Securement to Prevent Noncuffed Central Venous Catheter Dislodgement in Pediatrics: The SECURED Superiority Randomized Clinical Trial.

Importance: Catheter dislodgement is a common complication for children with tunneled or peripherally inserted noncuffed central venous catheters (CVCs). A subcutaneous anchor securement system (SASS) may reduce this risk compared with traditional adhesive securement. Objective: To compare dislodgement of noncuffed CVCs secured with SASS with dislodgement of noncuffed CVCs secured with sutureless securement devices (SSDs). Design, Setting, and Participants: The SECURED (Securing Central Venous Catheters to Prevent Dislodegment) trial was a pragmatic, multicenter, superiority randomized clinical trial with an internal pilot and was conducted from August 5, 2020, to August 30, 2022, at 2 Australian quaternary pediatric hospitals. Data analysis was performed in January 2023. Patients aged 0 to 18 years requiring a noncuffed CVC (≥3F catheter) were eligible for inclusion. Follow-up duration was 8 weeks or until device removal. Interventions: Patients were randomly assigned 1:1 to receive an SASS or SSD, stratified by hospital and catheter type. Only 1 catheter was studied per patient. Main Outcomes and Measures: The primary outcome was dislodgement (partial or total), defined as movement of the catheter tip by greater than 1 cm (change in external catheter length) at any point during catheter dwell. Dislodgement, reported as a risk ratio (RR), was estimated using a generalized linear model with binomial family and log link. Secondary outcomes were reported as incidence rate ratios and were analyzed using Poission regression. Outcomes reported as mean differences (MDs) were analyzed using linear regression. Results: Of 310 randomized patients, 175 patients (56.5%) were male and median (IQR) patient age was 48 (16-120) months. A total of 307 patients had a catheter device inserted, of which 153 (49.8%) were SASS and 154 (50.2%) were SSD, and were included in the intention-to-treat (ITT) analysis. Device dislodgement was lower with SASS (8 dislodgements in 153 patients [5.2%]) compared with SSD (35 dislodgements in 154 patients [22.7%]) (RR, 0.23; 95% CI, 0.11-0.48; P < .001). The per-protocol analysis was consistent with the ITT analysis. Partial dislodgement accounted for most dislodgement events, including 6 partial dislodgements in the SASS group (3.9%) and 30 partial dislodgements in the SSD group (19.5%) (RR, 0.18; 95% CI, 0.08-0.42). This contributed to fewer complications during dwell in the SASS group (37 reported complications [24.2%]) vs the SSD group (60 reported complications [39.0%]) (RR, 0.62; 95% CI, 0.44-0.87). Staff reported greater difficulty removing devices anchored with SASS vs SSD (mean [SD], 29.1 [31.3] vs 5.3 [17.0], respectively; MD, 23.8; 95% CI, 16.7-31.0). However, use of SASS resulted in reduced per-participant health care costs of A$36.60 (95% credible interval, 4.25-68.95; US $24.36; 95% credible interval, 2.83-45.89). Conclusions and Relevance: In the SECURED trial, noncuffed CVCs secured with SASS had fewer dislodgements compared with SSDs, with a lower cost per patient and an acceptable safety profile. Future efforts should be directed at SASS implementation at the health service level. Trial Registration: anzctr.org.au Identifier: ACTRN12620000783921.

Keratin-Positive Giant Cell Tumor of Bone and Soft Tissue With HMGA2::NCOR2 Fusion in Children Under 10 With Response to Imatinib Therapy: A Case Series.

HMGA2::NCOR2 keratin-positive giant cell tumors in children with response to imatinib in an infant.

Conflicting views of physicians and surgeons concerning pediatric urinary tract infection: a comparative review.

BACKGROUND: A first febrile urinary tract infection (UTI) is a common condition in children, and pathways of management have evolved over time. OBJECTIVE: To determine the extent to which pediatricians and surgeons differ in their investigation and management of a first febrile UTI, and to evaluate the justifications for any divergence of approach. MATERIALS AND METHODS: A literature search was conducted for papers addressing investigation and/or management following a first febrile UTI in children published between 2011 and 2021. Searches were conducted on Medline, Embase, and the Cochrane Controlled Trials Register. To be eligible for inclusion, a paper was required to provide recommendations on one or more of the following: ultrasound (US) and voiding cystourethrogram (VCUG), the need for continuous antibiotic prophylaxis and surgery when vesicoureteral reflux (VUR) was detected. The authorship required at least one pediatrician or surgeon. Authorship was categorized as medical, surgical, or combined. RESULTS: Pediatricians advocated less imaging and intervention and were more inclined to adopt a "watchful-waiting" approach, confident that any significant abnormality, grades IV-V VUR in particular, should be detected following a second febrile UTI. In contrast, surgeons were more likely to recommend imaging to detect VUR (p<0.00001), and antibiotic prophylaxis (p<0.001) and/or surgical correction (p=0.004) if it was detected, concerned that any delay in diagnosis and treatment could place the child at risk of kidney damage. Papers with combined authorship displayed intermediate results. CONCLUSION: There are two distinct directions in the literature regarding the investigation of an uncomplicated first febrile UTI in a child. In general, when presented with a first febrile UTI in a child, physicians recommend fewer investigations and less treatment, in contrast to surgeons who advocate extensive investigation and aggressive intervention in the event that imaging detects an abnormality. This has the potential to confuse the carers of affected children.

Intravascular Tumor Extension and Pulmonary Tumor Embolism in Children With Solid Malignancies: Is There a Role for Inferior Vena Cava Filters?

Intravascular tumor extension is an uncommon complication of solid malignancies that, when present in the inferior vena cava (IVC), can result in fatal pulmonary tumor embolism. Currently, neoadjuvant chemotherapy and surgery are the mainstays of treatment; however, there are no consensus guidelines for management. We describe three cases of pediatric solid malignancies with associated IVC extension and pulmonary tumor embolism. We hypothesize that there is scope for IVC filter placement in such cases to mitigate the risk of fatal pulmonary tumor embolism.

Diagnostic yield and safety of ultrasound-guided percutaneous testicular biopsies in children.

BACKGROUND: Traditionally, testicular biopsy is performed using an open surgical approach. Ultrasound-guided percutaneous biopsy is a less invasive alternative and can be performed in children. OBJECTIVE: The aim of this study is to report our technique and to assess the diagnostic accuracy and safety of ultrasound-guided percutaneous biopsy of testicular masses in children. MATERIALS AND METHODS: This is a 16-year retrospective review of ultrasound-guided percutaneous testicular biopsies at a single pediatric hospital. RESULTS: We performed nine ultrasound-guided testicular biopsies in 9 patients (median age: 3 years, range: 4 months-11 years; median weight: 20.9 kg, range: 8.4-35 kg; median volume of testicular lesion biopsied: 4.4 mL, range: 1.2-17 mL). A percutaneous co-axial technique was used for 5/9 biopsies with absorbable gelatin sponge tract embolization performed in 4 of those biopsies. A non-co-axial technique was used in 4/9 biopsies. A median of three cores, range 2-6, were obtained. The diagnostic yield was 89% with one biopsy yielding material suggestive of, but insufficient for, a definitive diagnosis. The most common histological diagnosis was leukemic infiltration, occurring in 6/9 biopsies. Of the remaining three biopsies, one biopsy was suggestive of, but not confirmatory for, juvenile granulosa cell tumor and two biopsies confirmed normal testicular tissue; the long-term follow-up of which demonstrated normal growth and no lasting damage. There was one (clinically insignificant) complication out of nine biopsies (11%, 95% confidence interval 0-44%): a mild, self-resolving scrotal hematoma. CONCLUSION: Ultrasound-guided testicular biopsy can be performed safely in children as an alternative to open surgical biopsy, with a high diagnostic yield and low complication rate.

Presentation, treatment, and outcome of renovascular hypertension below 2 years of age.

Renovascular hypertension in most cases requires endovascular treatment and/or surgery. This is technically much more difficult in small children and there is very limited published knowledge in this age group. We here present treatment and outcome of young children with renovascular hypertension at our institution. Children below 2 years of age, with renovascular hypertension between January 1998 and March 2020 were retrospectively reviewed. Demographics and treatment modalities were noted. Primary outcome was blood pressure within a week after the procedures and at last available visit. Sixty-six angiographies were performed in 34 patients. Median age at time of first angiography was 1.03 (interquartile range (IQR) 0.4-1.4) years and systolic blood pressure at presentation 130 (IQR 130-150) mm Hg. Thirty-eight percent (13/34) of children were incidentally diagnosed and 18% (6/34) presented with heart failure. Twenty-six (76%) children had main renal artery stenosis and 17 (50%) mid-aortic syndrome. Seventeen (50%) children showed intrarenal, six (18%) mesenteric, and three (9%) cerebrovascular involvement. Twenty patients underwent 45 percutaneous transluminal angioplasty procedures and seven children surgeries. In 44% of the 16 patients who underwent only percutaneous transluminal angioplasty blood pressure was normalized, 38% had improvement on same or decreased treatment and 19% showed no improvement. Complications were seen in 7.5% (5/66) of angiographies. In four of the seven (57%) children who underwent surgery blood pressure was normalized, two had improved (29%) and one unchanged (14%) blood pressure. CONCLUSION: In small children with renovascular hypertension below the age of 2 years, percutaneous transluminal angioplasty caused significant improvement in blood pressure with low complication profile. Surgery can be recommended where percutaneous transluminal angioplasty and medical treatments failed. WHAT IS KNOWN: • Renovascular hypertension is diagnosed in all age groups from a few weeks of life until adulthood. • Both angioplasty and surgery are significantly more difficult to perform in small children and the published information on short and long-term outcome in these children is very scarce. WHAT IS NEW: • Children below the age of two years can safely and successfully undergo selective renal angiography and also safely be treated with angioplasty. • We here present a large group of babies and infants where angioplasty and in some cases surgery effectively and safely improved their blood pressure.

Long-term outcomes following failure of Nissen fundoplication.

PURPOSE: To determine the management and outcomes of patients with gastro-oesophageal reflux (GOR) that requires further intervention following failure of Nissen fundoplication (NF). METHODS: After institutional audit department approval, a retrospective review of paediatric patients who had further intervention following failure of primary NF between January 2006 and December 2015 for GOR at our centre was performed. Data are presented as median (range). RESULTS: Of 820 patients who underwent NF, 190 (23%) received further procedures for GOR management at a median of 21 months of age (6-186); 90/190 (47%) had gastro-jejunal feeding (GJ). Of these, 67 (74%) remained on GJ feeds up to a median of 48 months and 23/90 (26%) had a second NF after GJ feeding. 97/190 (51%) had a redo fundoplication without having had a GJ; thus, 120/190 (63%) of patients having a further procedure went on to have a second NF after a median period of 15 months (1-70 months). Three patients (2%) had early emergency wrap revision 4 days after first fundoplication (we classed this as an 'early complication'). Of the seven patients who failed a 3rd NF, 4 continued GJ feeding, 2 of had oesophagogastric dissociation; 2 had 4th NF of which 1 was successful and 1 patient had gastric pacemaker and is successfully feeding orally. Patients who were finally successfully managed with GJ underwent 2 (2-5) tube changes/year. We found patients who had a previous GJ were more likely to have failure of the redo fundoplication than those who had not to have the GJ (16/24 vs. 30/90, p = 0.005). CONCLUSION: The chance of success decreases with every further attempt at fundoplication. The only factor significantly associated with failure of redo fundoplication was whether the patient previously had a GJ tube. In patients with failed fundoplications, when symptom free on jejunal feedings, further anti-reflux surgical intervention should be avoided. A randomized prospective study is needed for patient selection.

Pediatric interventional radiology - does it add value?

Although attempts have been made to show that pediatric interventional radiology adds value in children's hospitals, none has been particularly persuasive. An analysis of individual procedures would seem to be the most scientific approach, but there are numerous problems, including the effects that different health care systems have on clinical practice and the difficulty of generalizing the results of a single-center study to other hospitals, even within the same type of health care system. It is unsurprising that there are no published randomized controlled trials comparing both the costs and outcomes of specific pediatric interventional radiology procedures with surgical alternatives, and in fact these may not be feasible. There is only anecdotal evidence of the value of pediatric interventional radiology in multidisciplinary teams in children's hospitals. Currently, the best justification may be the counterfactual: demonstrating what can go wrong if pediatric interventional radiology expertise is not available.

Imaging of Airway Obstruction in Children.

Various imaging techniques may be used to diagnose airway obstruction in children. Digital radiography, computed tomography and magnetic resonance imaging are the most important modalities, but the choice of technique will depend on the level and nature of suspected obstruction, as well as patient-specific factors such as age and ability to cooperate. This review examines the forms of airway obstruction that are commonly encountered in childhood.

Interventional radiology in the airway in children.

Interventional procedures in the airway can be performed in interventional radiology suites or the operating room, by radiologists or other specialists. The most common therapeutic interventions carried out by radiologists are balloon dilatation, stenting, and the treatment of certain airway fistulas. These operations can be very challenging for anesthetists in terms of planning, airway management, the identification and treatment of procedural complications and postoperative care. In particular, a multidisciplinary approach to decision-making and planning is important to obtain the best results.

Self-expanding esophageal stents for the management of benign refractory esophageal strictures in children: A systematic review and review of outcomes at a single center.

BACKGROUND: This study aimed to evaluate our outcomes and complication rate following placement of self-expanding esophageal stents in children for the management of refractory esophageal strictures and comparing these to the existing literature. METHODS: Outcomes following placement of stents in consecutive patients under 18 years at a single center from 2003 to 2018 were reviewed. A PRISMA-guided systematic review was conducted identifying studies with 5 or more children evaluating self-expanding stents published from 1975 to 2018. Endpoints for both the retrospective and systematic reviews were the requirement for further intervention and stent-associated complications. RESULTS: 25 patients received 65 stents. There were 12 caustic injury-related strictures (48%), 9 anastomotic strictures (36%), and 4 esophagitis-related strictures (16%). Four patients were lost to follow-up. 19/21 patients (90%) required further intervention, and 8/21 (38%) had esophageal replacement. Nine studies, all case series, were included in the systematic review. 97 patients received 160 stents for esophageal strictures and/or perforation. 36 out of 69 patients (52%) with strictures required no further treatment post-stenting, and 22/29 (76%) of esophageal perforations closed with stenting. CONCLUSIONS: Esophageal stents may have a role as a bridge to definitive surgery and for the management of esophageal leaks, but complete stricture resolution post-stenting is unlikely. TYPE OF STUDY: Treatment Study (Case Series with no Comparison Group) LEVEL OF EVIDENCE: Level IV.

Diagnostic yield and safety of ultrasound-guided bowel mass biopsies in children.

BACKGROUND: Traditionally, ultrasound (US)-guided bowel mass biopsies are avoided in favour of endoscopic or surgical biopsies. However, endoscopy cannot easily reach lesions between the duodenojejunal flexure and the terminal ileum and lesions not involving the mucosa may not be accessible via an endoscopic route. OBJECTIVE: The aim of this study was to report our technique and to assess the diagnostic accuracy and safety of US-guided biopsy of bowel masses in children. MATERIALS AND METHODS: We conducted a 14-year retrospective review of US-guided bowel mass biopsies at a single paediatric hospital. RESULTS: Twenty US-guided bowel mass biopsies were performed in 19 patients (median age: 6 years and 6 months, range: 22 months-17 years, median weight: 22 kg, range: 10.2-48.4 kg). For 14 biopsies, there was no other lesion that could potentially be biopsied. A percutaneous coaxial technique was used for 19 biopsies and a transanal non-coaxial biopsy was performed in 1. A median of 9 (range: 2-15) cores of tissue was obtained at each biopsy. The technical success rate and adequacy of diagnostic yield were 100%. The most common diagnosis was lymphoma, which occurred in 16 biopsies. Three biopsies contained mucosa. There was one complication out of 20 biopsies (5%, 95% confidence interval 0-15%): a self-limiting, post biopsy pyrexia. Nineteen procedures were accompanied by a bone marrow aspirate and/or trephine within 2 weeks of the bowel biopsy, only one of which was diagnostic. CONCLUSION: US-guided bowel mass biopsy can be performed safely in children, with a high diagnostic yield and low complication rate.

Pancreatic pseudocyst drainage in children by image-guided cystogastrostomy and stent insertion.

BACKGROUND: Endoscopic ultrasound is seldom available at paediatric centres; therefore drainage of pancreatic pseudocysts in children has traditionally been achieved by surgery. OBJECTIVE: This study assessed the feasibility and safety of performing image-guided internal drainage of pancreatic pseudocysts with a flanged self-expanding covered nitinol pancreatic pseudocyst drainage stent. MATERIALS AND METHODS: We conducted a retrospective case note review of children undergoing image-guided cystogastrostomy at two paediatric hospitals. Percutaneous access to the stomach was achieved via an existing gastrostomy tract or image-guided formation of a new tract. Under combined ultrasound, fluoroscopic or cone-beam CT guidance the pancreatic pseudocysts were punctured through the posterior wall of the stomach. A self-expanding covered nitinol stent was deployed to create a cystogastrostomy opening. RESULTS: Image-guided cystogastrostomy was performed in 6 children (4 male; median age 6 years, range 46 months to 15 years; median weight 18 kg, range 13.8-47 kg). Two children had prior failed attempts at surgical or endoscopic drainage. Median maximum cyst diameter was 11.5 cm (range 4.7-15.5 cm) pre-procedure. Technical success was 100%. There were no complications. There was complete pseudocyst resolution in five children and a small (2.1-cm) residual pseudocyst in one. Pseudocyst-related symptoms resolved in all children. CONCLUSION: Pancreatic pseudocyst drainage can be successfully performed in children by image-guided placement of a cystogastrostomy stent. In this cohort of six children there were no complications.

Arterial Recanalization for Access for Arterial Intervention in Children: Techniques and Outcomes.

PURPOSE: To assess technical success of arterial recanalization in children requiring repeated arterial access and intervention. MATERIALS AND METHODS: Over 14 years, 41 attempts to cross 30 arterial occlusions were made in 22 patients (13 male, 9 female). Median patient age was 12 months (15 days-14 years), and weight was 7.6 kg (3.0-77.3 kg). Techniques and outcomes were recorded. RESULTS: Twenty-five of 41 (61%) attempts at crossing an arterial occlusion were successful. Nineteen of 30 (63%) first attempts to cross occlusions were successful, and 6 of 11 (55%) repeat attempts were successful. The occluded segments were combinations of common femoral artery (n = 4), external iliac artery (n = 36), common iliac artery (n = 11), and aorta (n = 1). Complications occurred in 5 of 41(12%) attempts: 3 minor complications (hematoma, extravasation, and transient leg ischemia) and 2 major complications (rupture and thrombosis). CONCLUSIONS: Arterial access by recanalization of occluded segments is technically feasible in children, with a low complication rate.

Surgical jejunostomy and radiological gastro-jejunostomy tube feeding in children: risks, benefits and nutritional outcomes.

PURPOSE: Radiologically inserted gastrojejunal tubes (RGJ) and surgical jejunostomy (SJ) are established modes of jejunal feeding. The aim of the study is to review nutritional outcomes, complications and the practical consideration to enable patients and carers to make informed choice. METHODS: Retrospective review of patient notes with a RGJ or SJ in 2010, with detailed follow-up and review of the literature. RESULTS: Both RGJ and SJ are reliable modes to provide stable enteral nutrition. Both have complications and their own associated limitations. CONCLUSIONS: The choice has to be tailored to the individual patient, the social care available, the inherent medical disease and risk/benefit of repeated anaesthetic and radiation exposure. RGJ and SJ are important tools for nutritional management that achieve and maintain growth in a complex group of children. The risk and benefits should be reviewed for each individual patient.