Most children experience resolution of idiopathic pediatric rectal prolapse with bowel management alone.

BACKGROUND: Recent studies in children with idiopathic rectal prolapse report up to 48% require surgical intervention to manage refractory disease. We sought to examine outcomes of our non-surgical approach to managing rectal prolapse using a bowel management program. METHODS: A retrospective review was performed for all children with the diagnosis of rectal prolapse between 2011 and 2020. Children with a rectal polyp or hemorrhoid were excluded. RESULTS: 47 children with rectal prolapse were identified (median age at diagnosis of 4 years (IQR 3,7.75); age ≤ 4 years n = 30; age > 4 years n = 17). Associated diagnoses included constipation (n = 45, 96%) and psychiatric diagnoses (n = 7, 14%). Children underwent a bowel management program including stimulant laxatives in 44 (94%) and osmotic laxatives in 2 (4%). Median follow-up time was 181 days (IQR 77, 238). Median time to resolution of rectal prolapse was 9 months (IQR 4, 13) with a maximum time to resolution of 31 months. We compared children ≤ 4 years old (Group A) to those > 4 years old (Group B). Psychiatric diagnoses were less common in Group A (3.5 vs. 38.9%, p = 0.003). Median time to spontaneous resolution was 6.5 months (IQR 3.5, 9.5) in Group A versus 13.5 (IQR 4, 16) months in Group B, p = 0.13. No differences in surgical intervention were identified. Three (6.4%) patients required surgery for prolapse. CONCLUSIONS: A bowel management program is an effective treatment for most children with rectal prolapse. This data suggests that surgical intervention is unnecessary in most children. LEVEL OF EVIDENCE: III.

Use of expedited post-operative protocol for children undergoing appendicostomy reduces length of hospitalization.

BACKGROUND: An appendicostomy (ACE) is a surgical option for antegrade enemas in children with severe constipation and/or fecal incontinence who have failed medical management.  In 2019, we initiated an expedited post-operative protocol and sought to examine our short-term outcomes compared with our historical cohort. METHODS: A retrospective review was performed of all children undergoing ACE between 2017 and 2020. Children were excluded if they underwent an associated procedure (e.g. colon resection). Patients were divided into two cohorts: historical cohort (2017-2018, Group A) and the expedited protocol (2019 to present, Group B). The primary outcome was length of stay. RESULTS: 30 patients met inclusion (Group A = 16, Group B = 14). The most common indications for ACE were constipation (50%) and constipation or fecal incontinence associated with anorectal malformation (43%). Group B experienced a decreased length of stay (1 vs 3 days, P = 0.001) without differences in 30-day surgical site infection (7.1% vs 18.8%, p = 0.61) or unplanned visit (15.4% vs 18.8%, p = 1.0). Group B had a higher prevalence of MiniACE® button placed through the appendix vs. Malone (42.8% vs 12.5%, p = 0.10). CONCLUSIONS: Our expedited post-op protocol decreased length of stay without other significant adverse clinical sequelae. LEVEL OF EVIDENCE: Retrospective Comparative Study, Level III.

Novel device to detect enterotomies in real time during laparoscopy: first in human trial during Roux-en-y gastric bypass.

BACKGROUND: Undetected bowel perforations occur in 0.3-1% of laparoscopic surgical procedures with an associated mortality rate of 5.3%. OBJECTIVE: The purpose of the study was to evaluate the clinical feasibility of a novel medical device to accurately detect bowel gas, specifically hydrogen (H2) and methane (CH4), from a sample of gas from the abdominal cavity during laparoscopic surgery when a known bowel wall perforation has occurred. SETTING: University (Academic) Hospital. METHODS: A prospective single arm study was composed of 8 patients undergoing a standard laparoscopic roux-en-y gastric bypass. At seven time points during the operation intra-abdominal gas was pulled from the abdominal cavity and analyzed using the novel device for H2 and CH4. The time points included after insufflation (T1), after first jejunotomy (T2), after closure of jejunotomy (T3), after recycle of carbon dioxide gas (T4), after gastrostomy (T5), after jejunotomy (T6), at procedure end (T7). RESULTS: Eight patients were enrolled in the study; in 7 (87.5%) patients data from all 7 time points were obtained. After the first opening of the small bowel (T2) mean hydrogen levels were significantly increased compared to baseline hydrogen levels (T1, T4, T7) (p < 0.001). At all time points, there was no significant detection of methane. There were no intra-operative or post-operative complications during the study. CONCLUSION: Hydrogen gas is released into the intra-abdominal cavity when bowel is opened and can be detected in real time using a novel device during laparoscopic surgery. The presence or absence of hydrogen directly correlates to whether the bowel is open (perforated) or intact. This device could be used in the future to detect unintended bowel perforations during laparoscopic surgery, prior to the conclusion of the operation. This technology could also potentially lead to novel mechanism for detecting postoperative leaks using gas detection technology.

Innovation within a university setting.

Elisabeth K. Wynne, MD, completed her undergraduate degree in bioengineering and is currently a surgical resident in training at the University of Washington. From 2014-2016, she served as a Biodesign Fellow at Stanford University. She plans to pursue a career of innovation as an academic surgeon. Thomas M. Krummel, MD, is the Emile Holman Professor and Chair Emeritus of the Department of Surgery at Stanford University School of Medicine. Throughout his career, Dr Krummel has been a pioneer and an innovator. For >12 years, he has partnered with Dr Paul Yock to co-direct the Stanford Biodesign program, which is designed to teach innovation at the emerging frontiers of engineering and biomedical sciences. Dr Krummel is Chairman of the Fogarty Institute for Innovation Board of Directors, and President of the International Scientific Committee at Institut de Recherche contre les Cancers de l'Appareil Digestif - IRCAD at the University of Strasbourg and is a frequent consultant to the medical device industry.

Use of a left ventricular assist device in hypertrophic cardiomyopathy.

Late stages of hypertrophic cardiomyopathy (HCM) result in medically refractory heart failure. Current treatments include septal myomectomy or alcohol ablation; however, not all patients are eligible for these procedures. We describe the technical aspects of implantation of a HeartMate II left ventricular assist device as a bridge to transplant therapy for a patient with HCM and end-stage heart failure. Pre- and post-operative imaging demonstrates the importance of establishing a functional inflow tract for the device.

Epidermoid cyst of the breast: Mammography, ultrasound, MRI.

Epidermal cysts are common cysts located cutaneously or subcutaneously in the head, neck, and trunk. However, deep epidermal cysts of the breast are very rare, and are frequently associated with traumatic implantation. We present the case of a 62-year-old woman with a palpable mass in the right breast. The patient was evaluated using mammography, ultrasound, and MRI, which uniquely characterized the mass and revealed a second mass. Histological analysis revealed fragments of an epidermoid cyst. The origin of the cysts and location deep within the breast tissue likely were due to a previous bilateral-reduction mammoplasty.