Repeat serial transverse enteroplasty leads to reduction in parenteral nutrition in children with short bowel syndrome.

BACKGROUND/PURPOSE: Following a serial transverse enteroplasty (STEP) procedure some children develop redilation of the small intestine leading to impaired enteral tolerance and inability to wean parenteral nutrition (PN). The benefit of a second STEP procedure (2STEP) has been controversial. METHODS: We performed a retrospective review of our experience (2008-2018) performing 2STEP, with comparative analysis of nutritional outcomes pre- and postsurgery. RESULTS: During this period 2STEP was performed in 23 patients (13 F:10 M) at a median (25%-75%) age of 2.2 (1.2-3.6) years. Median intestinal length was 68 (40-105) cm before and 85 (40-128) cm after 2STEP. Leading up to 2STEP, PN provided almost 75% of estimated calorie needs. By 24 weeks following 2STEP drops in mean PN percent approached statistical significance (p = 0.07) and at most recent follow up the mean PN percentage was statistically better than at the time of operation or 4 weeks prior to 2STEP, and was nearly significant compared with 12 weeks (p = 0.07) and 24 weeks (p = 0.06) prior. Thirteen children were completely off parenteral support. CONCLUSION: When small intestine redilation occurs following a STEP procedure and where PN cannot otherwise be weaned we believe these data support performing a 2STEP. We cannot predict preoperatively which children will ultimately benefit. LEVEL OF EVIDENCE: 3 (retrospective comparative study).

Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis.

BACKGROUND: The role of percutaneous cholecystostomy (PC) is undefined in patients with multiple comorbidities presenting with emergent calculous cholecystitis (CC). This study compared outcomes between PC, laparoscopic (LC), and open cholecystectomy (OC). METHODS: The Vizient UHC database was queried for high-risk patients with CC who underwent PC, LC, OC, or laparoscopic converted to open cholecystectomy (CONV). Demographics, outcomes, mortality, length of stay (LOS), and direct cost were compared between the groups. RESULTS: LC was the most common approach with the lowest risk of death, complications, LOS, and cost. Complication risk was highest in OC. Nearly 20% of patients underwent PC. Complication rate, LOS, infection, aspiration pneumonia, and mortality were higher in PC. Direct cost was lowest in LC, followed by CONV, PC, and OC. CONCLUSIONS: Emergent cholecystectomy for CC in high-risk patients is safer and more cost effective than PC and this study supports the use of cholecystectomy as the primary treatment approach in these patients.

Performance of the On-Q pain infusion device during changes in environmental temperature.

BACKGROUND: The On-Q infusion device is an elastomeric device with a flow regulator that controls the flow of a local anesthetic agent through a peripheral catheter. As variations in external temperature may affect the diameter of the tubing or viscosity of the fluid, it is feasible that alterations in flow may be caused by such temperature variations. This study evaluates the performance of this device during variations in environmental temperature. METHODS: The disposable 400 ml On-Q pain ball infusion devices were filled and connected to a single, end hole infusion catheter and set to infuse at 14 ml·h(-1) . Eighteen devices were used in the study (six of each at three different temperatures). The temperatures included hot (54°C), room temperature (21°C), and cold (6°C). The devices were allowed to flow for 24 h. The fluid delivered during each 12-h period was measured using a graduated column. RESULTS: There were significant differences in the output from the devices at the hot (54°C) temperature and the cold (6°C) temperature when compared to room temperature (21°C). When compared to room temperature, the output decreased to 67% and 54% of the control group (room temperature) during hours 0-12 and 12-24, respectively, in a cold environment (6°C). An increased external temperature resulted in a greater output from the devices. When compared to the room temperature devices, the output was 49% higher during the first 12 h and 40% higher during the second 12 h at an external temperature of 54°C. CONCLUSIONS: This preliminary investigation demonstrates what may be clinically significant changes in output from the On-Q pain device based on the external temperature. These alterations in flow could result in inadequate analgesia or even potentially toxicity if these devices are used in smaller patients especially the pediatric population.