Biocompatible Cable Ties Are an Alternative to Metal Stabilizers for Bar Securement During Minimally Invasive Pectus Excavatum Repair.

Background: Bar stabilization during minimally invasive pectus excavatum repair (MIRPE) is critical to avoid dislodgement. Multiple techniques are described including stabilizers, wires, and sutures. This retrospective study compared bar movement and outcomes between existing techniques and ZipFix™, a biocompatible cable tie. Methods: Patients ≤20 years of age who underwent MIRPE with ZipFix between January 2021 and September 2022 were compared with historical controls who underwent repair by same surgeons between January 2018 and December 2020 using stabilizers or polydioxanone suture (PDS). Demographics, clinical details, and outcomes were compared using Kruskal-Wallis and chi-square tests. Results: Of the 116 patients who underwent repair, 45 had bars secured with ZipFix (39%) and 71 (61%) were historical controls (35 stabilizer, 36 PDS). Median (interquartile range) age was 15 (14-16) years and Haller index was 3.9 (3.6-4.5). Nine (8%) patients required two bars. Haller index and use of second bar were comparable between stabilization techniques (P > .05). In total, 49 patients (40%) reported any pain at 1 month and this was similar between stabilization techniques (P = .45). Median bar movement was greater for bars secured with PDS than with ZipFix or stabilizers at 1 month (5.5 versus 2.3 versus 3.3°, P = .010) and last follow-up (6.5 versus 2.1 versus 3.6°, P < .001). One patient whose bar was secured with PDS required revision for dislodgement. Conclusion: Pectus bar stabilization with ZipFix is a safe alternative to metal stabilizers and both techniques are superior to suture stabilization alone. The use of ZipFix may be preferred given its lower cost and ease of use.

Post-injury outcomes of children with behavioral health disorders.

BACKGROUND: The impact of Behavioral Health Disorders (BHDs) on pediatric injury is poorly understood. We investigated the relationship between BHDs and outcomes following pediatric trauma. METHODS: We analyzed injured children (age 5-15) from 2014 to 2016 using the Pediatric Trauma Quality Improvement Program. The primary outcome was in-hospital mortality. Univariable and multivariable analyses compared children with and without a comorbid BHD. RESULTS: Of 69,305 injured children, 3,448 (5%) had a BHD. These 3,448 children had a median of 1 [IQR: 1, 1] BHD diagnosis: ADHD (n = 2491), major psychiatric disorder (n = 1037), drug use disorder (n = 250), and alcohol use disorder (n = 29). A higher proportion of injured children with BHDs suffered intentional and penetrating injury. Firearm injuries were more common for BHD patients (3% vs 1%, p<0.001). Children with BHDs were more likely to have an ISS>25 compared to children without (5% vs 3%, p<0.001). While median LOS was longer for BHD patients (2 [1, 3] vs 2 [1, 4], p<0.001), mortality was similar (1% vs 1%, p = 0.76) and complications were less frequent (7% vs 8%, p = 0.002). BHD was associated with lower risk of mortality (OR 0.45, 95%CI [0.30, 0.69]) after controlling for age, sex, race, trauma type, and injury intent and severity. CONCLUSION: Children with BHDs experienced lower in-hospital mortality risk after traumatic injury despite more severe injury upon presentation. Intentional and penetrating injuries are particularly concerning, and future work should assess prevention efforts in this vulnerable group.

Thoracic paravertebral nerve catheter reduces postoperative opioid use for vertebral body tethering patients.

PURPOSE: Vertebral body tethering is increasingly being performed, yet postoperative pain management has not yet been optimized. We sought to determine whether the addition of a thoracic paravertebral block in addition to a standard multimodal postoperative pain management program could provide greater pain relief, reduced analgesic requirement, and reduced length of stay. METHODS: Patients who underwent VBT at a single tertiary referral center were retrospectively reviewed. All patients received a single-shot intrathecal (IT) injection at the completion of the procedure in addition to a standardized multimodal pain management program. 45 patients received a thoracic paravertebral catheter with lidocaine infusion (TPVB) which was left in place for 4-6 days, whereas 24 control patients did not have a TPVB. Length of stay, maximum postoperative Numeric Pain Intensity Scale (NPIS), and total dose of opioids, ibuprofen, ketorolac and acetaminophen administered during hospitalization were evaluated. RESULTS: 69 patients met inclusion criteria. The mean cumulative dose of opioids administered during hospitalization was 148 oral morphine milligram equivalent (MME) in the control group vs. 47 MME in the TPVB group (p < 0.0001). Severe postoperative NPIS of ≥ 7 was reported in 9 out of the 24 control patients (38%) and in 13 out of the 45 patients (29%) who received a TPVB in addition to the standardized care (p = 0.46). There was no significant difference in the mean cumulative dose of NSAIDs (ibuprofen, ketorolac) consumed by the control group compared to the TPVB group (2632 mg vs. 1630 mg, p = 0.77). Mean length of stay in the control group was 3.8 vs. 3.0 days in the TPVB group (p < 0.001). There were no major complications associated with use of the TPVB. CONCLUSION: In this series compared to controls, patients treated with a TPVB had reduced postoperative requirement of opioids and decreased length of hospital stay.

Defining the learning curve in CT-guided navigated thoracoscopic vertebral body tethering.

Estimated blood loss (EBL), anesthesia time, operative time, and length of stay decreased over 67 navigated vertebral body tethering (VBT) surgeries performed in a 5-year period, indicating a steep learning curve. DESIGN: Retrospective review of prospectively collected data. HYPOTHESIS: There would be a significant improvement in the performance of VBT procedures over time at a single tertiary center in terms of perioperative and postoperative outcomes. PURPOSE: Learning a new procedure for surgeons takes time, and previous studies have described improved efficiency as experience grows. VBT procedures are increasingly being performed in the US, but there is limited data regarding the learning curve specifically regarding the use of CT-guided navigation. We sought to assess the learning curve of VBT with respect to estimated blood loss, anesthesia time, operative time, length of stay, percent correction of the major curve at first follow-up. We further sought to characterize change in rates of 90-day complications. METHODS: Pediatric scoliosis patients who underwent thoracic or lumbar CT-guided navigated VBT with a consistent surgical team at a single tertiary referral center between 2015 and 2020 were included. Student t-test was used to assess change in perioperative parameters over time, and also results between first and latest group of 20 patients were compared. RESULTS: 67 patients met inclusion criteria. Estimated blood loss (EBL), operative time, anesthesia time and length of stay significantly decreased over the 5-year study period. Specifically, on comparison of our first 20 patients with our last 20, the former had greater EBL (282 vs 116 ml, p = 0.0005; 8.5% vs 3.6%, p = 0.0024), operative time (4.8 h vs. 3.3 h, p < 0.001), anesthesia time (7.4 h vs. 5.7 h, p = 0.0001), and length of stay (3.7 days vs. 3.2 days, p = 0.019). We also found significant reduction in EBL, operative time, anesthesia time and LOS in patients who underwent VBT surgery after 2019. There was no significant change in the percent correction of the major Cobb angle at first erect imaging or 90-day complications over the 5-year study period or between the various cohorts. CONCLUSION: This series has demonstrated improvements in surgical efficiency for VBT including reduced EBL, operative time, anesthesia time and hospital stay over a 5-year period. This indicates improved surgical technique and outlines the significant learning curve for surgeons who wish to perform this procedure. Improved surgeon training programs and newer instrumentation may reduce this learning curve. TAKE HOME POINT: 67 cases in a 5-year period, VBT procedures performed at a single center had significantly decreased EBL, anesthesia time, operative time, and length of stay, indicating a steep learning curve.

Evolution of pediatric gastrointestinal ulcer disease: Is acute surgical intervention relevant?

BACKGROUND: There is a lack of contemporary data about pediatric gastrointestinal ulcer disease. We hypothesized that ulcers found in immunosuppressed children were more likely to require surgical intervention. METHODS: All children <21 years (n = 129) diagnosed with ulcers at a quaternary hospital from 1990 to 2019 were retrospectively reviewed. Clinical findings and pertinent information were collected. RESULTS: Of 129 cases, 19 (14.7%) were immunosuppressed. Eight were post-transplant; four were diagnosed with post-transplant lymphoproliferative disease (PTLD).  Eight were associated with cancer. Three were both.  Three of 19 immunosuppressed and 28/110 immunocompetent patients were taking acid suppression therapy. Nine immunosuppressed patients required surgical intervention, including all PTLD cases, compared to 14 immunocompetent (47.3% vs 16.4%, p < 0.01). Five patients had duodenal perforation, two had multiple small bowel perforations, and two had uncontrolled bleeding. Of 9/19 immunosuppressed patients, surgical complications included bleeding (n = 7), sepsis (n = 2), ostomy reoperation/readmissions (n = 2), and death within 30 days (n = 2). Two/eighteen immunocompetent patients had bleeding complications. CONCLUSION: Surgical treatment for ulcers remains relevant for pediatric patients. Immunosuppressed patients have more complications, longer hospital stays, and are more likely to need surgical intervention. Efforts should be made for ulcer prophylaxis with a low threshold to investigate epigastric pain in these complex patients. LEVEL OF EVIDENCE: Prognosis Study Level III Evidence.

Does preoperative and intraoperative imaging for anterior vertebral body tethering predict postoperative correction?

PURPOSE: Anterior vertebral body tethering (AVBT) is an emerging approach for idiopathic scoliosis. However, overcorrection and under-correction are common causes of revision surgery, and intraoperative tensioning of the cord is one key component to achieve appropriate curve correction. We sought to determine whether preoperative flexibility radiographs or intraoperative radiographs would predict correction at first erect imaging for scoliosis patients undergoing anterior vertebral body tethering (AVBT). METHODS: Single-center retrospective review. Fifty-one patients with a diagnosis of idiopathic scoliosis underwent anterior body tethering. Preoperative flexibility films and intraoperative radiographs were compared to first erect standing radiographs to determine if there was a correlation in Cobb angle. RESULTS: Preoperative major Cobb angle measured 52° ± 9°. Major Cobb angle on bending films was 24° ± 8°. Intraoperative imaging showed correction to a mean of 17° ± 8°. Postoperative first erect standing radiographs showed correction to a mean of 26° ± 10°. The mean difference in major Cobb angle between intraoperative radiograph and a first erect radiograph was 10° ± 4°, whereas the mean difference from preoperative bending radiograph at first erect was 2° ± 7°. Thus, correction on preoperative flexibility films correlated with the first erect radiograph. CONCLUSION: Preoperative bending radiographs provide a reasonable estimate of postoperative correction for patients undergoing AVBT with tensioning of the cord. Surgeons should expect the major Cobb angle to increase on first erect radiographs compared to intraoperative radiographs. These findings may guide patient selection and assist surgeons in achieving appropriate correction intraoperatively.

Initial experience with transanal proctectomy in children.

BACKGROUND: The use of transanal proctectomy may have particular advantages for pediatric patients with small pelvic working space. We report short-term outcomes of transanal completion proctectomy (taCP) during surgery for inflammatory bowel disease. METHODS: All patients (age≤19) underwent taCP from January 1, 2018 to December 31, 2019. Prior total abdominal colectomy (TAC) was performed using a single-incision technique. At operation, patients underwent single-incision laparoscopy with taCP. Patient demographics, pre and perioperative details, and postoperative complications were abstracted. RESULTS: Seven patients (n = 6) with a median age of 18 years [Range: 13-19] were included in this initial series. All patients had a prior TAC with end-ileostomy with taCP occurring a median of 6 [Range: 3-89] months after TAC. Six of 7 had a diagnosis of ulcerative colitis (UC) while 1 patient had Crohn's colitis. For patients with UC, taCP was part of an ileal pouch-anal anastomosis with the majority (n = 4) proceeding as a modified-two stage and the remaining (n = 2) a three-stage approach. Single-incision laparoscopy through the prior ileostomy site was used in all IPAA patients. Median operative time was 226 [Range: 150-264] minutes with no conversions to more invasive technique. Median hospital length of stay (LOS) was 5 [Range: 2-8] days. In-hospital complications occurred in two patients who had watery diarrhea that prolonged LOS but resolved postdischarge. One patient was readmitted for bowel obstruction that resolved with placement of red rubber catheter at the ileostomy site. Of the 4 patients with a functioning ileal pouch, 1 patient reported 6-10 bowel movements per day, while 3 others reported ≤5 bowel movements per day. Half (n = 2) reported 1-2 nocturnal bowel movements at their first postoperative visit. No patients reported soiling or leakage, though one patient had a single episode of incontinence. CONCLUSION: In this pilot series, transanal proctectomy was effective and safe. Future work should compare traditional MIS completion proctectomy to taCP for applications in pediatric inflammatory bowel disease. TYPE OF STUDY: Case series. LEVEL OF EVIDENCE: IV.

A Comparison of Single-Incision Versus Multiport Laparoscopic Splenectomy in Children.

Background: Although single-incision endoscopic splenectomy (SIES-Sp) has been shown to be feasible and safe, few have compared the SIES-Sp with multiport laparoscopic splenectomy (MPLS). The purpose of this study was to compare the two techniques in children undergoing total splenectomy. Materials and Methods: We reviewed all children (age <18 years) who underwent minimally invasive total splenectomy at a single tertiary referral center from January 1, 2000 to January 1, 2019. The primary outcome was complication rate 30 days after discharge defined by maximum Clavien-Dindo score. Secondary outcomes included conversion, operative time, hospital length of stay, postoperative pain scores, and readmission within 30 days of discharge. SIES-Sp and MPLS were compared using univariate analysis. Results: Of 48 children undergoing laparoscopic total splenectomy, 60% (n = 29) were SIES-Sp and 40% (n = 19) were MPLS. Subjects were 48% female (n = 23). Common diagnoses were idiopathic thrombocytopenic purpura (33% [n = 16]), hereditary spherocytosis (29% [n = 14]), and other congenital hemolytic anemias (23% [n = 11]). There were no differences in age, gender, or diagnosis between groups (all P > .05). One in three cases involved additional procedures. Spleens were smaller in both greatest dimension (13.0 cm versus 16.4 cm) and weight (156.5 g versus 240.0 g) in SIES-Sp compared with MPLS patients (both P < .05). Readmission and reoperation rates were similar (both P > .05). Complications occurred in 7% (n = 2) of SIES-Sp and in 11% (n = 2) of MPLS patients (P > .99). Severe complications included: cardiac arrest in 1 SIES-Sp patient and bleeding requiring reoperation in 1 MPLS patient. Conclusion: SIES-Sp is a safe alternative to the traditional MPLS for children. Additional procedures do not preclude a less invasive approach, but larger spleens may present a challenge.

The incidence of venous thromboembolism in children following colorectal resection for inflammatory bowel disease: A multi-center study.

BACKGROUND/PURPOSE: Children with inflammatory bowel disease (IBD) have increased risk for venous thromboembolism (VTE). We sought to determine incidence and risk factors for postoperative VTE in a multicenter cohort of pediatric patients undergoing colorectal resection for IBD. METHODS: Retrospective review of children ≤18 years who underwent colorectal resection for IBD from 2010 to 2016 was performed at four children's hospitals. Primary outcome was VTE that occurred between surgery and last follow-up. Factors associated with VTE were determined using univariable and multivariable analyses. RESULTS: Two hundred seventy-six patients were included with median age 15 years [13,17]. Forty-two children (15%) received perioperative VTE chemoprophylaxis, and 88 (32%) received mechanical prophylaxis. DVT occurred in 12 patients (4.3%) at a median of 14 days postoperatively [8,147]. Most were portomesenteric (n = 9, 75%) with the remaining catheter-associated DVTs in extremities (n = 3, 25%). There was no association with chemoprophylaxis (p > 0.99). On Cox regression, emergent procedure [HR 18.8, 95%CI: 3.18-111], perioperative plasma transfusion [HR 25.1, 95%CI: 2.4-259], and postoperative infectious complication [HR 10.5, 95%CI: 2.63-41.8] remained predictive of DVT. CONCLUSION: Less than 5% of pediatric IBD patients developed postoperative VTE. Chemoprophylaxis was not protective but rarely used. Patients with risk factors identified in this study should be monitored or given prophylaxis for VTE. LEVEL OF EVIDENCE: Treatment Study, Level III.

The effect of diversion on readmission following ileal pouch-anal anastomosis in children.

BACKGROUND: Readmission rates as high as 20% have been reported after ileal pouch-anal anastomosis (IPAA) in children, with obstruction and dehydration as the most commonly listed reasons. We hypothesized that a diverting ileostomy contributes to unplanned readmission after IPAA creation. METHODS: Children (age <18) who underwent IPAA creation from January 2007 to August 2018 at two affiliated institutions were reviewed. Patient demographics, operative details, and post-operative length of stay (LOS) were abstracted. Unplanned readmission within 30 days and details on patient readmission were reviewed. RESULTS: Ninety-three patients (57% female) with a median age of 15 years (range: 18 months-17 years) underwent IPAA. Indications for IPAA included ulcerative colitis (n = 63; 68%), familial adenomatous polyposis (n = 24; 26%), indeterminate colitis (n = 5; 5%), and total colonic Hirschsprung's (n = 1; 1%). Sixty-one (66%) patients were diverted at the time of IPAA creation. Fourteen patients (15%) were readmitted, and reasons for readmission included bowel obstruction (n = 9; 64%), dehydration (n = 2; 14%), anastomotic leak (n = 2; 14%), and gastrointestinal (GI) bleeding (n = 1; 6%). Patients with a diverting ileostomy at the time of IPAA were more often readmittted than patients who were not diverted (21% vs 3%, p = 0.03). Further, 10 (71%) of the readmitted patients had complications attributable to their ileostomy. In patients readmitted for obstructive symptoms, six (67%) required red rubber catheter insertion for resolution, two (22%) patients required reoperation for obstructions at the level of the stoma, and one (11%) resolved with bowel rest alone. CONCLUSION: Readmission following IPAA creation in children is often secondary to preventable issues related to diverting ileostomy. Surgeons should carefully consider the necessity of diversion. When it is necessary, particular attention to fascial aperture size and post-discharge initiatives to reduce dehydration may reduce readmission rates. LEVEL OF EVIDENCE: Level III.

Open versus thoracoscopic thymectomy for juvenile myasthenia gravis.

BACKGROUND: Juvenile myasthenia gravis (JMG) is an antibody mediated autoimmune disorder that manifests as progressive voluntary muscle weakness and fatigue. In medically refractory cases, thymectomy has been shown to abrogate symptoms and reduce glucocorticoid dependence. While transcervical or transsternal incisions have been the traditional approach, adult trends now favor thoracoscopic thymectomy. Little data exist to support this approach in children. METHODS: A retrospective review of all patients younger than 20 years of age who underwent a thymectomy for JMG at two pediatric institutions between 2001 and 2018 was performed. Children were divided into either an open (transcervical or transsternal) or thoracoscopic group and baseline characteristics, perioperative, and postoperative outcomes were compared. RESULTS: Thirty-four thymectomies were performed during the 18-year study period; 18 via an open and 16 via a thoracoscopic approach. The operative time was shorter for open procedures compared thoracoscopic ones (108 ±â€¯49 and 145 ±â€¯43 min, respectively, p = 0.025). Thoracoscopic thymectomy was associated with less intraoperative blood loss (5.5 ±â€¯6.0 vs 55 ±â€¯67 ml, p = 0.007), decreased duration of postoperative intravenous narcotic use (5.0 ±â€¯1.5 vs 20 ±â€¯23 h, p = 0.018), and a shorter length of hospitalization (1.7 ±â€¯1.0 vs 2.7 ±â€¯1.1 days, p = 0.009). No perioperative complication occurred in either group. Clinical improvement was reported in 94% of children in both groups. CONCLUSIONS: Thoracoscopic thymectomy in children is a safe and effective surgical technique for the treatment of JMG. Increased acceptance of this minimally invasive approach by children, families, and referring neurologists may enable earlier surgical intervention. TYPE OF STUDY: Clinical research paper. LEVEL OF EVIDENCE: III.

Fertility and Sexual Function in Women Following Pediatric Ileal Pouch-Anal Anastomosis.

PURPOSE: Ileal Pouch-Anal Anastomosis (IPAA) is the standard of care for children requiring surgical treatment of severe colitis or polyposis syndromes. This study aims is to investigate the sexual function and fertility in women after undergoing childhood IPAA. METHODS: A prospectively maintained colon and rectal database of consenting patients was queried from January 1980 to October 2015. We included all females that replied to at least 1 survey between the ages of 20 and 45 years that had undergone IPAA younger than 20 years of age. RESULTS: Two hundred females met inclusion criteria, whereas 149 women replied to the sexual function questions. Ulcerative colitis was diagnosed in 122 (83%) patients, with the remainder having polyposis. Seven patients had a laparoscopic proctectomy. Only 2 patients had a pelvic infection, whereas 21 had intestinal obstruction postoperatively. A severely restricted sex life was reported in 6 (5%) patients. Of the 93 (62%) women who attempted pregnancy, 68 (73%) became pregnant. Median age of pregnancy and IPAA was 34 (range 22-45) and 17 years (range 9-20), respectively. Medical intervention to assist fertilization was required in 14/68. A total of 29 women reported problems during pregnancy with 58/68 (88%) giving birth to a live baby. Elective termination was reported in 2/68 surveys. Vaginal delivery occurred in 26/58 mothers with 27/58 planned and 9/58 unplanned cesarean sections. Age at IPAA, diagnosis, procedure type, pelvic infection, and obstruction were not associated with decreased fertility. All 7 patients operated laparoscopically have become pregnant. Change in pouch function after delivery was reported in 20/68 (32%, 5 missing) surveys. CONCLUSIONS: 73% of women who desired children become pregnant, and 88% had a successful delivery after pediatric IPAA. Only 5% reported severely restricted sexual function. Changes in pouch function occurred with pregnancy and persisted in 1/3 after delivery. Minimally invasive techniques may improve fertility rates but equire continued follow-up. LEVEL OF EVIDENCE: Level IV. TYPE OF STUDY: Observational study.

Pouchogram Prior to Ileostomy Reversal after Ileal Pouch-Anal Anastomosis in Pediatric Patients: Is it Useful in the Setting of Routine EUA?

PURPOSE: To determine if there is a role for routine pouchogram before ileostomy reversal after IPAA in pediatric patients. METHODS: The medical records of pediatric patients who underwent pouchogram between 2007 and 2017 prior to ileostomy reversal after IPAA at two affiliated hospitals were reviewed for concordance between exam under anesthesia (EUA) and pouchogram findings, management of abnormal pouchogram findings, and short and long-term outcomes after ileostomy reversal. Clinical notes were used to find patient-reported symptoms at the time of pouchogram. RESULTS: Sixty patients (57% female) underwent pouchogram before planned ileostomy reversal. The median time from IPAA formation to pouchogram was 60.5 days (IQR: 46-77) and median follow-up was 4 years (IQR: 1-6). Fifty-seven patients (95%) were asymptomatic prior to reversal. Of the 40 asymptomatic patients with a normal EUA, pouchogram detected one stricture (3%), but reversal proceeded as planned. In the 16 patients with strictures on EUA, pouchogram only detected six (40%). One of 50 (2%) asymptomatic patients with normal pouchogram had anastomotic dehiscence found on EUA. Despite normal pouchogram and EUA, four asymptomatic patients required subsequent diversion for pouch-related complications between 13 and 60 months after ileostomy reversal. Three patients had pelvic pain prior to pouchogram; associated symptoms included perineal pain (n = 1) hematochezia (n = 1), and tenesmus (n = 1). EUA and pouchogram were concordant in two patients (n = 1 anastomotic complication, n = 1 pouch septum) and ileostomy reversal was delayed. In the remaining symptomatic patient, pouchogram detected an anastomotic leak where EUA detected only a stricture, and this prompted a delay in reversal. Long term, none of these patients required diversion or excision of their pouch. CONCLUSION: Routine pouchogram in asymptomatic pediatric patients does not change management and can be omitted, thereby sparing patients discomfort and unnecessary radiation exposure. Pouchogram may have diagnostic value in symptomatic patients. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Study of Diagnostic Test.

Mesenchymal Hamartoma in Children: A Diagnostic Challenge.

Mesenchymal hamartoma is a benign tumor of the liver with a poorly understood pathogenesis. It is uncommon in older children, especially after 2 years of age. The signs and symptoms may be nonspecific; therefore, a high index of suspicion is required for diagnosis and treatment. We report a 5-year-old previously healthy male who presented with acute abdominal pain, fatigue, and fever. He was diagnosed with pneumonia initially and treated with antibiotics. A computed tomography (CT) scan done for evaluation of his persistent abdominal pain demonstrated a hepatic mass. Follow-up magnetic resonance imaging (MRI) of the liver demonstrated multiple serpiginous tubular-type structures, read as possible Caroli syndrome. He had a normal abdominal examination and normal biochemistries including alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, alkaline phosphatase, and alpha-fetoprotein. He was referred to our institution for second opinion. On further review of his imaging studies, the lesion was thought to be a mesenchymal hamartoma. He subsequently underwent resection of the mass. Pathology confirmed the diagnosis of mesenchymal hamartoma.

Utilization of Maneuvers to Increase Mesenteric Length Employed in Children Undergoing Ileal Pouch-Anal Anastomosis.

Background: Operative maneuvers to increase mesenteric length during ileal pouch-anal anastomosis (IPAA) are frequently utilized in adults, but limited data exist on the need for their use in children. Materials and Methods: A retrospective chart review of children (age <18) considered for IPAA creation at two affiliated tertiary referral centers from 2007 to 2017 was conducted, and patient factors, operative details, and 30-day postoperative complications were abstracted. Body mass index (BMI) was normalized to BMI percentile-for-age-and-sex and classified as underweight (BMI <5th percentile), healthy weight (5th ≤ BMI percentile <85th), or overweight/obese (BMI ≥85th percentile). Maneuvers were identified from operative notes. Univariate analysis and multivariable logistic regression were performed to determine independent factors associated with the use of maneuvers. Results: A total of 94 patients underwent attempt at IPAA creation, which was successful in 91 (97%). Fourteen (15%) of 91 patients were classified as overweight or obese. The 3 failures occurred secondary to inability to reach in 3 patients, with specific mention of patients' obesity in 2 and pouch ischemia in 1. Sixty (66%) patients required maneuvers to lengthen the mesentery. Overweight/obese patients required maneuvers more often than nonoverweight/obese patients (93% versus 61%, P = .03). There were no differences in 30-day maximum Clavien-Dindo scores between patients with and without maneuvers performed (P = .83). Being overweight/obese was an independent risk factor for requiring maneuvers (odds ratio: 9.3, 95% confidence interval: 1.1-82.8) after adjusting for age, sex, height, operative stage, and surgeon. Conclusion: Surgeons should be prepared to perform mesenteric lengthening maneuvers when operating on pediatric patients to ensure minimal tension on the IPAA, and more so when operating on obese children. Whether these maneuvers have an impact on long-term pouch function is undetermined.

Altering the Traditional Approach to Restorative Proctocolectomy After Subtotal Colectomy in Pediatric Patients.

Purpose: Restoration of intestinal continuity by ileal pouch-anal anastomosis (IPAA) following subtotal colectomy may not require a temporary, protective ileostomy. Diversion contributes to patient discomfort, cost, and additional operative risk at the time of subsequent reversal. We compared the outcomes of pediatric patients undergoing modified two-stage to three-stage IPAA after recovering from subtotal colectomy. Methods: We reviewed children (age <18) who underwent IPAA creation for ulcerative or indeterminate colitis from January 1, 2007 to December 31, 2017. Patient characteristics, operative details, 30-day complications, and postoperative length of stay (LOS) were abstracted. Total LOS for the three-stage group included both the IPAA and the ileostomy reversal operations. Univariate comparisons between patients undergoing modified two-stage and three-stage operations were performed. Results: A total of 43 patients underwent IPAA after subtotal colectomy; 32 (74%) underwent a three-stage approach, and 11 (26%) had a modified two-stage approach. Operative approach was laparoscopic in 33 (77%), planned open in 9 (21%), and converted to open in 1 (2%). Single-incision technique was used in 12 of 33 (36%) laparoscopic cases. Modified two-stage procedures had shorter total median LOS (7 days versus 9 days, P = .005). Incidence of postoperative leak, readmission, return to the operating room, and maximum 30-day Clavien-Dindo scores at the time of IPAA creation did not differ between modified two- and three-stage approaches (all P > .05). Conclusion: The modified two-stage approach to IPAA creation resulted in fewer hospital days compared to the three-stage approach. Considering the risks and patient burdens of diversion, further research is needed to assist in decisions regarding protective ileostomy after completion proctectomy with IPAA.

Assessing the Safety of Overlapping Surgery at a Children's Hospital.

IMPORTANCE: Media reports have questioned the safety of overlapping surgical procedures, and national scrutiny has underscored the necessity of single-center evaluations of its safety; however, sample sizes are likely small. We compared the safety profiles of overlapping and nonoverlapping pediatric procedures at a single children's hospital and discussed methodological considerations of the evaluation. DATA AND DESIGN: Retrospective analysis of inpatient pediatric surgical procedures (January 2013 to September 2015) at a single pediatric referral center. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure. Mixed models adjusting for Vizient-predicted risk, case-mix, and surgeon compared inpatient mortality and length of stay (LOS). RESULTS: Among 315 overlapping procedures, 256 (81.3%) were matched to 645 nonoverlapping procedures. There were 6 deaths in all. The adjusted odds ratio for mortality did not differ significantly between nonoverlapping and overlapping procedures (adjusted odds ratio = 0.94 vs overlapping; 95% CI, 0.02-48.5; P = 0.98). Wide confidence intervals were minimally improved with Bayesian methods (95% CI, 0.07-12.5). Adjusted LOS estimates were not clinically different by overlapping status (0.6% longer for nonoverlapping; 95% CI, 9.7% shorter to 12.2% longer; P = 0.91). Among the 87 overlapping procedures with the greatest overlap (≥60 min or ≥50% of operative duration), there were no deaths. CONCLUSIONS: The safety of overlapping and nonoverlapping surgical procedures did not differ at this children's center. These findings may not extrapolate to other centers. LOS or intraoperative measures may be more appropriate than mortality for safety evaluations due to low event rates for mortality.

Postoperative outcomes in vedolizumab-treated pediatric patients undergoing abdominal operations for inflammatory bowel disease.

INTRODUCTION: Recent studies have found vedolizumab to be an independent predictor of increased rates of postoperative complications and surgical site infections (SSIs) in adults with inflammatory bowel disease (IBD), but studies in the pediatric surgical population are lacking. We sought to determine the 30-day postoperative infectious complication rate among pediatric IBD patients who received vedolizumab within 12weeks of a major abdominal operation. METHODS: A retrospective chart review was performed on pediatric IBD patients who underwent an abdominal operation between 5/20/2014 and 6/1/2017. The study cohort was comprised of pediatric patients (≤18years) who received vedolizumab within 12weeks prior to their abdominal operation. The control cohort was all patients operated on for IBD during the same time on anti-TNF therapy within 12weeks of their abdominal operation. RESULTS: Thirteen pediatric patients (5 female) received vedolizumab within 12weeks of an abdominal operation and 36 patients received anti TNF therapy (20 female). There were no differences in the vedolizumab and anti-TNF therapy with regard to sex, median age of diagnosis or operation, IBD type, body mass index (BMI), smoking status, diabetes mellitus (DM), preoperative serum laboratory values, steroid or immunomodulatory use. The number of biologics previously exposed to was significantly higher in the vedolizumab treated patients (p<0.0001). There were no significant differences in operative characteristics including laparoscopic versus open surgery, construction of an anastomosis, or diversion of an anastomosis. There were also no significant differences found in 30-day postoperative complications including nonsurgical site infections (SSIs), all SSIs, small bowel obstruction (SBO)/ileus, hospital readmission, or return to the operating room (ROR). There were four RORs in total: one in the vedolizumab group was for a missed enterotomy and stoma revision; three in the anti-TNF cohort were for ileostomy revisions. CONCLUSIONS: None of the thirteen pediatric patients who received vedolizumab within 12weeks of an abdominal operation experienced a 30-day postoperative SSI or non SSI infectious complication, suggesting that vedolizumab is safe in the perioperative period for pediatric patients with IBD. Owing to the small sample size, future study, perhaps multi-institutional, will be important to confirm these findings. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Colectomy in refractory Crohn's colitis improves nutrition and reduces steroid use.

BACKGROUND: Pediatric patients with severe refractory Crohn's colitis (CC) may require total colectomy (TC) or diverting loop ileostomy (DLI). Our understanding of outcomes (postoperative complications, nutrition and restoration of intestinal continuity) is currently limited. METHODS: Pediatric patients with severe CC who underwent TC or DLI were identified. Demographics, pre and postoperative anthropometric and biochemical data, surgical complications and medication requirements were recorded. RESULTS: Twenty-seven patients (TC=22, DLI=5) with a median age of 15.0years (range 3-18) were identified, 64% male with a median follow-up of 45months (range 3-120). Mean weight and BMI improved for TC patients by 1year postoperatively - weight z-score from -1.08 to -0.54 (p=0.02), BMI z-score from -0.83 to -0.38 (p=0.04), with a non-significant height change from - 0.79 to -0.65 (p=0.07). Mean hemoglobin and albumin both also improved - 9.88g/dl to 11.76g/dl (p=0.003) and 3.44g/dl to 4.03g/dl (p=0.004) respectively. These measures did not significantly improve after DLI. Most TC patients (59%) had attempted restoration of intestinal continuity with 45% in continuity at end of follow-up. One DLI patient underwent ileostomy takedown but subsequently needed re-diversion. CONCLUSIONS: In severe CC, TC offers an opportunity to improve nutrition and growth, with a reasonable likelihood of restoring intestinal continuity. LEVEL OF EVIDENCE: Level IV - Case series.