arrest, massive transfusion protocol activation, transfusion requirement, or hemorrhage control surgery. These patients defined the cohort of severely injured patients. From this cohort, patients with intraabdominal injuries for which REBOA may provide temporary hemorrhage control were identified, including solid organ injury necessitating intervention, vascular injury, or pelvic hemorrhage. RESULTS: There were 239 severely injured patients out of 6538 pediatric traumas. Of these, 38 had REBOA-amenable injuries (15.9%) with 34.2% mortality, accounting for 10.2% of all pediatric trauma deaths at one center. Eleven patients with REBOA-amenable injuries had TBI (28.9%). Patients with REBOA-amenable injuries represented 0.6% of all pediatric traumas. CONCLUSION: Nearly 20% of severely injured pediatric patients could potentially benefit from REBOA. The overall proportion of pediatric patients with REBOA-amenable injuries is similar to adult studies. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Does the pediatric hemodynamic cliff exist in response to hemorrhagic shock?

BACKGROUND: The paradigm that children maintain normal blood pressure during hemorrhagic shock until 30%-45% hemorrhage is widely accepted. There are minimal data supporting when decompensation occurs and how a child's vasculature compensates up to that point. We aimed to observe the arterial response to hemorrhage and when mean arterial pressure (MAP) decreased from baseline in pediatric swine. METHODS: Piglets were hemorrhaged in 20% increments of their total blood volume to 60%. MAP and angiograms of the thoracic aorta (TA) and abdominal arteries were obtained. Percent change in area of the vessels from baseline was calculated. RESULTS: Piglets (n = 8) had a differential vasoconstriction starting at 20% hemorrhage (celiac artery 36.3% [31.4-44.6] vs TA 16.7% [10.7-19.1] p = 0.0012). At 40% hemorrhage, the differential vasoconstriction favored shunting blood away from the abdominal visceral branches to the TA (celiac artery 54.7% [36.9-60.6] vs TA 29.5% [23.9-36.2] p = 0.0056 superior mesenteric artery 46.7% [43.9-68.6] vs TA 29.5% [23.9-36.2] p = 0.0100). This was exacerbated at 60% hemorrhage. MAP decreased from baseline at 20% hemorrhage (66.4 ±â€¯6.0 mmHg vs 41.4 ±â€¯10.4 mmHg, p < 0.0001), and worsened at 40% and 60% hemorrhage. CONCLUSION: In piglets, a differential vasocontriction shunting blood proximally occurred in response to hemorrhage. This did not maintain normal MAP at 20%, 40% or 60% hemorrhage. LEVEL OF EVIDENCE: Level II.

Resuscitative endovascular balloon occlusion of the aorta in a pediatric swine model: Is 60 minutes too long?

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is recommended in adults with a noncompressible torso hemorrhage with occlusion times of less than 60 minutes. The tolerable duration in children is unknown. We used a pediatric swine controlled hemorrhage model to evaluate the physiologic effects of 30 minutes and 60 minutes of REBOA. METHODS: Pediatric swine weighing 20 kg to 30 kg underwent a splenectomy and a controlled 60% total blood volume hemorrhage over 30 minutes, followed by either zone 1 REBOA for 30 minutes (30R) or 60 minutes (60R). Swine were then resuscitated with shed blood and received critical care for 240 minutes. RESULTS: During critical care, the 30R group's (n = 3) pH, bicarbonate, base excess, and lactate were no different than baseline, while at the end of critical care, these variables continued to differ from baseline in the 60R group (n = 5) and were worsening (7.4 vs. 7.2, p < 0.001, 30.4 mmol/L vs. 18.4 mmol/L, p < 0.0001, 5.6 mmol/L vs. -8.5 mmol/L, p < 0.0001, 2.4 mmol/L vs. 5.7 mmol/L, p < 0.001, respectively). Compared with baseline, end creatinine and creatinine kinase were elevated in 60R swine (1.0 mg/dL vs. 1.7 mg/dL, p < 0.01 and 335.4 U/L vs. 961.0 U/L, p < 0.001, respectively), but not 30R swine (0.9 mg/dL vs. 1.2 mg/dL, p = 0.06 and 423.7 U/L vs. 769.5 U/L, p = 0.15, respectively). There was no difference in survival time between the 30R and 60R pediatric swine, p = 0.99. CONCLUSION: The physiologic effects of 30 minutes of zone 1 REBOA in pediatric swine mostly resolved during the subsequent 4 hours of critical care, whereas the effects of 60 minutes of REBOA persisted and worsened after 4 hours of critical care. Sixty minutes of zone 1 REBOA may create an irreversible physiologic insult in a pediatric population.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in a pediatric swine liver injury model: A pilot study.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has not been studied in children. We hypothesized that REBOA was feasible and would improve hemorrhage control and survival time, compared to no aortic occlusion, in a pediatric swine liver injury model. METHODS: Pediatric swine were randomized to Zone 1 REBOA or no intervention (control). Piglets underwent a partial liver amputation and free hemorrhage followed by either REBOA or no intervention for 30 min, then a damage control laparotomy and critical care for 4 h. RESULTS: Compared to control piglets (n = 5), REBOA piglets (n = 6) had less blood loss (34.0 ±â€¯1.6 vs 61.3 ±â€¯2.5 mL/kg, p < 0.01), higher end hematocrit (28.1 ±â€¯2.1 vs 17.1 ±â€¯4.1%, p = 0.03), higher end creatinine (1.4 ±â€¯0.1 vs 1.2 ±â€¯0.1 mg/dL, p = 0.05), higher end ALT and AST (56 ±â€¯4 vs 32 ±â€¯6 U/L, p = 0.01 and 155 ±â€¯26 vs 69 ±â€¯25 U/L, p = 0.05) and required more norepinephrine during critical care (1.4 ±â€¯0.3 vs 0.3 ±â€¯0.3 mg/kg, p = 0.04). All REBOA piglets survived, whereas 2 control piglets died, p = 0.10. CONCLUSION: In pediatric swine, 30 min of REBOA is feasible, decreases blood loss after liver injury and may improve survival. LEVEL OF EVIDENCE: Level 1.

Development of transfusion guidelines for injured children using a Modified Delphi Consensus Process.

BACKGROUND: There is wide variability of transfusion practices for children with hemorrhagic injuries across trauma centers. We are planning a multicenter, randomized clinical trial evaluating tranexamic acid in children with hemorrhage. Standardization of transfusion practices across sites is important to minimize confounding. Therefore, we sought to generate consensus-based transfusion guidelines for the trial. METHODS: We used a modified Delphi process utilizing a multi-site, multi-disciplinary panel of experts to develop our transfusion guidelines. A survey of 23 clinical categories on various aspects of transfusion practices was developed and distributed via SurveyMonkey®. Statements were graded on a 5-point Likert scale ("Strongly agree" to "This intervention may be harmful"). Statements were accepted if ≥ 80% of the panelists rated the statement as "Strongly agree" or "Agree". After each round, the responses were calculated and the results included on subsequent rounds. RESULTS: 35 panelists from four pediatric trauma centers participated in the study, including 11 (31%) pediatric EM physicians, 8 (23%) pediatric trauma surgeons, 5 (14%) transfusionists, 5 (14%) pediatric anesthesiologists, and 6 (17%) pediatric critical care physicians (range of 8 to 10 from each clinical site). Four survey iterations were performed. In total 176 statements were rated and 39 were accepted by criteria across all 23 categories. An rational algorithm for transfusion in trauma was then developed. CONCLUSIONS: We successfully developed transfusion guidelines for various aspects of the management of children with hemorrhagic injuries using a modified Delphi process with broad interdisciplinary participation. We anticipate implementation of these guidelines will help minimize heterogeneity of transfusion practices across clinical sites for the upcoming clinical trial evaluating tranexamic acid in children with hemorrhage.

Age-related mortality in abusive head trauma.

BACKGROUND: Abusive head trauma (AHT) peaks during early infancy and decreases in toddler years. Infants and toddlers experience different injuries, possibly impacting the risk of mortality. We aimed to evaluate the association of age with mortality. METHODS: We conducted a retrospective study of AHT hospitalizations in 2000, 2003, 2006, 2009, and 2012 from the Kid's Inpatient Claims Database. An accidental head trauma cohort was included to hypothesize that the association between age and mortality is unique to abuse. A nested multivariable logistic regression was used to perform the analysis. RESULTS: Children aged 2 years to 4 years experienced higher mortality than those younger than 2 years (22% vs. 10%, p < 0.0001; adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.2). The presence of subarachnoid hemorrhage (OR, 1.9; 95% CI, 1.3-2.9), cerebral edema (OR, 4.0; 95% CI, 2.9-5.4), and retinal hemorrhage (OR, 1.9; 95% CI, 1.5-2.5) were associated with an increase risk in mortality. Children younger than 2 years experienced more fractures and hemorrhage (subdural, subarachnoid, retinal) while children aged 2 years to 4 years encountered more internal injuries and cerebral edema.In children with accidental head trauma, those aged 2 years to 4 years have a lower mortality compared with those younger than 2 years (OR, 0.4; 95% CI, 0.3-0.6). Among children younger than 2 years, AHT and accidental trauma had comparable risk of mortality (OR, 0.9; 95% CI, 0.6-1.3). However, among those aged 22 years to 4 years, AHT had a higher risk of mortality than accidental trauma (OR, 3.3; 95% CI, 2.1-5.1). CONCLUSION: There is a considerable risk of mortality associated with age at diagnosis in children with AHT.Children younger than 2 years and those aged 2 years to 4 years present with different types of injuries. The high risk of mortality in the children aged 2 years to 4 years is unique to AHT. Efforts should be made to increase awareness about the risk of mortality and identify factors that can aide in a timely accurate diagnosis. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Epidemiology of Hirschsprung disease in California from 1995 to 2013.

PURPOSE: This study seeks to update current epidemiology of Hirschsprung disease (HD) in California. METHODS: Using data from the California Office of Statewide Health Planning and Development Linked Birth (1995-2012) and Patient Discharge Databases (1995-2013), patients from either dataset with an ICD-9 diagnosis code of HD (751.3) or procedure code of Soave (48.41), Duhamel (48.65), or Swenson/other pull-through (48.49) were included. Patients > age 18 during their first admission were excluded. RESULTS: Of 9.3 million births, 2,464 patients were identified. Incidence was 2.2 cases/10,000 live births, with rates peaking at 2.9/10,000 births in 2002. Incidence was highest among African American (4.1/10,000) and Asian/Pacific Islander (2.5/10,000) births. Most were male (n = 1652, 67.1%). Sixty patients (2.4%) had Down syndrome. The median gestational age at birth was 38 weeks 6 days (interquartile range [IQR] 37 weeks 1 day-40 weeks 1 day). Mortality during the first year of life was 1.7%. Median age at death was 14.5 days (IQR 0-113 days). CONCLUSION: This is one of the largest population-based studies of HD. In California, the incidence of HD is stable, risk is highest among African American children, and the mortality rate is < 2%.

Epidemiology of gastroschisis: A population-based study in California from 1995 to 2012.

BACKGROUND: Although the incidence of gastroschisis is increasing, risk factors are not clearly identified. METHODS: Using the Linked Birth Database from the California Office of Statewide Health Planning and Development from 1995 to 2012, patients with gastroschisis were identified by ICD-9 diagnosis/procedure code or birth certificate designation. Logistic regressions examined demographics, birth factors, and maternal exposures on risk of gastroschisis. RESULTS: The prevalence of gastroschisis was 2.7 cases per 10,000 live births. Patients with gastroschisis had no difference in fetal exposure to alcohol (p = 0.609), narcotics (p = 0.072), hallucinogenics (p = 0.239), or cocaine (p = 0.777), but had higher exposure to unspecified/other noxious substances (OR 3.27, p = 0.040; OR 2.02, p = 0.002). Gastroschisis was associated with low/very low birthweight (OR 5.08-16.21, p < 0.001) and preterm birth (OR 3.26-10.0, p < 0.001). Multivariable analysis showed lower risk in black (OR 0.44, p < 0.001), Asian/Pacific Islander (OR 0.76, p = 0.003), and Hispanic patients (OR 0.72, p < 0.001) compared to white patients. Risk was higher in rural areas (OR 1.24-1.76, p = 0.001). Compared to women age < 20, risk decreased with advancing maternal age (OR 0.49-OR 0.03, p < 0.001). Patients with gastroschisis had increased total charges ($336,270 vs. $9012, p < 0.001) and length of stay (38.1 vs. 2.9 days, p < 0.001). Mortality was 4.6%. CONCLUSIONS: This is the largest population-based study summarizing current epidemiology of gastroschisis in California. TYPE OF STUDY: Retrospective comparative cohort study. LEVEL OF EVIDENCE: III.

Subcutaneous local anesthetic infusion could eliminate use of epidural analgesia after the Nuss procedure.

AIM: To compare outcomes of continuous subcutaneous infusion of local anesthetic and epidural analgesia following the Nuss procedure. PATIENTS & METHODS: A retrospective chart review compared patients managed with subcutaneous local anesthetic infusion (n = 12) versus thoracic epidural (n = 19) following the Nuss procedure from March 2013 to June 2015. RESULTS: There was no difference in hospital length of stay or days on intravenous narcotics. Epidural catheter placement prolonged operating room time (146.58 ± 28.30 vs 121.42 ± 21.98 min, p = 0.01). Average pain scores were slightly higher in the subcutaneous infusion group (3.72 ± 1.62 vs 2.35 ± 0.95, p = 0.02), but of negligible clinical significance. CONCLUSION: Continuous subcutaneous infusion of local anesthetic could eliminate the need for thoracic epidural for pain management after the Nuss procedure.

Strength and histology of a nanofiber scaffold in rats.

BACKGROUND: Full-thickness soft tissue defects from congenital absence or traumatic loss are difficult to surgically manage. Healing requires cell migration, organization of an extracellular matrix, inflammation, and wound coverage. PLCL (70:30 lactide:caprolactone, Purac), poly(propylene glycol) nanofibrous scaffolds enhance cell infiltration in vitro. This study compares strength and tissue ingrowth of aligned and unaligned nanofibrous scaffolds to absorbable and permanent meshes. We hypothesize that PLCL nanofibrous grafts will provide strength necessary for physiological function while serving as a scaffold to guide native tissue regeneration in vivo. MATERIALS AND METHODS: Abdominal wall defects were created in 126 rats followed by underlay implantation of Vicryl, Gore-Tex, aligned, or unaligned PLCL Nanofiber mesh. Specimens were harvested at 2, 6, and 12 wk for strength testing and 2, 12, and 24 wk for histopathologic evaluation. Specimens were graded for cellular infiltration, multinucleated giant cells (MNG), vascularity, and tissue organization. Mean scores were compared and analyzed with non-parametric testing. RESULTS: The PLCL grafts maintained structural integrity until at least 12 wk and exhibited substantial tissue replacement at 24 wk. At 12 wk, only the aligned PLCL had persistent cellular infiltration of the graft, whereas both aligned and unaligned PLCL grafts showed the presence of MNG. The presence of MNGs decreased in the aligned PLCL graft by 24 wk. CONCLUSIONS: The aligned PLCL nanofiber mesh offers early strength comparable to Gore-Tex but breaks down and is replaced with cellular ingrowth creating a favorable option in management of complex surgical wounds or native soft tissue defects.

Novel titanium constructs for chest wall reconstruction in children.

PURPOSE: We have previously reported the use of the vertical expandable prosthetic titanium rib (VEPTR) for treatment of thoracic dystrophy. This report describes our experience with this device and other novel titanium constructs for chest wall reconstruction. METHODS: This is a retrospective chart review of all children and adolescents undergoing chest wall reconstruction with titanium constructs between December 2005 and May 2010. RESULTS: Six patients have undergone chest wall reconstruction with VEPTR or other titanium constructs. Four had chest wall resection for primary malignancy, 1 had metastatic chest wall tumor resection, and 1 had congenital chest wall deformity. There were no immediate complications, and all patients have exhibited excellent respiratory function with no scoliosis. CONCLUSIONS: Chest wall reconstruction after tumor resection or for primary chest wall deformities can be effectively accomplished with VEPTR and other customized titanium constructs. Goals should be durable protection of intrathoracic organs and preservation of thoracic volume and function throughout growth. Careful preoperative evaluation and patient-specific planning are important aspects of successful reconstruction.

Magnamosis II: Magnetic compression anastomosis for minimally invasive gastrojejunostomy and jejunojejunostomy.

BACKGROUND: Previously we demonstrated the safety and patency of a magnetic compression anastomosis (magnamosis). We present the further development of this technique, with specific focus on optimizing device design for minimally invasive magnamosis. STUDY DESIGN: The magnamosis device was designed to incorporate 3 features: 2 convex-concave radially symmetric halves that magnetically self-align, a central channel for immediate patency, and specially engineered radial topography of the mating surfaces to promote gradual remodeling. Each symmetrical half consists of a ring-shaped neodymium-iron-boron magnet encased in polycarbonate casing. Twenty-one young adult pigs underwent either magnetic gastrojejunostomy (n = 13) or jejunojejunostomy (n = 8). Animals were euthanized at 1, 2, 4, and 6 weeks after operation. Anastomoses were studied with contrast radiography, burst pressure, and histology. RESULTS: Gastrojejunostomy: In all animals with successful placement of magnets, anastomoses were patent by contrast fluoroscopy, well healed by histologic examination, and showed excellent burst strength. Jejunojejunostomy: All animals had uneventful clinical courses, indicating that the magnamosis with immediate patency functioned properly without device dislodgement. At sacrifice, all magnamoses were patent, well healed by histology, and had burst strengths that equaled or exceeded that of traditional stapled anastomoses. CONCLUSIONS: Minimally invasive placement of a custom magnetic device in the stomach and jejunum allows intraluminal self-alignment and subsequent compression anastomosis over 3 to 10 days. The magnamosis is immediately patent and develops strength equal to or greater than that of hand-sewn or stapled anastomoses. Magnamosis is effective in the pig model, and may be a safe, effective, and minimally invasive alternative to current anastomotic strategies in humans.

The effect of fiber alignment and heparin coating on cell infiltration into nanofibrous PLLA scaffolds.

Biodegradable nanofibers simulate the fibril structure of natural extracellular matrix, and provide a cell-friendly microenvironment for tissue regeneration. However, the effects of nanofiber organization and immobilized biochemical factors on cell infiltration into three-dimensional scaffolds are not well understood. For example, cell infiltration into an electrospun nanofibrous matrix is often limited due to relatively small pore size between the fibers. Here we showed that biophysical and biochemical modification of nanofibrous scaffolds facilitated endothelial cell infiltration in three-dimensional scaffolds in vitro and in vivo. Aligned nanofibers significantly enhanced cell infiltration into the nanofibrous matrices in vitro. In a full-thickness dermal wound model, the nanofiber scaffolds enhanced epidermal skin cell migration across the wound when compared to a control group without scaffold. Aligned nanofibers promoted the infiltration of endothelial cells into the scaffolds. Furthermore, heparin-coated nanofibers also increased cell infiltration significantly. These results shed light on the importance of biophysical and biochemical properties of nanofibers in the regulation of cell infiltration into three-dimensional scaffolds and tissue remodeling.

In utero repair of gastroschisis in the sheep (Ovis aries) model.

OBJECTIVE: Gastroschisis is associated with inflammatory changes in the exposed bowel which leads to intestinal dysmotility after postnatal repair. The insult is a combined effect of amniotic fluid exposure and mechanical constriction. We hypothesized that in utero anatomic repair is possible in a sheep model, and that it may halt the inflammatory damage caused by both mechanisms. METHODS: Gastroschisis was surgically created in mid-gestation (day 75) in 8 sheep fetuses. On gestational day 100, 2 fetuses underwent open fetal gastroschisis repair, where the eviscerated bowel was returned to the peritoneal cavity, and the abdominal wall was primarily closed. All fetuses were harvested at 135 days of gestation. RESULTS: Six fetuses survived the initial operation, and both fetuses that underwent gastroschisis repair survived to term. At 100 and 135 days of gestation, the eviscerated bowel showed progressive signs of inflammation and peel development. The gross and microscopic inflammatory changes in the gastroschisis bowel at 100 days of gestation were completely resolved at term following in utero repair. CONCLUSION: In utero anatomic repair of gastroschisis is possible in mid-gestation in the fetal lamb model, and it appears to ameliorate the inflammatory process.

Magnamosis: magnetic compression anastomosis with comparison to suture and staple techniques.

PURPOSE: An ideal anastomosis between hollow viscera should be easily performed, strong, and operator independent. We hypothesized that transluminal attraction between magnets in the intestine could be harnessed to create an intestinal compression anastomosis (magnamosis) with these characteristics. We further hypothesized that variation of attraction force and geometry of compression would affect the quality of the intestinal anastomosis. METHODS: We designed a self-orienting device composed of 2 neodymium-iron-boron magnets affixed to polytetrafluoroethylene moldings. Two topologies were evaluated: one designed with 'uniform' compression and the other with 'gradient' compression. Sixteen young adult pigs (Sus scrofa) underwent laparotomy with creation of a magnetic side-to-side anastomosis: 8 with the uniform device and 8 with the gradient device. Each also had a stapled anastomosis, and 5 had an additional hand-sutured anastomosis. Animals were euthanized at 1, 2, and 3 weeks after operation, then anastomoses were compared on the basis of gross appearance, histology, functional radiography, and mechanical integrity. RESULTS: All magnetic devices formed patent anastomoses without leak. One stapled anastomosis resulted in a contained leak. Mechanical integrity of magnetic anastomoses was not statistically significantly different from staple or suture counterparts, and there was a trend toward greater strength with magnetic anastomoses. Comparison between device types revealed the gradient device trended toward greater strength and earlier patency (67% vs 33% at 1 week). There was no evidence of stenosis, and histologic examination demonstrated tissue remodeling with mucosal and serosal apposition across the magnamoses. CONCLUSIONS: The magnetic compression anastomosis (magnamosis) device is a safe and effective means of sutureless full-thickness intestinal anastomosis with serosal apposition in a pig model. Gradient compression is superior to uniform compression. This technique is compatible with endoscopic and natural orifice approaches.

Compressive orthotic bracing in the treatment of pectus carinatum: the use of radiographic markers to predict success.

PURPOSE: The treatment of pectus carinatum (PC) has classically been operative, though compressive orthotic braces have been used with good success in recent years. The purpose of this article is to evaluate the use of radiologic measurements in a successful bracing protocol. METHODS: Sixty-three patients with PC have been evaluated for an 8-year span. The average age is 13.3 +/- 2.5. Follow-up is from 4 to 60 months, with a median of 24 months. Seventeen patients with mild defects elected observation alone. The remaining 46 patients began the bracing protocol. Baseline chest computed tomography (CT) was obtained, and custom-fitted orthotic braces were constructed for each patient. Radiographic markers were evaluated to include the Haller index, angle of sternal rotation, and asymmetry index. Patient surveys and chart review were used to identify compliance and success rates. Pretreatment CTs were retrospectively reviewed by bracing outcomes and radiographic measurements were compared. Ten patients received posttreatment CTs after successful bracing. RESULTS: Of 63 patients with PC, 17 patients (27%) with mild defects elected observation alone. The remaining 46 patients began the bracing protocol as described above. Of these, 10 are excluded from analysis, with 6 patients currently in the early treatment phase and 4 who have been lost to follow-up. Of the remaining 36 patients, 8 failed bracing because of noncompliance. Of the 28, 24 patients who completed treatment report either good or excellent results after bracing. Eight patients have required surgical intervention, 4 as a result of noncompliance and 4 who were compliant but failed bracing. In patients who were compliant, significant differences were seen on initial CT between those with successful outcomes and those who required surgical repair. Haller index (2.85 vs 2.05; P < .05), angle of sternal rotation (27.3 vs 14.8; P < .05), and asymmetry index (1.23 vs 1.06; P < .01) were all higher in the group who failed bracing. In those who successfully completed treatment, there was no significant difference in the Haller or asymmetry indices, but the average improvement in sternal rotation was 53.8%. CONCLUSION: Compressive orthotic bracing is a successful method of treatment of pectus carinatum. The associated sternal rotation can be significantly improved with appropriate bracing that results in a subjective improvement in the deformity. Asymmetry of chest diameter related to concomitant excavatum-type deformity is less likely to respond to bracing attempts. In this way, initial chest CT can be of value in treatment planning.

Nonoperative management of spontaneous splenic rupture in infectious mononucleosis: a case report and review of the literature.

Spontaneous rupture of the spleen is a rare complication of infectious mononucleosis with no clear consensus on appropriate management. Although management of traumatic splenic rupture has largely moved to nonoperative treatment, splenectomy is still frequently used in dealing with rupture of the diseased spleen. Here we report the case of a 16-year-old boy with splenic rupture secondary to laboratory-confirmed infectious mononucleosis in the absence of trauma. Nonoperative management including ICU admission, serial computed tomography scans, and activity limitation was used successfully. Our experience, along with a review of the literature, leads us to conclude that splenic preservation can be a safe alternative to splenectomy in hemodynamically stable patients with spontaneous splenic rupture. This is of particular importance in the pediatric population, which is at higher risk for postsplenectomy sepsis.