Laparoscopic-Assisted Pancreatic Necrosectomy: Technique and Initial Outcomes

BACKGROUND

Necrotizing pancreatitis (NP) may result de novo or following procedures such as ERCP or partial pancreatectomy (post-procedural), and may require surgical debridement. Video-assisted retroperitoneal debridement (VARD) is a standard approach for NP that employs a 5 cm incision with varying degrees of blind and open debridement. We describe our technique and outcomes of a modified VARD called laparoscopic-assisted pancreatic necrosectomy (LAPN) performed through a single 12 mm incision that uses direct laparoscopic visualization during debridement.

METHODS

At one medical center, all LAPN patients (2012-2020) were assessed for demographics, disease factors, and outcomes. Bivariate logistic regression analyses were performed to identify factors independently associated with recovery after LAPN for patients with de novo vs post-procedural necrosum.

RESULTS

Over 9 years, 60 patients underwent LAPN for NP. Median age was 57 years (IQR: 47-66) and 43 (69%) were men. Pancreas necrosum was de novo in 39 (63%) patients and post-procedural in 23 (37%). NP resolved with a median of 1 LAPN procedure and median hospitalization was 33 days. The LAPN major morbidity rate and in-hospital mortality rate were 47% and 5%. No significant differences were seen between NP etiology cohorts, although post-procedure NP patients trended towards a faster clinical recovery to baseline compared to de novo patients (193 vs 394 days; p-value = .07).

CONCLUSIONS

LAPN offers a smaller incision with excellent visualization and non-inferior outcomes, regardless of etiology, with likely faster recovery for patients with post-procedural vs de novo necrotizing pancreatitis.

Establishing Reference Values for Lean Muscle Mass in the Pediatric Patient

OBJECTIVES

Adults with decreased muscle mass experience worse outcomes and more frequent complications. The effects of sarcopenia on pediatric outcomes are unknown. Our objective was to define reference values for lean muscle mass in a healthy pediatric population to facilitate future studies on the impact of lean muscle mass on pediatric outcomes.

PATIENTS AND METHODS

Bilateral psoas muscle surface area was measured by computed tomography in a healthy pediatric population undergoing evaluation after trauma. Pearson correlation coefficients (PCCs) were calculated for age, weight, height, body mass index (BMI), total psoas muscle area, and psoas muscle index (PMI; defined as psoas muscle area divided by height squared). Quantile regression was used to determine age- and sex-specific percentiles of psoas muscle area and PMI.

RESULTS

Analysis of 494 male and 288 female patients with available imaging (median age: 9.3 years, interquartile range: 5.4-13.4; 63.1% male) was performed. For males, age correlated strongly with total psoas volume (PCC = 0.87), height (0.95), and weight (0.88) and poorly with BMI (0.45). In females, age correlated strongly with total psoas volume (0.88), height (0.92), weight (0.88) and poorly with BMI (0.19). Gender-specific curves and charts were created using output from the quantile regression from reference values of the total psoas muscle area corresponding to the 25th, 50th, and 75th percentiles across all ages.

CONCLUSIONS

We created gender-specific reference charts for total and height-normalized psoas muscle area in healthy children based on age. These results can be used in future studies to establish the effects of sarcopenia in pediatric patients.

The pediatric surgery match by the numbers: Defining the successful application

BACKGROUND

Pediatric surgery remains the most competitive general surgery subspecialty. The authors suspected significant inflation in academic metrics since the last published paper. This study aimed to identify factors associated with applicant success in the match.

METHODS

After IRB approval, all applications to a single accredited pediatric surgery fellowship program were reviewed for match years 2014-2018. Matched and unmatched applicants were compared in an unadjusted and adjusted analysis.

RESULTS

This training program received 414 of 425 total applications (97%). Match results were available for 388 (94%). Matched applicants were more likely to train in programs with pediatric surgery fellowships (64% vs. 28%) and to have dedicated research time (55% vs. 21%; all p < 0.01). Matched applicants had more total publications (median: 12 vs. 7, p < 0.01) and higher ABSITE scores (median: 64th vs. 59th percentile, p < 0.01). Training in multiple programs negatively impacted the chance to match (p < 0.01). The median number of publications per applicant increased over the study time period from 7 to 11 (p < 0.01).

CONCLUSIONS

The likelihood of matching into a pediatric surgery fellowship was related to the type of residency attended, dedicated research time, ABSITE scores, and number of publications. Overall, the total number of publications reported by all applicants increased.

TYPE OF STUDY

Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Suction Rectal Biopsy is Accurate in Late Preterm Infants with Suspected Hirschsprung Disease

BACKGROUND

Few data are available to substantiate the dogma commonly held by pediatric surgeons and pediatric pathologists that rectal biopsies may be inaccurate or risky in preterm neonates. We aimed to address these concerns.

METHODS

We performed a single-institution retrospective review of patients who underwent suction rectal biopsies at <37 weeks corrected age from 2009 to 2018. The primary outcomes were accuracy of biopsy results and procedural complications.

RESULTS

Forty-nine patients underwent suction rectal biopsy at <37 weeks corrected age. Mean gestational age at biopsy was 35.2 weeks (range 32.1-36.9) and mean weight was 2126 g (range 1590-3100). Five (10%) infants had biopsies positive for Hirschsprung Disease. All 5 later underwent pull-through operations and had pathologic confirmation of an aganglionic segment. The remaining 44 (90%) had biopsies showing ganglion cells. None were later found to have HD during the follow up period. Those who underwent biopsy at <2000 g (16/44) had 100% sensitivity [95% CI 48, 100] and specificity [95% CI 92, 100] (2 true positives, 14 true negatives). There were no complications identified.

CONCLUSION

Suction rectal biopsy can be performed safely in preterm infants as small as 1590-2000 g with high accuracy. Clinicians should not hesitate to perform a biopsy for a premature infant when clinically appropriate.

TYPE OF STUDY

Study of a diagnostic test.

LEVEL OF EVIDENCE

Level IV.

Orientation in Perpetuity: An Online Clinical Decision Support System for Surgical Residents

BACKGROUND

Limiting variability is an essential element to improving quality of care. Frequent resident turnover represents a significant barrier to clinical standardization. Trainees joining new surgical services must familiarize themselves with the guidelines and protocols that direct patient care as well as their learning objectives and expectations. A clinical decision support system (CDSS) is a dynamic, searchable electronic resource intended for use at the point of care. The CDSS can provide convenient and timely access to relevant information for residents, allowing them to incorporate the most up-to-date protocols and guidelines in their daily care of patients. The objective of this quality improvement intervention was to determine the objective rate of CDSS utilization and its subjective value to residents.

MATERIALS AND METHODS

An internally developed, web-based CDSS including essential, clinically useful documents was created for use by trainees on a busy pediatric surgery service. A standardized orientation was provided to each resident and fellow on joining the service, complemented by a summary card to be attached to the trainee's ID badge. CDSS usage was monitored using web analytics. Trainees who rotated before and after the CDSS launch were surveyed regarding attitudes toward clinical resources and confidence in patient management.

RESULTS

Documents published to the CDSS included 33 clinical guideline documents and 207 additional educational and support files including reference materials from service orientation were made available to trainees and staff. Goals for resident usage were established by evaluation and adaptation of early traffic patterns. Analysis of web traffic collected over 14 consecutive months revealed utilization above target levels, with 4.0 average weekly page views per trainee (IQR: 1.6-5.6). A total of 60 survey responses were received (54% of trainees invited); majorities of rotating trainees and survey respondents were trainees in general surgery and most were interns. Mean composite scores reflected a trend toward improved satisfaction when seeking CDSM (before intervention 3.18 [SD 0.73], after intervention 3.92 [SD 0.70], range 1-5) which was statistically significant (P = 0.005). Mean scores also improved across five of six components of the composite score (mean improvement 0.75, range: 0.53-0.92), four of which were statistically significant (P = 0.001-0.038). Most (59%) respondents reported that they used the CDSS frequently.

CONCLUSIONS

Convenient access to a CDSS resulted in greater than expected utilization as well as higher resident satisfaction with and confidence in materials provided. A CDSS is a promising tool offering quick access to high-quality information in challenging trainee environments.

Complications after proctocolectomy and ileal pouch-anal anastomosis in pediatric patients: A systematic review

BACKGROUND/PURPOSE

Colectomy with ileal pouch-anal anastomosis (IPAA) is the standard of care for patients with familial adenomatous polyposis (FAP) and refractory ulcerative colitis (UC). The rates of postoperative complications are not well established in children. The objective of this systematic review is to establish benchmark data for morbidity after pediatric IPAA.

METHODS

PubMed, Embase, and The Cochrane Library were searched for studies of colectomy with IPAA in patients ≤21 years old. UC studies were limited to the anti-tumor necrosis factor-α agents era (1998-present). All postoperative complications were extracted.

RESULTS

Thirteen studies met the inclusion criteria (763 patients). Compared to patients with FAP, UC patients had a higher prevalence of pouch loss (10.6% vs. 1.5%). Other major complications such as anastomotic leak, abscess, and fistula were uncommon (mean prevalence 4.9%, 4.2%, and 5.0%, respectively, for patients with UC; 8.7%, 4.2%, and 4.3% for FAP). The most frequent complication was pouchitis (36.4% of UC patients).

CONCLUSIONS

Devastating complications from colectomy and IPAA are rare, but patients with UC have poorer outcomes than those with FAP. Much of the morbidity may therefore stem from patient or disease factors. Multicenter, prospective studies are needed to identify modifiable risks in patients with UC undergoing IPAA.

LEVEL OF EVIDENCE

Prognostic, level II.

Whole Body Protein Turnover and Net Protein Balance After Pediatric Thoracic Surgery: A Noninvasive Single-Dose 15 N Glycine Stable Isotope Protocol With End-Product Enrichment

BACKGROUND

We used the 15 N glycine urinary end-product enrichment technique to quantify whole body protein turnover following thoracic surgery.

MATERIALS AND METHODS

A single dose of 15 N glycine (2 mg/kg) was administered orally on postoperative day 1 to children (1-18 years) following thoracic surgery. 15 N enrichment of ammonia and urea was measured in mixed urine after 12 and 24 hours, respectively, and protein synthesis, breakdown, and net balance determined. Nitrogen balance (dietary intake minus urinary excretion) was calculated. Urinary 3-methylhistidine:creatinine ratio was measured as a marker of skeletal muscle protein breakdown.

RESULTS

We enrolled 19 subjects-median (interquartile range): age, 13.8 years (12.2-15.1); weight, 49.2 kg (38.4-60.8)-who underwent thoracotomy (n = 12) or thoracoscopic (n = 7) surgery. Protein synthesis and breakdown by 15 N enrichment were 7.1 (5.5-9) and 7.1 (5.6-9) g·kg-1 ·d-1 with ammonia (12 hours) as the end product, and 5.8 (3.8-6.7) and 6.7 (4.5-7.6) with urea (24 hours), respectively. Net protein balance by the 15 N glycine and urinary urea nitrogen methods were -0.34 (-0.47, -0.3) and -0.48 (-0.65, -0.28) g·kg-1 ·d-1 , respectively (rs = 0.828, P < .001). Postoperative change in 3-methylhistidine:creatinine ratio did not correlate significantly with protein breakdown or balance.

CONCLUSION

The single-dose oral administration of 15 N glycine stable isotope with measurement of urinary end-product enrichment is a feasible and noninvasive method to investigate whole body protein turnover in children. After major surgery, children manifest increased protein turnover and net negative balance due to increased protein breakdown.

Cost comparison of initial lobectomy versus fine-needle aspiration for diagnostic workup of thyroid nodules in children

BACKGROUND

Though uncommon in children, pediatric thyroid nodules carry a higher risk of malignancy than adult nodules. While fine-needle aspiration (FNA) has been well established as the initial diagnostic test in adults, it has been more slowly adopted in children. The purpose of this study was to examine the comparative cost of FNA versus initial diagnostic lobectomy (DL) in the pediatric patient with an ultrasound-confirmed thyroid nodule.

METHODS

A decision tree model was created using an adolescent with an asymptomatic thyroid nodule as the reference case. Probabilities were defined based on review of the pediatric and adult literature. Costs were determined from previous literature and the publicly available Medicare physician fee schedule. Tornado plot and sensitivity analyses were performed to assess sources of cost variation.

RESULTS

Using decision analysis, FNA was less costly than DL with an estimated cost of $2529 vs. $5680. Tornado analysis demonstrated that the probability of an initial indeterminate FNA result contributed most to cost variation. On sensitivity analysis, when probability of an indeterminate FNA result was increased to 35%, the maximum value found in the literature, FNA remained less costly. In Monte Carlo simulation set to 10,000 iterations, FNA was superior to DL in 74% of cases.

CONCLUSIONS

In this theoretical model based on available literature and costs, FNA is less costly than DL for initial diagnostic workup of thyroid nodules in children. Securing resources to offer FNA in the work-up of thyroid nodules may be financially beneficial to hospitals and patients.

LEVEL OF EVIDENCE

Level 1 cost effectiveness study - using reasonable costs and alternatives used in study with values obtained from many studies, study used multi-way sensitivity analysis.

Cadaver-Based Simulation Increases Resident Confidence, Initial Exposure to Fundamental Techniques, and May Augment Operative Autonomy

OBJECTIVE

Surgical simulation is an important adjunct in surgical education. The majority of operative procedures can be simplified to core components. This study aimed to quantify a cadaver-based simulation course utility in improving exposure to fundamental maneuvers, resident and attending confidence in trainee capability, and if this led to earlier operative independence.

DESIGN

A list of fundamental surgical procedures was established by a faculty panel. Residents were assigned to a group led by a chief resident. Residents performed skills on cadavers appropriate for PGY level. A video-recorded examination where they narrated and demonstrated a task independently was then graded by attendings using standardized rubrics. Participants completed surveys regarding improvements in knowledge and confidence.

SETTING

The course was conducted at the Emory University School of Medicine and the T3 Laboratories in Atlanta, GA.

PARTICIPANTS

A total of 133 residents and 41 attendings participated in the course. 133 (100%) participating residents and 32 (78%) attendings completed surveys.

RESULTS

Resident confidence in completing the assigned skill independently increased from 3 (2-3) to 4 (3-4), p < 0.01. Residents stated that a median of 40% (interquartile range: 20%-60%) of procedures were performed for the first time in the course, and the same number had been performed only in the course. The percentage of skills attendings believed residents could perform independently increased from 40% (40%-60%) to 60% (60%->80%), p < 0.04. Attendings were more likely to grant autonomy in the operating room after this exercise (4 [3-5]).

CONCLUSIONS

A cadaveric skills course focused on fundamental maneuvers with objective confirmation of success is a viable adjunct to clinical operative experience. Residents were formally exposed to fundamental surgical maneuvers earlier as a result of this course. This activity improved both resident and attending confidence in trainee operative skill, resulting in increased attending willingness to grant a higher level of autonomy in the operating room.

Necrotizing enterocolitis is associated with earlier achievement of enteral autonomy in children with short bowel syndrome

PURPOSE

Necrotizing enterocolitis (NEC) remains one of the most common underlying diagnoses of short bowel syndrome (SBS) in children. The relationship between the etiology of SBS and ultimate enteral autonomy has not been well studied. This investigation sought to evaluate the rate of achievement of enteral autonomy in SBS patients with and without NEC.

METHODS

Following IRB approval, 109 patients (2002-2014) at a multidisciplinary intestinal rehabilitation program were reviewed. The primary outcome evaluated was achievement of enteral autonomy (i.e. fully weaning from parenteral nutrition). Patient demographics, primary diagnosis, residual small bowel length, percent expected small bowel length, median serum citrulline level, number of abdominal operations, status of the ileocecal valve (ICV), presence of ileostomy, liver function tests, and treatment for bacterial overgrowth were recorded for each patient.

RESULTS

Median age at PN onset was 0 weeks [IQR 0-0]. Median residual small bowel length was 33.5 cm [IQR 20-70]. NEC was present in 37 of 109 (33.9%) of patients. 45 patients (41%) achieved enteral autonomy after a median PN duration of 15.3 [IQR 7.2-38.4]months. Overall, 64.9% of patients with NEC achieved enteral autonomy compared to 29.2% of patients with a different primary diagnosis (p=0.001, Fig. 1). Patients with NEC remained more likely than those without NEC to achieve enteral autonomy after two (45.5% vs. 12.0%) and four (35.7% vs. 6.3%) years on PN (Fig. 1). Logistic regression analysis demonstrated the following parameters as independent predictors of enteral autonomy: diagnosis of NEC (p<0.002), median serum citrulline level (p<0.02), absence of a jejunostomy or ileostomy (p=0.013), and percent expected small bowel length (p=0.005).

CONCLUSIONS

Children with SBS because of NEC have a significantly higher likelihood of fully weaning from parenteral nutrition compared to children with other causes of SBS. Additionally, patients with NEC may attain enteral autonomy even after long durations of parenteral support.

Abdominal MRI without Enteral Contrast Accurately Detects Intestinal Fibrostenosis in Patients with Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) presenting for surgical evaluation require thorough small bowel surveillance as it improves accuracy of diagnosis (ulcerative colitis versus Crohn's) and differentiates those who may respond to nonoperative therapy, preserving bowel length. MRI has not been validated conclusively against histopathology in IBD. Most protocols require enteral contrast. This study aimed to 1) evaluate the accuracy of MRI for inflammation, fibrosis, and extraluminal complications and 2) compare MRI without enteral contrast to standard magnetic resonance enterography. Adults with Crohn's disease or ulcerative colitis who underwent abdominal MRI and surgery were retrospectively reviewed. Of 65 patients evaluated, 55 met inclusion criteria. Overall sensitivity and specificity of MRI for disease involvement localized by segment were 93 per cent (95% confidence interval = 89.4–95.0) and 95 per cent (95% confidence interval = 92.3–97.0), respectively (positive predictive value was 86%, negative predictive value was 98%). Sensitivity and specificity between MRI with and without oral and rectal contrast were similar (96% vs 91% and 99% vs 94%, P > 0.10). As were positive predictive value and negative predictive value (85% vs 96%, P = 0.16; 97% vs 99%, P = 0.42). Magnetic resonance is highly sensitive and specific for localized disease involvement and extraluminal abdominal sequelae of IBD. It accurately differentiates patients who have chronic transmural (fibrotic) disease and thus may require an operation from those with acute inflammation, whose symptoms may improve with aggressive medical therapy alone. MRI without contrast had comparable diagnostic yield to standard magnetic resonance enterography.

Abdominal MRI without Enteral Contrast Accurately Detects Intestinal Fibrostenosis in Patients with Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) presenting for surgical evaluation require thorough small bowel surveillance as it improves accuracy of diagnosis (ulcerative colitis versus Crohn's) and differentiates those who may respond to nonoperative therapy, preserving bowel length. MRI has not been validated conclusively against histopathology in IBD. Most protocols require enteral contrast. This study aimed to 1) evaluate the accuracy of MRI for inflammation, fibrosis, and extraluminal complications and 2) compare MRI without enteral contrast to standard magnetic resonance enterography. Adults with Crohn's disease or ulcerative colitis who underwent abdominal MRI and surgery were retrospectively reviewed. Of 65 patients evaluated, 55 met inclusion criteria. Overall sensitivity and specificity of MRI for disease involvement localized by segment were 93 per cent (95% confidence interval = 89.4-95.0) and 95 per cent (95% confidence interval = 92.3-97.0), respectively (positive predictive value was 86%, negative predictive value was 98%). Sensitivity and specificity between MRI with and without oral and rectal contrast were similar (96% vs 91% and 99% vs 94%, P > 0.10). As were positive predictive value and negative predictive value (85% vs 96%, P = 0.16; 97% vs 99%, P = 0.42). Magnetic resonance is highly sensitive and specific for localized disease involvement and extraluminal abdominal sequelae of IBD. It accurately differentiates patients who have chronic transmural (fibrotic) disease and thus may require an operation from those with acute inflammation, whose symptoms may improve with aggressive medical therapy alone. MRI without contrast had comparable diagnostic yield to standard magnetic resonance enterography.

Predictors of Enteral Autonomy in Children with Intestinal Failure: A Multicenter Cohort Study

OBJECTIVES

In a large cohort of children with intestinal failure (IF), we sought to determine the cumulative incidence of achieving enteral autonomy and identify patient and institutional characteristics associated with enteral autonomy.

STUDY DESIGN

A multicenter, retrospective cohort analysis from the Pediatric Intestinal Failure Consortium was performed. IF was defined as severe congenital or acquired gastrointestinal diseases during infancy with dependence on parenteral nutrition (PN) >60 days. Enteral autonomy was defined as PN discontinuation >3 months.

RESULTS

A total of 272 infants were followed for a median (IQR) of 33.5 (16.2-51.5) months. Enteral autonomy was achieved in 118 (43%); 36 (13%) remained PN dependent and 118 (43%) patients died or underwent transplantation. Multivariable analysis identified necrotizing enterocolitis (NEC; OR 2.42, 95% CI 1.33-4.47), care at an IF site without an associated intestinal transplantation program (OR 2.73, 95% CI 1.56-4.78), and an intact ileocecal valve (OR 2.80, 95% CI 1.63-4.83) as independent risk factors for enteral autonomy. A second model (n = 144) that included only patients with intraoperatively measured residual small bowel length found NEC (OR 3.44, 95% CI 1.36-8.71), care at a nonintestinal transplantation center (OR 6.56, 95% CI 2.53-16.98), and residual small bowel length (OR 1.04 cm, 95% CI 1.02-1.06 cm) to be independently associated with enteral autonomy.

CONCLUSIONS

A substantial proportion of infants with IF can achieve enteral autonomy. Underlying NEC, preserved ileocecal valve, and longer bowel length are associated with achieving enteral autonomy. It is likely that variations in institutional practices and referral patterns also affect outcomes in children with IF.

Operative indications in recurrent ileocolic intussusception

BACKGROUND

Air-contrast enema (ACE) is standard treatment for primary ileocolic intussusception. Management of recurrences is less clear. This study aimed to delineate appropriate therapy by quantifying the relationship between recurrence and need for bowel resection, pathologic lead points (PLP), and complication rates.

METHODS

After IRB approval, a single institution review of patients with ileocolic intussusception from 1997 to 2013 was performed, noting recurrences, outcomes, and complications. Fisher's exact and t-tests were used.

RESULTS

Of 716 intussusceptions, 666 were ileocecal. Forty-four underwent bowel resection, with 29 PLPs and 9 ischemia/perforation. Recurrence after ACE occurred in 96 (14%). Recurrence did not predict PLP (P=0.25). Recurrence (≥3) was associated with higher resection rate (P=0.03), but not ischemia/perforation (P=0.75). ACE-related complications occurred in 4 (0.5%) patients. Successful initial ACE had 98% negative predictive value for resection and PLP (e.g., after successful ACE, 2% had resections, 2% PLP). After failed initial ACE, 36% received resection, and 23% had PLP (P<0.001).

CONCLUSIONS

Recurrence is associated with a greater risk of resection but not PLP or ACE-complication. Failed ACE is associated with increased risk for harboring PLP and receiving resection. ACE should be the standard treatment in recurrent intussusception, regardless of number of recurrences.

Metabolic bone disease in pediatric intestinal failure patients: prevalence and risk factors

PURPOSE

Patients with intestinal failure (IF) are known to have impaired absorption of nutrients required for maintenance of skeletal mass. Rates and risk factors of low bone mineral density (BMD) are unknown in pediatric IF patients.

METHODS

Following IRB approval, patients with IF having undergone DXA scans were identified and laboratory, clinical, and nutritional intake variables were recorded. Low BMD was defined by a z-score of less than or equal to -2.0. Univariate followed by multivariable regression analysis was performed.

RESULTS

Sixty-five patients underwent a total of 99 routine DXA scans. Twenty-seven (41%) had vitamin D deficiency, 22 (34%) had low BMD, and nineteen (29%) had a history of fractures. Variables noted to be associated with low BMD (p<0.1) on univariate analysis were considered for multivariable regression. Multivariable regression identified WAZ and serum calcium levels (p<0.05) as independent predictors of low BMD z-score. None of the other evaluated factors were associated with the risk of low BMD. Low BMD was not associated with risk of fractures.

CONCLUSION

There is a significant incidence of low BMD in children with IF. WAZ and lower serum calcium levels are associated with risk of low BMD. Additional long term prospective studies are needed to further characterize the risk factors associated with low BMD.

Patterns of surgical practice in very low birth weight neonates born in the United States: a Vermont Oxford Network analysis

BACKGROUND/PURPOSE

The distribution of surgical care of very low birth weight (VLBW) neonates among centers with varying specialized care remains unknown. This study quantifies operations performed on VLBW neonates nationally with respect to center type.

METHODS

VLBW neonates born 2009-2012 were assessed using a prospectively collected multi-center database encompassing 80% of all VLBW neonates in the United States. Surgical centers were categorized based on availability of pediatric surgery (PS) and anesthesia (PA).

RESULTS

48,711 major procedures (29,512 abdominal operations) were performed on 24,318 neonates. Of all patients, 20,892 (85.9%) underwent surgery at centers with PS and PA available on site. 1663 (6.8%) patients were treated at centers with neither specialty on site. Neonates requiring complex operations were more likely to receive surgery at centers with both PS and PA on staff than those requiring non-complex operations (95.6% vs 93.6%).

CONCLUSION

This study confirms that most operations on VLBW neonates in the U.S. are performed at centers with pediatric surgeons and anesthesiologists on staff. Further research is necessary, however, to elucidate why a significant minority of this challenging population continues to be managed at centers without pediatric specialists.

Extraluminal helicoidal stretch (Helixtretch): a novel method of intestinal lengthening

PURPOSE

We sought to test a novel, extraluminal method of intestinal lengthening that precludes violation of the intestinal wall.

METHODS

Sprague-Dawley rats (n=45) with size-matched bowel segments isolated by Roux-en-Y reconstruction were divided into three groups. Group 1 (n=14) had no further manipulations. In Groups 2 (n=12) and 3 (n=19), the isolated segment was wrapped around a length-matched device in a helicoidal fashion. In Group 2, the device consisted of plain polyurethane tubing. In Group 3, it consisted of a gradually expanding hygroscopic hydrogel (12.5mm final diameter). Euthanasia was performed at 8-21 days. Statistical analysis was by two-way ANOVA (P<0.05).

RESULTS

Overall survival was 87% (39/45). There was a statistically significant increase in bowel length in Group 3 compared to the other two groups (P<0.001). This increase correlated with the number of helicoidal coils (P=0.018), but not with post-operative time (P>0.50). There were no significant differences in total DNA/protein ratio across the groups (P=0.65). Histologically, there was an apparent increase in the goblet cell density in Group 3.

CONCLUSIONS

Measured extraluminal helicoidal stretch (Helixtretch) is tolerated by the intestine. Helixtretch induces bowel lengthening in a rodent model. Further analysis of this novel, minimally invasive alternative for intestinal augmentation is warranted.

Mortality associated with laparotomy-confirmed neonatal spontaneous intestinal perforation: a prospective 5-year multicenter analysis

BACKGROUND

Spontaneous intestinal perforation (SIP) has been recognized as a distinct disease entity. This study sought to quantify mortality associated with laparotomy-confirmed SIP and to compare it to mortality of laparotomy-confirmed necrotizing enterocolitis (NEC).

METHODS

Data were prospectively collected on 177,618 very-low-birth-weight (VLBW, 401-1500g) neonates born between January 2006 and December 2010 admitted to US hospitals participating in the Vermont Oxford Network (VON). SIP was defined at laparotomy as a focal perforation of the intestine without features suggestive of NEC or other intestinal abnormalities. The primary outcome was in-hospital mortality.

RESULTS

At laparotomy, 2036 (1.1%) neonates were diagnosed with SIP and 4076 (2.3%) with NEC. Neonates with laparotomy-confirmed SIP had higher mortality (19%) than infants without NEC or SIP (5%, P=0.003). However, laparotomy-confirmed SIP patients had significantly lower mortality than those with confirmed NEC (38%, P<0.0001). Mortality in both NEC and SIP groups decreased with increasing birth weight and mortality was significantly higher for NEC than SIP in each birth weight category. Indomethacin and steroid exposure were more frequent in the SIP cohort than the other two groups (P<0.001).

CONCLUSIONS

In VLBW infants, the presence of laparotomy-confirmed SIP increases mortality significantly. However, laparotomy-confirmed NEC mortality was double that of SIP. This relationship is evident regardless of birth weight. The variant mortality of laparotomy-confirmed SIP versus laparotomy-confirmed NEC highlights the importance of differentiating between these two diseases both for clinical and research purposes.

Factors Affecting Spontaneous Closure of Gastrocutaneous Fistulae After Removal of Gastrostomy Tubes in Children With Intestinal Failure

BACKGROUND

Children with intestinal failure (IF) frequently require gastrostomy tubes (GTs) for long-term nutrition support. Risk factors for persistent gastrocutaneous fistulae (GCFs) in pediatric patients with IF are largely unknown but may include underlying nutrition status and duration of indwelling GT.

MATERIALS AND METHODS

Records of patients with IF having undergone GT removal and allowed a trial at spontaneous closure were reviewed. Nonparametric continuous variables were analyzed using the Wilcoxon rank sum test. Post hoc analysis was performed to identify the optimal threshold of GT duration predicting probability of spontaneous closure identified using receiver operating characteristic curve analysis.

RESULTS

Fifty-nine children with IF undergoing GT removal were identified. Spontaneous closure occurred in 36 (61%) sites, while 23 (39%) underwent operative closure at a median 67 days after GT removal. The duration of indwelling GT was significantly shorter in the spontaneous closure group (11.5 vs 21 months, P = .002). Of 33 GT indwelling for ≤ 18 months, 28 (85%) closed spontaneously, compared with only 9 of 26 (35%) with duration >18 months (P < .001). With GCF persisting beyond 7 days, only 21% (6/28) of sites closed spontaneously, but this dropped to 6% (1/18) of cases with concurrent GT duration >18 months.

CONCLUSIONS

Of the risk factors evaluated, only prolonged GT duration was associated with an increased likelihood of failure to close spontaneously. It is significantly less likely in pediatric patients with IF in whom GCF persists >7 days, particularly if the duration of GT is >18 months. Relatively earlier operative closure should be considered in this group.

Gastrointestinal bleeding as a complication of serial transverse enteroplasty

PURPOSE

Serial transverse enteroplasty (STEP) lengthens and tapers bowel in patients with intestinal failure. Evaluation and treatment of serious late gastrointestinal bleeding (GIB) in three STEP patients are described.

METHODS

Patients participating in an interdisciplinary intestinal rehabilitation program were reviewed to identify those who underwent STEP and had GIB requiring transfusion.

RESULTS

Of 296 patients, 23 underwent STEP, and 3 (13%) had subsequent GIB requiring transfusion. Diagnoses were vanishing gastroschisis/atresia, malrotation/atresia, and gastroschisis.. STEP was performed at ages 3-5 months, using 5-15 stapler-firings with an increase in mean bowel length from 39 to 62 cm. GIB was diagnosed 5-30 months post-op and resulted in 1-7 transfusions per patient. Endoscopy demonstrated staple-line ulceration in two patients and eosinophilic enterocolitis in the third. All were treated with enteral antibiotics, sulfasalazine, and luminal steroids. Those with ulcers responded to bowel rest, and the patient with eosinophilic enterocolitis stabilized with luminal steroids. In all three, hemoglobin levels improved despite persistent occult bleeding.

CONCLUSIONS

Significant GIB is a potential late complication of STEP. Endoscopy identified the underlying source of GIB in all three patients. A combination of enteral antibiotics, anti-inflammatory medications, and bowel rest was effective in treating post-STEP GIB, without the need for additional bowel resection.

Citrulline levels following proximal versus distal small bowel resection

PURPOSE

Citrulline, a nonprotein amino acid synthesized by enterocytes, is a biomarker of bowel length and the capacity to wean from parenteral nutrition. However, the potentially variant effect of jejunal versus ileal excision on plasma citrulline concentration [CIT] has not been studied. This investigation compared serial serum [CIT] and mucosal adaptive potential after proximal versus distal small bowel resection.

METHODS

Enterally fed Sprague-Dawley rats underwent sham operation or 50% small bowel resection, either proximal (PR) or distal (DR). [CIT] was measured at operation and weekly for 8 weeks. At necropsy, histologic features reflecting bowel adaptation were evaluated.

RESULTS

By weeks 6-7, [CIT] in both resection groups significantly decreased from baseline (P<0.05) and was significantly lower than the concentration in sham animals (P<0.05). There was no difference in [CIT] between PR and DR at any point. Villus height and crypt density were higher in the PR than in the DR group (P≤0.02).

CONCLUSION

[CIT] effectively differentiates animals undergoing major bowel resection from those with preserved intestinal length. The region of intestinal resection was not a determinant of [CIT]. The remaining bowel in the PR group demonstrated greater adaptive potential histologically. [CIT] is a robust biomarker for intestinal length, irrespective of location of small intestine lost.

Effect of heat treatment on stainless steel lingual arch appliances

This study evaluated the effect of heat treatment on 0.036" diameter stainless steel wire. Forty wires were bent into arch forms (20 experimental and 20 control). The arch width changes were measured and the forces generated were determined over an eight week period. Heat treatment resulted in immediate and significant expansion (p < 0.001) followed by stabilization of arch width. The control wires continued to expand throughout the study. The force generated by the control group and experimental group expansion was capable of producing tooth movement.

Complete dentures for a child with hypohidrotic ectodermal dysplasia: a clinical report

Young children with anodontia caused by hypohidrotic ectodermal dysplasia not only have difficulties in eating and speaking but can also sense that their appearance is different than others. Enabling children with HED to look and act more like their peers through the use of well-fitting and functioning dentures with age-appropriate denture teeth will greatly assist in their transitioning into the school years. Although denture fabrication requires multiple patient appointments and good cooperation, it is shown that even young children can cooperate for the denture-making process. The desire to be like others who have teeth can be a motivator for cooperation in even the young child. Children should be given every opportunity to develop to their fullest potential. The dentist can make a significant contribution to the overall development and well being of a child with HED.

Progressive hemifacial atrophy (Parry-Romberg syndrome). Case report

Progressive hemifacial atrophy (Parry-Romberg syndrome) is a slowly progressing facial atrophy of subcutaneous fat and the wasting of associated skin, cartilage, and bone. This disorder includes an active progressive phase (2 to 10 years) followed by a burning out of the atrophic process with subsequent stability. This article presents a review of the literature and a case report with unique dental involvement as a result of this disease process.

Inactivation of the Porphyromonas gingivalis fimA gene blocks periodontal damage in gnotobiotic rats

Fimbrial production by Porphyromonas gingivalis was inactivated by insertion-duplication mutagenesis, using the cloned gene for the P. gingivalis major fimbrial subunit protein, fimA. by several criteria, this insertion mutation rendered P. gingivalis unable to produce fimbrilin or an intact fimbrial structure. A nonfimbriated mutant, DPG3, hemagglutinated sheep erythrocytes normally and was unimpaired in the ability to coaggregate with Streptococcus gordonii G9B. The cell surface hydrophobicity of DPG3 was also unaffected by the loss of fimbriae. However, DPG3 was significantly less able to bind to saliva-coated hydroxyapatite than wild-type P. gingivalis 381. This suggested that P. gingivalis fimbriae are important for adherence of the organism to saliva-coated oral surfaces. Further, DPG3 was significantly less able to cause periodontal bone loss in a gnotobiotic rat model of periodontal disease. These observations are consistent with other data suggesting that P. gingivalis fimbriae play an important role in the pathogenesis of human periodontal disease.

Poison centers in America: how well do they perform

Marked differences in cell volume, service area, and center resources continue to exist between poison centers certified by the American Association of Poison Control Centers as Regional Poison Centers and those not meeting these criteria. However, the present clinical significance, if any, of these factors remains unproven. The only previous study, conducted in 1980, used only 1 test problem and did not attempt to separately analyze each of the differences between Regional Poison Centers and Non-regional Poison Centers. This study solicited the participation of all 208 US poison centers existing. Fifty-four poison centers (REGIONAL CENTERS 16/34 = 47%, NON-REGIONAL CENTERS 38/173 = 22%) agreed to participate. Three problems were presented to each center by simulated callers. Considerable variation was observed in efficiency and in extent of information provided. Overall, Regional Centers provided complete and correct answers for 83% of the presented cases, while Non-regional Centers did so in 57% of the cases. Although Regional Center status, staff experience, center call volume, medical direction all appear to be important, the most predictive factors were staff and center experience.

American poison control centers: still not all the same?

Although poison control centers meeting the criteria for certification by the American Association of Poison Control Centers as regional centers are widely believed to differ from centers not meeting these criteria, this assumption has not recently been validated. We surveyed all poison control centers listed in the Emergency Medicine 1986 directory of poison control centers or in the 1986 American Association of Poison Control Centers membership directory regarding their operations. Of 208 poison control centers listed, 167 (80.2%) responded; 28 of 35 regional poison control centers (80.0%) responded, as did 139 of 173 nonregional poison control centers (80.3%). The median annual call volume was 3,899 for all centers. For regional poison control centers, the median was 44,429, and for nonregional poison control centers, 1,553 (P less than .001). There also were highly significant differences in population served, call volume per capita, center staffing, medical direction, staff orientation, and follow-up protocols.

Long-term outcome after neuroleptic malignant syndrome

Little information is available on long-term outcome after neuroleptic malignant syndrome (NMS). Four patients are described who had survived episodes of NMS 2 to 11 years earlier. Some were safely re-treated with neuroleptics, and all safely received general anesthesia. No major sequelae were identified. Recommendations for management of patients after NMS are provided.

Microbiological and immunological studies of adult periodontitis in patients with noninsulin-dependent diabetes mellitus

The subgingival microflora and serum antibody response was examined in periodontitis patients with noninsulin-dependent diabetes mellitus (NIDDM), impaired glucose tolerance (IGT), and normal glucose tolerance (NGT). The predominant cultivable microflora was determined for subgingival plaque sampled from two deep periodontal pockets in each of eight adult periodontitis patients with NIDDM. Indirect immunofluorescence for Bacteroides intermedius, Bacteroides gingivalis, and Haemophilus actinomycetemcomitans was used to examine these same samples as well as 186 additional subgingival plaque samples from 47 patients with moderate to severe generalized periodontitis including 25 subjects with NIDDM, six subjects with IGT, and 16 subjects with NGT. Serum antibody levels to 13 microorganisms including seven oral bacterial species and one nonoral control species were measured by enzyme-linked immunosorbent assays (ELISA) in 377 subjects including 84 normal subjects without periodontal disease, 112 normal subjects with periodontitis, 19 periodontally normal subjects with IGT, 65 periodontitis patients with IGT, 15 periodontally normal subjects with NIDDM, and 82 periodontitis patients with NIDDM. Three hundred eighty-two bacterial isolates were recovered from the eight patients. B. intermedius was the most frequently isolated microorganism constituting 16% of the total isolates followed by Wolinella recta and B. gingivalis, which each accounted for 13% of the total. Streptococcus sanguis was the most prevalent microorganism, which was found in 75% of the sites. Subgingival plaque samples examined by immunofluorescence demonstrate a high prevalence of black-pigmented Bacteroides and suggest that the proportion of B. gingivalis but not B. intermedius is higher in NIDDM with periodontitis than in other groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychometric differentiation of psychogenic and organic erectile disorders

A study was conducted to assess the discriminant validity of patient responses to a questionnaire in distinguishing between organic and psychogenic erectile dysfunction. A total of 56 urologist-referred veterans slept for 3 nights in a sleep laboratory for nocturnal penile tumescence recording. Based on nocturnal penile tumescence results 48 patients were assigned to an organic group and the remaining 8 were assigned to a psychogenic group. A discriminant function analysis of questionnaire responses yielded a highly significant discriminant function [chi-square (19) equals 63.88, p less than 10(-6)], and all 56 patients were classified correctly into the nocturnal penile tumescence-defined organic and psychogenic groups. It was concluded that verbally reported data contain diagnostically meaningful information and that such information can compare favorably with information collected through standard laboratory-based nocturnal penile tumescence techniques.

Levels of plasticizer in the frequent plasma donor

Di-2-ethylhexyl phthalate (DEHP), a commonly employed plasticizer reported to be carcinogenic in rats and mice, has been confirmed to leach from all plastic component parts of the equipment employed in plasma donation. Resident aqueous solutions of both sodium chloride and sodium citrate were found to contain only trace levels of DEHP (0.03 ppm), while stored plasma samples contained levels at least one order of magnitude higher (0.4 ppm). Since at least 5% of all plasma donations in the Los Angeles area are deemed to be of the high frequency classification, investigation into repeated red blood cell exposure to DEHP was considered imperative. However, there was no difference in the levels of DEHP found in the plasma of the frequent plasma donor (50-60 times per annum) relative to the first-time donor. It is concluded that there is no increased contamination threat to frequent plasma donation from migrating plasticizer via red blood cell exposure, at least during the collection process. Furthermore, there is no more risk to recipients of plasma products from frequent donors than from occasional donors. It would seem that the ambient level of DEHP to be expected in stored frozen plasma products averages no greater than about 0.5 ppm.

Double-blind comparison of buspirone and clorazepate in anxious outpatients

Buspirone, a new nonbenzodiazepine anxiolytic agent, was compared with clorazepate in a double-blind, multicenter trial conducted with 336 outpatients who had moderate to severe anxiety. The two treatments were equally effective for relief of symptoms, including anxiety with associated depression. Although both agents were generally well tolerated, the profile of side effects was dissimilar. Drowsiness and depression occurred significantly (p less than 0.055) more frequently with clorazepate, whereas nausea and headache occurred significantly (p less than 0.055) more frequently with buspirone. Clorazepate-treated patients were significantly (p less than 0.055) more likely to have had an adverse experience that was considered drug related or that interfered with the therapeutic effect. In this study, buspirone was shown to be an effective antianxiety agent, causing significantly less sedation than clorazepate.

Combined behavioral and pharmacological treatment of essential hypertension

Fifty-two pharmacologically treated hypertensive patients were randomized to one of four treatment groups: (1) diastolic blood pressure biofeedback, (2) progressive deep muscle relaxation training, (3) self-directed relaxation training, or (4) medication alone. Data collection occurred during baseline, treatment, and 1-year follow-up phases in a laboratory, a medical clinic, and the patient's own home. Patients from all four groups combined showed mean blood pressure reductions of -10.2/-5.5 mm Hg on clinic recordings and -2.4/-.7 mm Hg on home recordings, which were maintained throughout the follow-up period. There were no significant differences among the four groups in terms of blood pressure reduction. Patients given adjunctive behavioral treatment showed significantly larger reductions in medication usage compared to patients treated with medication alone, but there were no significant differences among the three behaviorally treated groups. Patients who showed medication reductions did not show subsequent blood pressure elevation. The results suggest that combined behavioral and pharmacological therapy may be superior to pharmacological therapy alone in the treatment of essential hypertension.

Gingival fibromatosis with hypertrichosis. A case report

A case of gingival fibromatosis with hypertrichosis is reported in a 3-year-old girl. Partial recurrence was observed 6 months after surgical treatment. Psychological benefits resulting from the cosmetic improvement may outweigh the probability of recurrences in this rare condition.

Cognitive and physiologic responses to EMG biofeedback and three types of pseudofeedback during a muscular relaxation task

Four groups of normal human subjects were tested for their ability to reduce frontal muscle tension levels during presentation of veridical auditory biofeedback or auditory pseudofeedback. A double-blind methodology was used. Three groups of subjects assigned to the pseudofeedback conditions received a feedback signal that was not contingent on EMG activity but that followed one of three different patterns. One group received a truly random signal, the second received a signal that gradually increased in frequency (apparent failure), and the third received a signal that gradually decreased in frequency (apparent success). Dependent measures included both physiologic (frontal and neck EMG) and subjective reactions to the relaxation task. The different patterns of pseudofeedback did produce reliably different subjective responses, suggesting that the manipulations succeeded in producing unequal nonspecific effects that were unrelated to the feedback contingency specifically. However, these differential subjective effects were not strongly reflected in the physiologic responses since the differences in EMG levels among the four groups did not differ significantly at any stage of training. An analysis of the integrity of the double-blind procedure showed that although experimenters were effectively kept blind to group assignment, subjects' responding suggested a response bias as well as the possibility that the double-blind was breached. The utility of the double-blind methodology in biofeedback experiments is discussed and suggestions for future research are offered.

The effects of smoking and cigarette nicotine content on smokers' preparation and performance of a psychosocially stressful task

This study examined the effects of tobacco smoking and cigarette nicotine content on four dimensions of emotional behavior (peripheral autonomic, electrocortical, cognitive, and overt motor) during both the preparation for and the performance of a psychosocially stressful task (extemporaneous speaking). Three groups of experienced smokers either did not smoke, smoked a low-nicotine cigarette, or smoked a high-nicotine cigarette while they were preparing to perform the speaking task. All subjects reported prior to the experiment that they did experience smoking as relaxing and that they did experience a stronger desire to smoke under a variety of negative affective states compared to a variety of positive affective states. In spite of these verbal reports, however, neither the smoking ritual nor the nicotine content of the cigarette smoked had a significant effect on any of the four dimensions of the emotional behavior studied during either the preparation for or the performance of the task. These results were discussed in terms of previous psychophysiological studies utilizing different types of stressors and behavioral indices of emotion.

Safety and efficacy of long-term diazepam therapy

Clinical evidence of withdrawal phenomena and efficacy was studied in 23 long-term users of diazepam (15 to 50 mg daily). No withdrawal reactions were observed in the ten patients who received placebo in a double-blind fashion for a two-week period. Changes in anxiety scores of both patients who received placebo and those who received diazepam suggest that the diazepam continued to be effective when used for one year or longer.

Investigation of a stigmatic

We report the case history of a 23-year-old Mexican-American female stigmatic whom we studied using psychophysiologic, psychologic, and laboratory measures. The stigmata have appeared often since 1971 and usually consist of bleeding through unbroken skin from her palms, feet, side, and head. The bleeding is painful and is usually (but not always) associated with religious ecstasy. Associated phenomena include oil exuding from her skin and her 2-year-old daughter receiving the stigmata. We discuss the case in detail and comment on the concept of stigmata in general. Methodologic difficulties and perplexing inconsistencies in this and similar cases leave us with many unanswered questions.

An alternate method of recording airflow during sleep

Respiratory activity recordings in polysomnographic recordings are important in the identification of the sleep apnea syndrome. However, simultaneous recordings of both respiratory effort and airflow are necessary to accomplish this identification. We describe a relatively inexpensive and trouble-free face mask that makes use of a linear thermistor in the ventilation tube to accomplish the recording of airflow in a noninvasive manner.