Outcomes of pediatric pilonidal disease treatment: excision with off-midline flap reconstruction versus endoscopic pilonidal sinus treatment.

PURPOSE: Pilonidal disease (PD) is marked by chronic inflammation and frequent recurrence which can decrease quality of life. However, debate remains regarding the optimal treatment for PD in the pediatric population. This study compares two recommended treatment approaches-excision with off-midline flap reconstruction (OMF: Bascom cleft lift flap, modified Limberg flap) and minimally invasive endoscopic pilonidal sinus treatment (EPSiT). METHODS: Single-center retrospective evaluation of patients 1-21 years of age with PD who underwent either excision with OMF reconstruction or EPSiT between 10/1/2011 and 10/31/2021. Outcomes included were disease recurrence, reoperation, and wound complication rates. Comparisons were performed using Chi-square and Mann-Whitney U tests. RESULTS: 18 patients underwent excision/OMF reconstruction and 45 patients underwent EPSiT. The excision/OMF reconstruction cohort was predominantly male (44.4% vs 17.8% p = 0.028), with history of prior pilonidal infection (33.3% vs 6.7%; p = 0.006), and longer median operative time (60 min vs 17 min; p < 0.001). The excision/OMF reconstruction cohort had a higher rate of wound complications (22.2% vs 0%; p = 0.001), but lower rates of disease recurrence (5.6% vs 33.3%; p = 0.022) and reoperation (5.6% vs 31.1%; p = 0.031). CONCLUSION: In pediatric patients with PD, excision with OMF reconstruction may decrease recurrence and reoperation rates with increased operative times and wound complication rates, compared to EPSiT.

Mesenchymal STRO-1/STRO-3+ precursor cells for the treatment of chronic heart failure with reduced ejection fraction.

The heart is susceptible to proinflammatory and profibrotic responses after myocardial injury, leading to further worsening of cardiac dysfunction. Important developments in the management of heart failure with reduced ejection fraction have reduced morbidity and mortality; however, these therapies focus on optimizing cardiac function through hemodynamic and neurohormonal pathways and not by repairing the underlying cardiac injury. The potential of cell-based therapy to reverse cardiac injury has received substantial attention. Herein are examined the phase II and III studies of bone marrow-derived mesenchymal STRO-1+ or STRO-1/STRO-3+ precursor cells in patients with ischemic and nonischemic heart failure with reduced ejection fraction, addressing the safety and efficacy of cell-based therapy throughout multiple clinical trials, the optimal dose and the steps toward revolutionizing the treatment of heart failure.

Heart disease can occur due to the blockage of blood flow to the heart muscle (heart attack). This damage reduces heart function, in part because of inflammation and fibrosis (scarring). Over time, these problems lead to heart failure and death. Advances in treating heart disease focus on maintaining heart function rather than healing the heart. A cell-based treatment designed to actually repair the heart has been used with some success. In this approach, stem cells are extracted from the bone marrow of a healthy adult, processed and then injected into a patient's diseased heart. This approach is promising, but heart repair remains incomplete. This article looks at a specific type of bone marrow stem cell that has been used as a treatment for patients with heart disease. This cell treatment was recently tested in the largest such study and the first phase III clinical trial to date in the area ­ the DREAM-HF study. This article addresses the safety and best dosage of these cells and examines how this new approach of cell-based therapy might change how heart disease is treated.

Endoscopic Management of a Double Duodenal Web: A Case Report of a Rare Alimentary Anomaly.

Duodenal webs are a rare clinical entity with the presentation of a double duodenal web being exceedingly uncommon. Management of duodenal webs traditionally involves duodenal web excision with duodenoduodenostomy, which is usually performed via a laparoscopic or an open approach. We report the case of a 6-month-old child who presented with progressively worsening bilious emesis with imaging findings concerning for a duodenal web. Endoscopic evaluation was performed that identified 2 webs in the fourth portion of the duodenum. These were managed completely endoscopically with balloon dilation. Although surgery is the mainstay of treatment of duodenal webs, this patient was successfully managed by endoscopic intervention without the need for open or laparoscopic excision, which has not been previously described for double duodenal webs. This work demonstrates the safety and efficacy of endoscopic management for infants with this anomaly.

Multiple Perianal Epidermal Cysts Found in a Case of Lowe Syndrome: A Case Report and Review of the Literature.

BACKGROUND Lowe syndrome, also known as oculocerebrorenal syndrome, is a rare genetic condition caused by an X-linked mutation of the OCRL1 gene, with an estimated prevalence in the general population of approximately 1 in 500 000. It is a multisystem disorder most commonly affecting the eyes, central nervous system, and kidneys. These commonly manifest as congenital cataracts, intellectual disability, and proximal renal dysfunction (Fanconi-type). Epidermal lesions are an uncommon manifestation of this condition, and the association is not completely understood. CASE REPORT Here we present a case of a 9-year-old boy with Lowe syndrome who presented with multiple cystic masses found in the perianal region. An excision was then performed to remove the masses and found that the lesions were epidermal cysts, which are infrequently found in Lowe syndrome. After excision, the patient recovered uneventfully without complications. CONCLUSIONS While epidermal cysts are an uncommon manifestation that have been documented, our case remains unique given the location and associated symptoms of the lesions. At presentation, the constellation of pain and perianal masses was concerning for a malignant etiology. However, after diagnostic imaging was performed, these lesions were found to be epidermal cysts, an infrequent manifestation of Lowe syndrome. Few previous case reports described cystic lesions in association with Lowe syndrome, and none, to our knowledge, have described multiple symptomatic perianal lesions. This case is important to consider because epidermal cystic lesions can be found with this presentation and should be considered on differential diagnoses for dermatologic findings in Lowe syndrome patients.

A 12-Year-Old Girl with Juvenile Granulosa Cell Tumor of the Ovary, Presenting with Adolescent Hyperprolactinemia, Galactorrhea, and Amenorrhea.

BACKGROUND Juvenile-type granulosa cell tumors (JGCTs) are a rare subtype of sex cord stromal tumor with a characteristic histology that is commonly found in the first 3 decades of life. It most commonly presents with symptoms of hyperestrogenism, which may present as precocious pseudopuberty or as menstruation-related symptoms, allowing for early detection of the tumor. CASE REPORT We present the case of a 12-year-old girl who presented to her primary care provider (PCP) with secondary amenorrhea with intermittent abdominal pain, who underwent an ultrasound for further evaluation, which revealed a large incidental pelvic mass. She was admitted to the Emergency Department (ED) and had findings of galactorrhea and hyperprolactinemia on examination. Imaging studies demonstrated a large ovarian mass measuring 15.0×9.0×18.8 cm that was resected, and subsequent pathology results showed JGCT stage 1A. CONCLUSIONS Prognosis of granulosa cell tumors (GCT) largely depends on its initial size, stage at diagnosis, residual tumors after surgery, and the subtype of GCT. If the patient is of reproductive age, fertility-sparing surgical options must be considered and patients must be regularly monitored for recurrence. JGCTs can present with minimal to no symptoms of precocious puberty in young girls but may present with amenorrhea, which may be considered normal for their developmental age. Although JGCTs are rare, they are important to include in differential diagnoses of younger female patients with abdominal pain, especially if accompanied by hormonal irregularities.

Postoperative narcotic utilization in single incision laparoscopic-assisted extracorporeal appendectomy (SILEA): a single-institution retrospective review.

PURPOSE: Laparoscopic appendectomy for pediatric acute appendicitis is commonly performed by pediatric surgeons. A single incision approach has been investigated, but the lack of technical uniformity has resulted in conflicting data. We hypothesized that an initial single incision laparoscopic-assisted extracorporeal appendectomy (SILEA) approach is associated with similar complication rates as compared to the standard three-incision laparoscopic appendectomy (TILA). METHODS: Approximately 1300 laparoscopic appendectomies were retrospectively reviewed for acute appendicitis over a 5 year period. Patients were split into TILA or SILEA cohorts. Propensity score matching identified 102 matched cases in both cohorts. Case and control cohort comparisons were then analyzed. RESULTS: Successful SILEA was associated with no difference in post-operative complication rate. SILEA was associated with decreased postoperative narcotic dosage and shorter operative time than TILA. CONCLUSIONS: An initial SILEA approach is safe and associated with similar complication rates as TILA. Based on this data, the authors advocate adoption of the an initial SILEA approach for uncomplicated, freely mobile, acute appendicitis with seamless conversion to TILA if the appendix is not amendable to SILEA. LEVEL OF EVIDENCE: Level III.

Nationwide outcomes of incidental appendectomy during cholecystectomy versus cholecystectomy alone in children: a propensity score-matched analysis.

BACKGROUND: The utility of incidental appendectomy, appendectomy during another index surgery in the absence of appendicitis, has not been evaluated in the pediatric population during cholecystectomy. This study sought to compare nationwide outcomes after cholecystectomy with incidental appendectomy in children. METHODS: Patients ≤ 18 years old who underwent cholecystectomy from 2010-2014 were identified from the Nationwide Readmissions Database. A propensity score-matched analysis (PSMA) with > 40 covariates including demographics, comorbidities, and hospitalization factors was performed between those receiving cholecystectomy alone versus incidental appendectomy at the time of cholecystectomy. RESULTS: 34,390 patients underwent cholecystectomy (median age 15 [13-17] years). Laparoscopic (92%) approach was utilized most frequently, with 2% requiring conversion to open cholecystectomy. PSMA demonstrated a higher frequency of perforation or laceration of adjacent organs occurring in those receiving cholecystectomy alone during index admission. No significant differences in readmissions within 30 days or the calendar year were detected. Those undergoing cholecystectomy alone had higher overall readmission costs ($11,783 [$4942-$39,836] vs. $6,100 [$2358-$19,719] cholecystectomy with appendectomy; p = 0.010). CONCLUSION: This nationwide PSMA indicates that incidental appendectomy in pediatric cholecystectomies is not associated with higher postoperative complications, cost, or readmissions. This suggests that incidental appendectomy during cholecystectomy is safe, cost-effective, and worthy of future study. LEVEL OF EVIDENCE: Level III.

Laparoscopic-assisted Open Pyloroduodenostomy Repair of Pyloric Atresia in an Infant: A Rare Congenital Anomaly.

PURPOSE: Pyloric atresia is an uncommon congenital anomaly that may present with emesis and dehydration early in infancy. Definitive therapy consists of pyloroplasty or gastroduodenostomy depending on the subtype of atresia involved. CASE PRESENTATION: We report the case of a 2-day-old girl infant who presented with nonbilious emesis with feeds. Abdominal ultrasound and upper gastrointestinal series were performed and demonstrated a dilated, air-filled stomach with no distal air or passage of contrast. The patient was successfully treated by laparoscopic-assisted open pyloroduodenostomy of a type 2 pyloric atresia. CONCLUSION: Type 2 pyloric atresia is a rare clinical entity that can present with symptoms of gastric outlet obstruction. The patient described was treated by laparoscopic-assisted open pyloroduodenostomy, which has not been previously described for pyloric atresia. This work demonstrates an example of the safety and efficacy of laparoscopic surgery for infants with this anomaly.

An Interprofessional Senior Medical Student Preparation Course: Improvement in Knowledge and Self-Confidence Before Entering Surgical Training.

PURPOSE: Senior medical students are variably prepared to begin surgical training; and a national curriculum was established through the American College of Surgeons to better prepare senior medical students for surgical training. The purpose of our course is to prepare senior medical students to more effectively enter surgical training programs. We recently enhanced our independently developed surgical training preparation course by increasing exposure to surgical anatomy, medical physiology, surgical skills, and point-of-care ultrasound. We evaluated the impact of our interprofessional training course to increase confidence and readiness among senior medical students entering surgical training. METHODS: The course focused on pre- and post-operative patient care, surgical anatomy, human physiology, and bedside ultrasound. Didactic lectures in anatomy, human physiology, and bedside ultrasound were provided prior to all hands-on simulated patient care sessions and mock surgical procedures. To evaluate our interprofessional curriculum, we administered pre- and post-course surveys, pre- and post-course knowledge tests, and a final surgical anatomy laboratory practical examination to 22 senior medical students who were enrolled in the course. All students created a final surgical anatomy presentation. RESULTS: The students demonstrated a 100% pass rate in surgical anatomy. The knowledge test, which included assessment of knowledge on perioperative surgical decision making, human physiology, and bedside ultrasound, demonstrated an average improvement of 10%. Statistically significant improvements in median confidence values were identified in 10 of 32 surveyed categories, including surgical skills (p < 0.05); 84% of student goals for the course were achieved. The medical students' surveys confirmed increased confidence related to the use of point-of-care ultrasound, teamwork experience, and basic surgical skills through small group interactive seminars and surgical simulation exercises. CONCLUSION: Our preparation for surgical training course resulted in high student satisfaction and demonstrated an increased sense of confidence to begin surgical training. The 10% improvement in medical student knowledge, as evaluated by a written examination, and the significant improvement in confidence level self-assessment scores confirms this surgery preparation course for senior medical students successfully achieved the desired goals of the course.

B-cell posttransplant lymphoproliferative disorder isolated to the central nervous system is Epstein-Barr virus positive and lacks p53 and Myc expression by immunohistochemistry.

In this retrospective study from one institution, we performed a clinicopathological study of a cohort of patients with posttransplant lymphoproliferative disorder (PTLD) confined to the central nervous system. We also identified a comparison cohort of patients with de novo primary diffuse large B-cell lymphoma of the central nervous system. We performed a detailed morphologic review, evaluated Epstein-Barr virus (EBV) by in situ hybridization, and interpreted a panel of immunohistochemical stains in a subset of cases including Hans classification markers (CD10, BCL6, MUM1), p53, CD30, Myc, and BCL2. All 17 of the posttransplant and none of 11 de novo cases were EBV positive (P < .005). Morphologic patterns identified in the PTLD cases were monomorphic diffuse large B-cell lymphoma pattern (10 patients) and "T-cell-rich" pattern (7 patients). The monomorphic posttransplant cases were more likely to be Myc negative (P = .015) and CD30 positive (P < .005) than the de novo cases, and showed a similarly low rate of p53 positivity by immunohistochemistry. No prognostic factors for overall survival were identified. Central nervous system PTLD is EBV positive, typically lacks p53 and Myc expression by immunohistochemistry, and can present with numerous background T lymphocytes.