The impact of surgical strategies on outcomes for pediatric chronic pancreatitis.

PURPOSE: To review our institutional experience in the surgical treatment of pediatric chronic pancreatitis (CP) and evaluate predictors of long-term pain relief. METHODS: Outcomes of patients ≤21 years surgically treated for CP in a single institution from 1995 to 2014 were evaluated. RESULTS: Twenty patients underwent surgery for CP at a median of 16.6 years (IQR 10.7-20.6 years). The most common etiology was pancreas divisum (n = 7; 35%). Therapeutic endoscopy was the first-line treatment in 17 cases (85%). Surgical procedures included: longitudinal pancreaticojejunostomy (n = 4, 20%), pancreatectomy (n = 9, 45%), total pancreatectomy with islet autotransplantation (n = 2; 10%), sphincteroplasty (n = 2, 10%) and pseudocyst drainage (n = 3, 15%). At a median follow-up of 5.3 years (IQR 4.2-5.3), twelve patients (63.2%) were pain free and five (26.3%) were insulin dependent. In univariate analysis, previous surgical procedure or >5 endoscopic treatments were associated with a lower likelihood of pain relief (OR 0.06; 95% CI 0.006-0.57; OR 0.07; 95%, CI 0.01-0.89). However, these associations were not present in multivariate analysis. CONCLUSION: In children with CP, the step-up practice including a limited trial of endoscopic interventions followed by surgery tailored to anatomical abnormalities and gene mutation status is effective in ensuring long-term pain relief and preserving pancreatic function.

Laparoscopic versus open inguinal hernia repair in children ≤3: a randomized controlled trial.

PURPOSE: Laparoscopy is being increasingly applied to pediatric inguinal hernia repair. In younger children, however, open repair remains preferred due to concerns related to anesthesia and technical challenges. We sought to assess outcomes after laparoscopic and open inguinal hernia repair in children less than or equal to 3 years. METHODS: A prospective, single-blind, parallel group randomized controlled trial was conducted at three clinical sites. Children ≤3 years of age with reducible unilateral or bilateral inguinal hernias were randomized to laparoscopic herniorrhaphy (LH) or open herniorrhaphy (OH). The primary outcome was the number of acetaminophen doses. Secondary outcomes included operative time, complications, and parent/caregiver satisfaction scores. RESULTS: Forty-one patients were randomized to unilateral OH (n = 10), unilateral LH (n = 17), bilateral OH (n = 5) and bilateral LH (n = 9). Acetaminophen doses, LOS, complications, and parent/caregiver scores did not differ among groups. Laparoscopic unilateral hernia repair demonstrated shorter operative time, a consistent finding for overall laparoscopic repair in univariate (p = 0.003) and multivariate (p = 0.010) analysis. No cases of testicular atrophy were documented at 2 (SD = 2.7) years. CONCLUSION: Children ≤3 years of age in our cohort safely underwent LH with similar pain scores, complications, and recurrence as OH. Parents and caregivers report high satisfaction with both techniques.

Hydrogen sulfide [corrected] increases survival during sepsis: protective effect of CHOP inhibition.

Sepsis is a major cause of mortality, and dysregulation of the immune response plays a central role in this syndrome. H2S, a recently discovered gaso-transmitter, is endogenously generated by many cell types, regulating a number of physiologic processes and pathophysiologic conditions. We report that H2S increased survival after experimental sepsis induced by cecal ligation and puncture (CLP) in mice. Exogenous H2S decreased the systemic inflammatory response, reduced apoptosis in the spleen, and accelerated bacterial eradication. We found that C/EBP homologous protein 10 (CHOP), a mediator of the endoplasmic reticulum stress response, was elevated in several organs after CLP, and its expression was inhibited by H2S treatment. Using CHOP-knockout (KO) mice, we demonstrated for the first time, to our knowledge, that genetic deletion of Chop increased survival after LPS injection or CLP. CHOP-KO mice displayed diminished splenic caspase-3 activation and apoptosis, decreased cytokine production, and augmented bacterial clearance. Furthermore, septic CHOP-KO mice treated with H2S showed no additive survival benefit compared with septic CHOP-KO mice. Finally, we showed that H2S inhibited CHOP expression in macrophages by a mechanism involving Nrf2 activation. In conclusion, our findings show a protective effect of H2S treatment afforded, at least partially, by inhibition of CHOP expression. The data reveal a major negative role for the transcription factor CHOP in overall survival during sepsis and suggest a new target for clinical intervention, as well potential strategies for treatment.

Pancreatic surgery for tumors in children and adolescents.

PURPOSE: Pancreatic neoplasms are uncommon in children. This study sought to analyze the clinical and pathological features of surgically resected pancreatic tumors in children and discuss management strategies. METHODS: We conducted a retrospective review of patients ≤21 years with pancreatic neoplasms who underwent surgery at a single institution between 1995 and 2015. RESULTS: Nineteen patients were identified with a median age at operation of 16.6 years (IQR 13.5-18.9). The most common histology was solid pseudopapillary neoplasm (SPN) (n = 13), followed by pancreatic neuroendocrine tumor (n = 3), serous cystadenoma (n = 2) and pancreatoblastoma (n = 1). Operative procedures included formal pancreatectomy (n = 17), enucleation (n = 1) and central pancreatectomy (n = 1). SPNs were noninvasive in all but one case with perineural, vascular and lymph node involvement. Seventeen patients (89.5 %) are currently alive and disease free at a median follow-up of 5.7 (IQR 3.7-10.9) years. Two patients died: one with metastatic insulinoma and another with SPN who developed peritoneal carcinomatosis secondary to a concurrent rectal adenocarcinoma. CONCLUSIONS: Pediatric pancreatic tumors are a heterogeneous group of neoplastic lesions for which surgery can be curative. SPN is the most common histology, is characterized by low malignant potential and in selected cases can be safely and effectively treated with a tissue-sparing resection and minimally invasive approach.

A nipple-valve technique for ureteroneocystostomy in pediatric kidney transplantation.

The ureteroneocystostomy in kidney transplantation can be performed with a variety of techniques. Over a 20-yr period, we utilized a technique of nipple-valve ureteroneocystostomy for the pediatric kidney transplants performed at our institution. The distal ureter is everted upon itself and anchored in place with four interrupted sutures to create a nipple valve, which is then inserted into the bladder and sewn mucosa-to-mucosa with the same sutures. The muscularis layer is closed around the ureter without tunneling and without routine ureteral stenting. After 109 transplants, patient survival was 97.2, 97.2, and 86.9% at one, five, and 10 yr, respectively. Graft survival was 91.7, 71.7, and 53.9% at one, five, and 10 yr, respectively. The most common cause of graft loss was acute or chronic rejection, seen in 75% of those experiencing graft loss. Two patients (1.8%) developed pyelonephritis in the transplanted kidney. Nipple-valve ureteroneocystostomy in pediatric kidney transplantation is a safe and simple method for performing the ureterovesical anastomosis with a low rate of pyelonephritis after transplantation.

Minimally invasive repair of pectus excavatum: analyzing contemporary practice in 50 ACS NSQIP-pediatric institutions.

BACKGROUND: Minimally invasive repair of pectus excavatum (MIRPE) is a well-established procedure. However, morbidity rate varies widely among institutions, and the incidence of major complications remains unknown. STUDY DESIGN: The American College of Surgeons 2012 National Surgical Quality Improvement Program-Pediatric (NSQIP-P) participant user file was utilized to identify patients who underwent MIRPE at 50 participant institutions. Outcomes of interest were overall 30-day morbidity, hospital readmission, and reoperation. RESULTS: Chest wall repair designated MIRPE accounted for 0.6% (n = 264) of all surgical cases included in the NSQIP-P database in 2012. The median age at surgical repair was 15.2 years. Thoracoscopy was used in 83.7% of cases. No mediastinal injuries or perioperative blood transfusions were identified. The 30-day readmission rate was 3.8%. Three patients (1.1%) required re-operation due to the following complications: superficial site infection, bar displacement and pneumothorax. The overall morbidity was 3.8% with no incidences of mortality. CONCLUSIONS: This analysis of a large prospective multicenter dataset demonstrates that major complications following MIRPE are uncommon in contemporary practice. Wound infection is the most common complication and the main cause of hospital readmission. Targeted quality improvement initiative should be focused on perioperative strategy to further reduce wound occurrences and hospital readmission.

Do prehospital criteria optimally assign injured children to the appropriate level of trauma team activation and emergency department disposition at a level I pediatric trauma center?

PURPOSE: To examine the association of prehospital criteria with the appropriate level of trauma team activation (TTA) and emergency department (ED) disposition among injured children at a level I pediatric trauma center. METHODS: Injured children younger than 15 years and transported by emergency medical services (EMS) from the scene of injury between January 1, 2008 and December 31, 2011 were identified using the institution's trauma registry. Logistic regression was used to study the main outcomes of interest, full TTA (FTTA) and ED disposition. RESULTS: Out of 3,213 children, 1,991 were eligible and analyzed. Only 279 children initiated the FTTA and 73.9% were admitted. Having a chest injury, abnormal heart rate or Glasgow Coma Scale less than 9 (GCSLT9) in the field was associated with higher odds of initiating the FTTA (odds ratio [OR] = 3.33, 95% confidence interval [CI] 1.54-7.20; OR = 2.59, CI 1.15-5.79 and OR = 2.67, CI 1.14-6.22, respectively). Children with the criteria above in addition to abdominal injury were more likely to be discharged to the ICU, OR or morgue compared to those without them. CONCLUSION: Children with GCSLT9, abnormal heart rate, chest and abdominal injury showed a strong association with FTTA and higher resource utilization.

The anatomic pattern of biliary atresia identified at time of Kasai hepatoportoenterostomy and early postoperative clearance of jaundice are significant predictors of transplant-free survival.

OBJECTIVE: The goals of this study were to describe the clinical and anatomic features of infants undergoing Kasai portoenterostomy (KPE) for biliary atresia (BA) and to examine associations between these parameters and outcomes. METHODS: Infants enrolled in the prospective Childhood Liver Disease Research and Education Network, who underwent KPE were studied. Patients enrolled in a blinded, interventional trial were excluded from survival analysis. Primary endpoints were successful surgical drainage (total bilirubin less than 2 mg/dL within the first 3 months), transplant-free survival (Kaplan-Meier), and time to transplant/death (Cox regression). RESULTS: KPE was performed in 244 infants (54% female; mean age: 65 ± 29 days). Transplant-free survival was 53.7% and 46.7% at 1 and 2 years post-KPE. The risk of transplant/death was significantly lower in the 45.6% of patients who achieved successful bile drainage within 3 months post-KPE (HR: 0.08, P < 0.001). The risk of transplant/death was increased in patients with porta hepatis atresia (Ohi type II and III vs type I; HR: 2.03, P = 0.030), nonpatent common bile duct (Ohi subtype: b, c, and d vs a; HR: 4.31, P = 0.022), BA splenic malformation syndrome (HR: 1.92, P = 0.025), ascites > 20 mL (HR: = 1.90, P = 0.0230), nodular liver appearance compared to firm (HR: = 1.61, P = 0.008), and age at KPE ≥ 75 days (HR: 1.73, P < 0.002). Outcome was not associated with gestational age, gender, race, ethnicity, or extent of porta hepatis dissection. CONCLUSION: Anatomic pattern of BA, BASM, presence of ascites and nodular liver appearance at KPE, and early postoperative jaundice clearance are significant predictors of transplant-free survival.

Increasing severity of pectus excavatum is associated with reduced pulmonary function.

OBJECTIVE: To determine whether pulmonary function decreases as a function of severity of pectus excavatum, and whether reduced function is restrictive or obstructive in nature in a large multicenter study. STUDY DESIGN: We evaluated preoperative spirometry data in 310 patients and lung volumes in 218 patients aged 6 to 21 years at 11 North American centers. We modeled the impact of the severity of deformity (based on the Haller index) on pulmonary function. RESULTS: The percentages of patients with abnormal forced vital capacity (FVC), forced expiratory volume in 1 second (FEV(1)), forced expiratory flow from 25% exhalation to 75% exhalation, and total lung capacity findings increased with increasing Haller index score. Less than 2% of patients demonstrated an obstructive pattern (FEV(1)/FVC <67%), and 14.5% demonstrated a restrictive pattern (FVC and FEV(1) <80% predicted; FEV(1)/FVC >80%). Patients with a Haller index of 7 are >4 times more likely to have an FVC of ≤80% than those with a Haller index of 4, and are also 4 times more likely to exhibit a restrictive pulmonary pattern. CONCLUSIONS: Among patients presenting for surgical repair of pectus excavatum, those with more severe deformities have a much higher likelihood of decreased pulmonary function with a restrictive pulmonary pattern.

The Agency for Healthcare Research and Quality (AHRQ) pediatric quality indicators (PDIs): accidental puncture or laceration during surgery in children.

CONTEXT: The Agency for Healthcare Research and Quality (AHRQ) pediatric quality indicators (PDIs) are measures designed to evaluate the quality of pediatric healthcare. They specifically focus on adverse events that are potentially avoidable, including complications and iatrogenic events. PDI 1 refers to accidental puncture or laceration. OBJECTIVE: To determine risk factors and outcomes associated with PDI 1 in a population of pediatric surgical patients. DESIGN, SETTING, AND PATIENTS: The Nationwide Inpatient Sample and Kids Inpatient Database were used to identify hospitalized pediatric surgical patients in the United States (age: 0-18) from 1988 to 2005. The data from these 1,939,540 patients was linked to the AHRQ PDIs using AHRQ WinQI software, and 7,033 pediatric patients with PDI 1 were identified. A 1:3 matched case control design was implemented with 6,459 cases (patients with PDI 1) and 19,377 controls (patients without PDI 1) matched on age, race, gender, and hospital ID. Cases and controls were stratified into procedure categories based on diagnosis related group procedure codes. MAIN OUTCOME MEASURES: To examine the relationship between PDI 1 and procedure category, as well as the outcomes of in-hospital mortality, length of stay, and total hospital charges for cases compared with controls. RESULTS: Of the 4,627 patients with PDI 1 stratified into procedure categories, the highest proportion of PDI 1 cases occurred in the gastrointestinal (30.19%), cardiothoracic (19.6%), and the orthopedic (11.13%) categories. Logistic regression analysis for PDI 1, controlling for admission type and insurance status, revealed a statistically significant higher odds of PDI 1 in the gynecology (OR: 1.69, P < 0.001) and transplant (OR: 1.45, P: 0.026) procedure categories. Multivariable regression analysis revealed patients with PDI 1 were more likely to die (OR: 1.91, P < 0.001), had a 4.81 day longer length of stay (95% CI: 4.26-5.36, P < 0.001) and had USD 36,291 higher total hospital charges (95% CI: USD 32,583-USD 40,000, P < 0.001) compared with patients without PDI 1. CONCLUSIONS: Cases of PDI 1 were most commonly associated with the gastrointestinal, cardiothoracic, and orthopedic procedure categories, and these were also 3 of the most common procedure categories overall. Controlling for type of procedure and other variables, the procedure categories having the highest likelihood of PDI 1 were gynecology and transplant. PDI 1 was found to be associated with greater mortality, longer length of stay, and greater total hospital charges.

Analysis of 23 million US hospitalizations: uninsured children have higher all-cause in-hospital mortality.

BACKGROUND: The number of uninsured children in the USA is increasing while the impact on children's health of being uninsured remains largely uncharacterized. We analyzed data from more than 23 million US children to evaluate the effect of insurance status on the outcome of US pediatric hospitalization. METHODS: In our analysis of two well-known large inpatient databases, we classified patients less than 18 years old as uninsured (self-pay) or insured (including Medicaid or private insurance). We adjusted for gender, race, age, geographic region, hospital type, admission source using regression models. In-hospital death was the primary outcome and secondary outcomes were hospital length of stay and total hospital charges adjusted to 2007 dollars. RESULTS: The crude in-hospital mortality was 0.75% for uninsured versus 0.47% for insured children, with adjusted mortality rates of 0.74 and 0.46%, respectively. On multivariate analysis, uninsured compared with insured patients had an increased mortality risk (odds ratio: 1.60, 95% CI: 1.45-1.76). The excess mortality in uninsured children in the US was 37.8%, or 16,787, of the 38,649 deaths over the 18 period of the study. CONCLUSION: Children who were hospitalized without insurance have significantly increased all-cause in-hospital mortality as compared with children who present with insurance.

Splenectomy in hereditary spherocytosis: Review of 1,657 patients and application of the pediatric quality indicators.

OBJECTIVE: The objective of the present study is to profile the outcome and safety of pediatric patients undergoing splenectomy with hereditary spherocytosis (HS) using a nationwide sample and the Agency for Healthcare Research and Quality (AHRQ) Pediatric Quality Indicators (PDIs). PATIENTS AND METHODS: A retrospective cross-sectional descriptive analysis of a non-overlapping combination of the National Inpatient Sample (NIS), and Kids' Inpatient Database (KID) databases (1988-2004) were performed. These combined databases contain information from nearly 93 million discharges in the United States. Children with an age at admission of <18 years of age and HS (ICD-9 diagnosis code of 282.0) who underwent total splenectomy (ICD-9 procedure code of 41.5) were identified. Variables of gender, race, co-existing diagnoses, hospital type, and charges adjusted to 2006 dollars, length of stay, inpatient mortality, and complications were collected. PDIs were identified for each patient by linking the data obtained from the NIS and KID databases with the PDIs using the AHRQ Quality Indicators Wizard. RESULTS: Splenectomy for HS was associated with low morbidity and mortality. Accompanying cholecystectomy and/or appendectomy appeared to be safely performed at the same operation. Of the 13 PDIs identified by AHRQ as potentially avoidable adverse events, none were observed to occur in more than 1% of the patients. CONCLUSIONS: Based on the results of this study, splenectomy in patients with HS appears safe and to result in a minimal number of potentially preventable complications as identified by the AHRQ PDIs. We have successfully demonstrated use of the indicators to aid in the analysis of a specific surgical procedure within a subset of the pediatric population.

Preoperative assessment of chest wall deformities.

Anterior chest wall anomalies vary by age at presentation, signs, and symptoms as well as evaluation and subsequent surgical treatment. The most common abnormalities include pectus excavatum, pectus carinatum, and Poland syndrome.

Retinal hemorrhages and shaken baby syndrome: an evidence-based review.

BACKGROUND: Among the causes of non-accidental head injury (NAHI), shaken baby syndrome (SBS) is difficult to diagnose and is associated with retinal hemorrhages (RH). DESCRIPTION: To identify findings and patterns of RH specific to SBS, a PubMed search using the keywords "shaken baby syndrome" or "child abuse" and "retinal hemorrhage" was conducted; 66 articles met the inclusion criteria. The published data address the utility of RH in three categories: 1) in diagnosing SBS; 2) as correlated to intracranial pathology; and 3) in prognosticating SBS. The present review aimed to summarize studies in a way that facilitates clinical decision-making. RESULTS: Studies found a 53-80% incidence of RH with abusive head injury and a 0-10% incidence with proven severe accidental trauma. RHs are found bilaterally 62.5-100% of the time in SBS cases, and flame-shaped hemorrhages are the most common. The incidence of RH from convulsions, chest compressions, forceful vomiting, and severe persistent coughing in the absence of another condition known to cause RH is 0.7%, 0-2.3%, 0%, and 0%, respectively. CONCLUSION: SBS remains a difficult cause of NAHI to diagnose. Ophthalmologic examination can provide critical diagnostic and prognostic information in cases of suspected SBS. Child abuse should be highly suspect in children with RH and a parental explanation of accidental head injury, especially if the RHs are found to be bilateral, flame-shaped, or to extend through to all layers of the retina.

Microdeformational wound therapy: A novel option to salvage complex wounds associated with the Nuss procedure.

BACKGROUND: Complex wounds associated with the Nuss procedure are a resource intensive complication that may lead to significant morbidity with potential removal of the implanted device and abandonment of the repair. We report our management technique of this complication utilizing microdeformational wound therapy (MDWT) that is safe, is efficacious and allows for salvage of the repair. OPERATIVE TECHNIQUE: We defined a complex wound as a wound that became suppurative and drained in the postoperative period and failed to resolve with a trial of conventional wound management and antibiotics. Upon recognition of a complex wound, we recommend an initial operative wound debridement. This allows wound cultures, wound assessment and precise initiation of MDWT. It is not uncommon to have exposed hardware in the wound early in the course of therapy. Metal allergy must be excluded. The patient is transitioned to oral antibiotics following resolution of the acute process. MDWT is performed until the wounds are completely epithelialized with no clinical signs of drainage or infection. The average length of MDWT in our patients was 39 days. Following complete wound healing the patients are maintained on antibiotics until implant removal. CONCLUSIONS: The use of microdeformational wound therapy in complex wounds associated with the Nuss procedure is a safe and effective modality. The technique may reduce the likelihood of implant removal with potential recurrent pectus excavatum. TYPE OF STUDY: Operative technique. LEVEL OF EVIDENCE: Level IV, case series with no comparison group.

Successful treatment of a child with late-onset T-cell post-transplant lymphoproliferative disorder/lymphoma.

We report a novel regimen for refractory post-transplant T-cell lymphoma (PTL). Our patient presented with non-Epstein-Barr virus (EBV) related, T-cell post-transplant lymphoproliferative disease (PTLD) 3.5 years after liver transplantation. Initially diagnosed as polyclonal PTLD, the disease progressed to a monoclonal, T-cell PTL that was refractory to several chemotherapy regimens but responded to a regimen consisting of fludarabine, cyclophosphamide, cytarabine, and alemtuzumab. Consolidation therapy included high-dose chemotherapy, autologous hematopoietic stem cell rescue, and radiation therapy. She remains in remission 2.5 years later. T-cell PTL is a rare disease with a poor prognosis; this regimen provides a novel, potentially curative approach for its treatment.

Safety and pharmacokinetics of daclizumab in pediatric renal transplant recipients.

This study examined the safety and pharmacokinetics/pharmacodynamics of daclizumab in combination with mycophenolate mofetil (or azathioprine), corticosteroids, and cyclosporine or tacrolimus, in 61 pediatric renal allograft recipients in three age groups: less than or equal to five yr (n = 18), 6-12 yr (n = 18), and 13-17 yr (n = 25). The dosing regimen was daclizumab 1.0 mg/kg before transplantation, followed by four biweekly doses. The pharmacokinetics of daclizumab were described using NONMEM software. Median (range) estimated trough daclizumab levels achieved on day 56 (before dose 5) were 3.88 microg/mL (2.48-8.78), 4.54 microg/mL (1.79-18.7), and 4.94 microg/mL (0.05-10.6) in the less than or equal to five yr (n = 15), 6-12 yr (n = 17), and 13-17 yr (n = 22) age groups, respectively. Steady-state median (range) daclizumab exposures were 2040 mg x h/mL (1585-3778), 2757 mg x h/mL (1873-3494) and 3297 mg x h/mL (1705-6453), respectively. Saturation of the IL-2R occurred rapidly and was maintained for greater than or equal to three months after transplantation. Daclizumab was generally well-tolerated with no acute allergic or anaphylactic reactions, deaths or malignancies during the study. The proportion of patients who developed acute rejection at six and 12 months was 8.5% and 16.7%, respectively. This study shows that adding daclizumab at 1 mg/kg to standard immunosuppressive therapy provides safe and effective IL-2R blockade.

Patient safety rounds in a pediatric tertiary care center.

BACKGROUND: Patient safety rounds were implemented in a pediatric tertiary care setting. Completed patient safety issues from three years of pediatric patient safety rounds and nine months of pediatric surgical safety rounds were analyzed. Completed issues were categorized into both Modified Vincent and University HealthSystem Consortium (UHC) categorization schemes to compare and contrast their attributes. FINDINGS: From January 2003 through January 2006, there were 159 completed patient safety issues, 148 (93%) from general pediatric safety rounds and 11 (7%) from pediatric surgical safety rounds. Using the UHC classification scheme, 35.8% of the issues were classified as care coordination/records, 27.0% as equipment safety situation/preventive maintenance, 21.4% as equipment/supplies/devices, 3.8% as error related to procedure/ treatment/test, and 3.8% as medication error. In the Modified Vincent classification scheme, 63.5% of the issues were classified as environmental factors, 23.3% as team factors, 6.9% as individual factors, 3.1% as task factors, and 1.9% as patient characteristics. Pediatric safety rounds were well received by both frontline staff and senior executives. DISCUSSION: The use of pediatric safety rounds is a low-cost intervention that helps to partner senior leaders and frontline staff on patient safety and is an effective tool for improving patient safety in a pediatric setting.

Prospective multicenter study of surgical correction of pectus excavatum: design, perioperative complications, pain, and baseline pulmonary function facilitated by internet-based data collection.

BACKGROUND: Given widespread adoption of the Nuss procedure, prospective multicenter study of management of pectus excavatum by both the open and Nuss procedures was thought desirable. Although surgical repair has been performed for more than 50 years, there are no prospective multicenter studies of its management. STUDY DESIGN: This observational study followed pectus excavatum patients treated surgically at 11 centers in North America, according to the method of choice of the patient and surgeon. Before operation, all underwent evaluation with CT scan, pulmonary function tests, and body image survey. Data were collected about associated conditions, hospital complications, and perioperative pain. One year after completion of treatment, patients will repeat the preoperative evaluations. This article addresses early results only. RESULTS: Of 416 patients screened, 327 were enrolled; 284 underwent the Nuss procedure and 43 had the open procedure. Median preoperative CT index was 4.4. Pulmonary function testing before operation showed mean forced vital capacity of 90% of predicted values; forced expiratory volume in 1 second (FEV(1)), 89% of predicted; and forced expiratory flow during the middle half of the forced vital capacity (FEF(25% to 75%)), 85% of predicted. Early postcorrection results showed that operations were performed without mortality and with minimal morbidity at 30 days postoperatively. Median hospital stay was 4 days. Postoperative pain was a median of 3 on a scale of 10 at time of discharge; the worst pain experienced was the same as was expected by the patients (median 8), and by 30 days after correction or operation, the median pain score was 1. Because of disproportionate enrollment and similar early complication rates, statistical comparison between operation types was limited. CONCLUSIONS: Anatomically severe pectus excavatum is associated with abnormal pulmonary function. Initial operative correction performed at a variety of centers can be completed safely. Perioperative pain is successfully managed by current techniques.

How We Manage Pediatric Deep Venous Thrombosis.

Over the past two decades, the incidence and recognition of venous thromboembolism (VTE) in children has significantly increased, likely as a result of improvements in the medical care of critically ill patients and increased awareness of thrombotic complications among medical providers. Current recommendations for the management of VTE in children are largely based on data from pediatric registries and observational studies, or extrapolated from adult data. The scarcity of high-quality evidence-based recommendations has resulted in marked variations in the management of pediatric VTE among providers. The purpose of this article is to summarize our institutional approach for the management of VTE in children based on available evidence, guidelines, and clinical practice considerations. Therapeutic strategies reviewed in this article include the use of conventional anticoagulants, parenteral targeted anticoagulants, new direct oral anticoagulants, thrombolysis, and mechanical approaches for the management of pediatric VTE.