Utility of Indocyanine Green for Sentinel Lymph Node Biopsy in Pediatric Sarcoma and Melanoma.

BACKGROUND: Indocyanine green (ICG) is a fluorescent dye with increasing use for adult sentinel lymph node biopsy (SLNB). The utility of ICG in pediatric oncology remains understudied. We aim to describe our experience using ICG for SLNB in pediatrics versus standard blue dye. METHODS: A retrospective review of pediatric patients with melanoma or sarcoma who underwent SLNB with technetium plus ICG or blue dye from 2014 to 2023 at a large academic children's hospital was conducted. RESULTS: Twenty-four patients were included; 58.3% were male with median age 13 years (range 4-21 years). The majority had a melanocytic tumor (91.7%) and 8.3% had sarcoma. All patients received technetium with concomitant blue dye (62.5%) or ICG (37.5%). ICG more reliably identified radioactive SLNs, compared to blue dye (mean 100% vs 78.3 ± 8.3%, p = 0.03). There was no significant difference in median operative time (ICG 82 min [68-203] vs blue dye 93 min [78-105], p = 0.84). Seven patients had positive SLNs (29.2%), with recurrence in 2 patients (8.3%) and 1 death (4.2%). There were no adverse events. CONCLUSION: ICG-directed SLNB in children is a safe and effective alternative to blue dye. Use of ICG did not add to operative time, and more often identified sentinel nodes versus blue dye. TYPE OF STUDY: Original Research Article, Retrospective Comparative Study. LEVEL OF EVIDENCE: III.

Operative technique and management of central foot polydactyly.

Polydactyly is characterized by the manifestation of supernumerary digits in the hands and feet. It can be isolated or associated with a genetic syndrome. Based on the location of duplication, it is categorized as preaxial, postaxial, or central. The latter is a rare abnormality, comprising approximately 6% of cases. There is a paucity in the literature regarding this congenital anomaly and its overall management. Nonoperative treatment is generally unsuccessful in managing symptoms such as excessive width, abnormal digit alignment, and growth. Though surgical management addresses the individual patient's needs, general goals include preservation of digits with the greatest axial alignment, resection of symptomatic digits, alignment correction of the remaining great toe, stabilization of the soft tissues, and adequate soft tissue coverage. This study aims to delineate effective operative techniques for central foot polydactyly. Two patient cases are discussed, providing a framework for pre and postoperative care, complications, and outcomes. The techniques detailed offer a straightforward, efficacious, and safe method to reconstruct central foot polydactyly, returning form and function to the patient.

Hyperbaric Oxygen Therapy for Large Composite Grafts: An Alternative in Pediatric Facial Reconstruction.

BACKGROUND: Management of pediatric facial defects can be challenging, as reattachment of large composite grafts is usually unsuccessful. Hyperbaric oxygen therapy (HBO) has been researched to augment composite graft survival, but clinical use for this application remains anecdotal. The authors present their successful experience managing select cases with large composite grafts and HBO as an adjunct. METHODS: A retrospective chart review identified children presenting with facial defects and managed operatively with large composite grafts (≥1.5 × 1.5 cm) and HBO therapy. Records were reviewed for defect characteristics, management details, and outcomes at last follow-up. RESULTS: Nine children (avg. 8.4 years, range 1.6-15.1) presented with ear or nose defects secondary to dog bites (n=7), falls (n=1), or congenital causes (n=1). Three experienced ear amputations, and six suffered nasal avulsions of varying degrees. All avulsed ears were reattached. Three cases of nose avulsions were reattached; the other three underwent secondary reconstruction with composite ear grafts. HBO was initiated immediately and continued for 8-10 days. All grafts survived at least 80% with no postoperative complications. At last follow-up (avg. 30.1 months; 0.8-63.9), all patients demonstrated good cosmetic results with minimal residual deformity. CONCLUSION: When reconstruction of pediatric facial defects warrants a large chondrocutaneous graft, immediate postoperative HBO therapy can increase survival. Particularly when reattaching amputated segments, if successful, this approach offers an anatomically ideal result without donor site morbidity. If unsuccessful, it does not "burn bridges" and decreases the extent of secondary reconstruction. The authors present their HBO protocol along with a review of available literature.

Management of Paronychia in Patients With Apert Syndrome.

Apert syndrome is a complex congenital syndrome that includes bicoronal craniosynostosis, craniofacial dysmorphologies, cleft palate, hearing loss, spina bifida occulta, cardiac anomalies, and affects the upper and lower extremities-producing complex syndactyly in these patients. Management of the hands yields several challenges and mandates close follow-up to balance repair of complex polysyndactyly with other pressing interventions, such as posterior cranial vault distraction and surgical management of the airway. Our goals of therapy for the hands are to preserve 10 digits, provide sufficient soft tissue coverage, optimize hand function, and minimize the number of surgical interventions. Ideally, surgical management of the hand differences occurs between the ages of 9 months and 2 years, to optimize neurocognitive development. In complex syndactyly observed in patients with Apert syndrome, there are broad, conjoined nail plates that overlie the fused digits, and paronychia occurs frequently. Suppurative infections can delay definitive surgical intervention for the patient's complex syndactyly, and resolution of paronychia is critical. This study aims to propose an effective and safe technique to manage paronychia when it occurs in patients with Apert complex syndactyly and to mitigate the length of delay to definitive polysyndactyly reconstruction. In the context of these patients' need for multiple surgical interventions within the first few years of life, this strategy for preventing or mitigating paronychia can play an important role in streamlining their complex surgical management while avoiding multiple cancellations.

Use of intraoperative nuclear imaging leads to decreased anesthesia time and real-time confirmation of lesion removal.

BACKGROUND: Lymphatic mapping to guide sentinel lymph node biopsy (SLNB) typically requires lymphoscintigraphy prior to surgery. In young pediatric patients, this process often requires intubation in the nuclear medicine suite followed by transport to the operating room (OR). METHODS: We reviewed 14 pediatric cases in which a portable nuclear imaging camera was utilized to perform the entirety of the SLNB in the OR. RESULTS AND CONCLUSION: This method, utilizing intraoperative nuclear imaging, helped to confirm removal of the sentinel lymph node in real time, decreased anesthesia time, and avoided transport of a sedated or intubated child. LEVEL OF EVIDENCE: III.

Alveolar reconstruction in cleft patients: decreased morbidity and improved outcomes with supplemental demineralized bone matrix and cancellous allograft.

BACKGROUND: The safety and efficacy of supplemental allograft combined with iliac crest autograft as a treatment for cleft alveolus defects is poorly characterized. The authors report the safety and efficacy of supplemental demineralized bone matrix and cancellous allograft with iliac crest bone autograft in cleft alveolar bone defects. METHODS: A retrospective review of one institution's experience with cleft alveolar bone defects treated with traditional open iliac crest bone graft alone (group 1) or minimal access iliac crest bone graft plus demineralized bone matrix and cancellous allograft (group 2) was performed. All patients (n = 36) were treated with alveolar fistula repair with primary closure. RESULTS: Twenty-two patients [17 unilateral and five bilateral clefts (n = 27)] were treated in group 1 and 14 [six unilateral clefts and eight bilateral clefts (n = 22)] in group 2. The average operative time per alveolus was 147 minutes in group 1 and 111 minutes in group 2. Average engraftment (Enemark Scale) was 1.96 in group 1 and 1.20 in group 2. In group 1, canine eruption was complete in 71.4 percent, partial in 21.4 percent, and unerupted in 3.5 percent; in group 2, canine eruption was complete in 22 percent, partial in 55 percent, and unerupted in 18 percent. Bone graft extrusion occurred in six patients in group 1. There were no wound infections or deaths. CONCLUSIONS: The addition of supplemental demineralized bone matrix and cancellous allograft in cleft alveolar defects is safe and effective. The authors' allograft supplemental surgical technique is associated with low morbidity, shorter operative times, and higher rates of bone graft survival.

A prospective assessment of diagnostic efficacy of blind protective bronchial brushings compared to bronchoscope-assisted lavage, bronchoscope-directed brushings, and blind endotracheal aspirates in ventilator-associated pneumonia.

BACKGROUND: The purpose of this study is to compare techniques for the diagnosis of suspected ventilator-associated pneumonia in the trauma patient. Per the literature, bronchoscope protected brushings and bronchoalveolar lavage were set as the standards for comparison because of their high specificity and sensitivity. We hypothesized that blind protected brushings were equivalent to bronchoscope-directed techniques and that endotracheal aspirates (ETA) were not. METHODS: With informed consent, 90 trauma patients with two or more of the following were accepted into the study: 48 hours or more on the ventilator, new or increasing infiltrate on chest radiograph, excess or purulent secretions, suspected aspiration, temperature of 38.5 degrees C or above, white blood cell count greater than or equal to 12,000/mm3, and respiratory distress. Four samplings were performed on each patient using bronchoscope-assisted and nonbronchoscopic techniques. Each patient had cultures obtained by and significances quantified as follows: ETA, moderate/many/abundant; bronchoscope-directed protected brushings (BDPB), 103 colony-forming units [CFU]/mL; blind protected brushing via endotracheal tube (BPB), 103 CFU/mL; and bronchoscopic bronchoalveolar lavage (BAL), 104 CFU/mL. Quantitative cultures were obtained and compared for the following pathogens: gram-positive cocci, gram-positive rods, gram-negative cocci, gram-negative rods, anaerobic bacteria, and yeast. An assessment of agreement for cultured pathogens between the sampling modalities was completed using kappa (kappa) analysis, and significance was set at p < or = 0.05. RESULTS: With patients used as their own controls, Gram's stain and pathogens cultured from the various sampling techniques were compared for agreement by kappa analysis. BDPB and BAL were set as the "gold standards" for comparison against each other and against the BPB and ETA. Kappa analysis was used to measure the strength of agreement for these findings; individual values from the comparisons of Gram's stain were then averaged for descriptive purposes of the data. Most kappa values were associated with a statistically significant value of p < 0.05. The greatest strength of agreement was found to be moderate comparing Gram's stain results of BPB and BDPB (kappa = 0.467), ETA and BAL (kappa = 0.535), and BPB and BAL (kappa = 0.547). Fair kappa values were shown in comparing Gram's stain results of ETA and BDPB (kappa = 0.382) and BAL and BDPB (kappa = 0.390). CONCLUSION: A quantitative analysis of bacteriologic cultures obtained by four standard sampling techniques has demonstrated with statistical significance that no difference exists between modality of sampling in reliability or in obtaining clinically significant pathogens. In reviewing the literature, this study is the first assessment of agreement for cultured pathogens between the four different sampling modalities and the largest to assess the efficacy of the blind protected brush technique.