Multicenter Assessment of Cryoanalgesia Use in Minimally Invasive Repair of Pectus Excavatum: A 20-center Retrospective Cohort Study.

OBJECTIVE: To assess the clinical implications of cryoanalgesia for pain management in children undergoing minimally invasive repair of pectus excavatum (MIRPE). BACKGROUND: MIRPE entails significant pain management challenges, often requiring high postoperative opioid use. Cryoanalgesia, which blocks pain signals by temporarily ablating intercostal nerves, has been recently utilized as an analgesic adjunct. We hypothesized that the use of cryoanalgesia during MIRPE would decrease postoperative opioid use and length of stay (LOS). MATERIALS AND METHODS: A multicenter retrospective cohort study of 20 US children's hospitals was conducted of children (age below 18 years) undergoing MIRPE from January 1, 2014, to August 1, 2019. Differences in total postoperative, inpatient, oral morphine equivalents per kilogram, and 30-day LOS between patients who received cryoanalgesia versus those who did not were assessed using bivariate and multivariable analysis. P value <0.05 is considered significant. RESULTS: Of 898 patients, 136 (15%) received cryoanalgesia. Groups were similar by age, sex, body mass index, comorbidities, and Haller index. Receipt of cryoanalgesia was associated with lower oral morphine equivalents per kilogram (risk ratio=0.43, 95% confidence interval: 0.33-0.57) and a shorter LOS (risk ratio=0.66, 95% confidence interval: 0.50-0.87). Complications were similar between groups (29.8% vs 22.1, P =0.07), including a similar rate of emergency department visit, readmission, and/or reoperation. CONCLUSIONS: Use of cryoanalgesia during MIRPE appears to be effective in lowering postoperative opioid requirements and LOS without increasing complication rates. With the exception of preoperative gabapentin, other adjuncts appear to increase and/or be ineffective at reducing opioid utilization. Cryoanalgesia should be considered for patients undergoing this surgery.

Evaluation of Postoperative Outcomes After Enterostomy Closure in Low Body Weight Infants: A Multi-Center Retrospective Analysis.

BACKGROUND: The minimum weight for enterostomy closure (EC) in infants remains debated with the current acceptable cut-off of >2 kg. As enterostomy-related complications or high enterostomy output (>30cc/kg/d) may prohibit a premature infant from reaching 2 kg, additional data is needed to evaluate the safety of EC in infants <2 kg. The objective of this study was to evaluate postoperative outcomes in low body weight (<2 kg) infants undergoing EC compared to larger infants. METHODS: We performed a multi-center retrospective analysis from 1/1/2012-12/31/2022 of all infants (age <1 year) who were <4 kg at time of EC. Primary outcomes included postoperative complications and 30-day mortality. Non-parametric analysis was performed using the Kruskal-Wallis one-way analysis of variance and chi-square tests. Univariable logistic regression was performed to identify factors associated with postoperative complications. RESULTS: Of 92 infants, 15 infants (16.3%) underwent EC at <2 kg, 16 (17.4%) at 2-2.49 kg, 31 (33.7%) at 2.5-2.99 kg, and 30 (32.6%) at ≥3 kg. Infants <2 kg at time of EC exhibited higher rates of hyperbilirubinemia (P = .030), neurologic comorbidities (P = .030), and high enterostomy output (P = .041). There was no difference in postoperative complications (P = .460) or 30-day mortality (P = .460) between the <2 kg group and larger weight groups. Low body weight was not associated with an increased risk for developing a postoperative complication (OR: 1.001, 95% CI: 1.001-1.001; P = .032). CONCLUSION: Our findings suggest that EC in infants <2 kg may be safe with comparable postoperative outcomes to larger weight infants. Thus, the timing of EC should be based on the infant's physiologic status, in contrast to a predetermined minimum weight cut-off.

Perioperative Pain Management in Cleft Lip and Palate Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Studies.

BACKGROUND: Developing effective strategies to manage perioperative pain remains a focus of cleft care. The present study's purpose was to systematically review perioperative pain control strategies for cleft lip and palate repair. METHODS: A systematic review and meta-analysis of randomized controlled trials was performed. Primary outcomes included pain scale scores and time to analgesia failure. Cohen d normalized effect size permitted comparison between studies, and a fixed-effects model was used for analysis. I2 and Q-statistic p values were calculated. RESULTS: Twenty-three studies were included: eight of 23 studies provided data for meta-analytic comparison. Meta-analyses evaluated the efficacy of intraoperative nerve blocks on postoperative pain management. Meta-analysis included a total of 475 treatment and control patients. Cleft lip studies demonstrated significantly improved pain control with a nerve block versus placebo by means of pain scale scores ( p < 0.001) and time to analgesia failure ( p < 0.001). Measurement of effect size over time demonstrated statistically significant pain relief with local anesthetic. Palatoplasty studies showed significantly improved time to analgesia failure ( p < 0.005) with maxillary and palatal nerve blocks. Multiple studies demonstrated an opioid-sparing effect with the use of local anesthetics and other nonopioid medications. Techniques for nerve blocks in cleft lip and palate surgery are reviewed. CONCLUSIONS: The present systematic review and meta-analysis of randomized controlled studies demonstrates that intraoperative nerve blocks for cleft lip and palate surgery provide effective pain control. Opioid-sparing effects were appreciated in multiple studies. Intraoperative nerve blocks should be considered in all cases of cleft lip and palate repair to improve postoperative pain management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Optimizing pediatric histrelin implantation to improve success rates in clinic without sedation.

OBJECTIVES: The purpose of this study was to review our success rate performing the histrelin implant procedure in clinic without sedation. METHODS: A retrospective study was performed for histrelin implant procedures done at our institution from 2008 to 2020. Wilcoxon rank-sum test or Fisher's exact test was utilized to identify significant differences (p<0.05). RESULTS: A total of 73 patients underwent 184 histrelin implant procedures from 2008 to 2020. In the past few years, there has been a decrease in procedures for precocious puberty and an increase for gender dysphoria. The majority of procedures were performed in clinic without sedation (82%). The only risk factor associated with requiring sedation was younger age (median 9 vs. 10 years; p<0.003). Complications (i.e. implant fracture or need for counter-incision) were noted in 10 of the procedures (5%). The only risk factor identified for a procedural complication during implant removal/replacement was interval time from insertion (21 vs. 13 months; p<0.01). The only documented wound problem reported was dermatitis in 1 patient (no suture granuloma, dehiscence, or implant extravasation). CONCLUSIONS: Procedural refinements and distraction therapy have enabled us to perform the majority of procedures in clinic without sedation. In our experience, procedural difficulty and complications appear to increase with prolonged implant duration. Histrelin implantation is increasingly being performed for gender dysphoria.

The Effect of Functional Nasal Surgery on Olfactory Function.

BACKGROUND: Functional and aesthetic nasal operations are some of the most common plastic surgery procedures performed in the United States. The purpose of the study was to evaluate the effects of septoplasty, septorhinoplasty, and rhinoplasty procedures on postoperative olfactory function and their relationship to nasal airflow and quality of life. METHODS: A systematic review and meta-analysis was performed evaluating olfactory function following nasal surgery. Preoperative and postoperative values for olfaction, nasal airflow, and quality of life/nasal symptoms were analyzed. The effect size was calculated from each study and used for meta-analysis. As studies evaluated patients at different points in the postoperative period, the latest time point reported by each study was used in the meta-analysis. The 95 percent confidence interval of the effect size was calculated for each study. Study quality was assessed using the Jadad and Methodological Index for Nonrandomized Studies instruments. All included studies were Level of Evidence II. RESULTS: There were 25 included studies. Following nasal surgery, patients experienced significant improvements in olfaction (p < 0.001), nasal airflow (p < 0.001), and quality of life/nasal symptoms (p < 0.001). Patients often experienced a transient decrease in olfaction immediately after surgery, followed by improvement postoperatively. Preoperative olfactory dysfunction rates were low and postoperative dysfunction was equally low. Olfaction improvement was directly correlated with improvement in nasal airflow and quality of life. CONCLUSIONS: Functional and aesthetic nasal operations appear to significantly improve olfaction, which is directly correlated with nasal airflow. Some studies report a transient worsening of these measures in the immediate postoperative period, which subsequently improved at later time points.

Anaphylactic Reaction to Lymphazurin 1% during Breast Reconstruction Surgery: An Uncommon but Serious Complication.

Lymphazurin 1% (isosulfan blue dye) is the most frequently used blue dye in the United States, and it is commonly used for sentinel node biopsy in breast cancer patients. Although cases of allergic reaction to lymphazurin have been reported in the general surgery literature, to our knowledge, no cases of an adverse reaction to isosulfan blue have been reported in the plastic surgery literature. We describe a case of an intraoperative biphasic anaphylactic reaction to isosulfan blue in a female patient undergoing bilateral mastectomy and immediate bilateral DIEP breast reconstruction. The severity of her anaphylactic reaction required that we stop flap dissection and abort the reconstruction. Although an allergic reaction is uncommon, recognizing the signs of an acute hypersensitivity reaction is critical to good outcomes in these situations. Given the volume of combined breast oncologic and breast reconstruction surgeries and the increasing number of vascularized lymph node transfer and lymphovenous anastomosis performed annually, it is essential for the plastic surgeon to be cognizant of this rare hypersensitivity reaction.