Next day discharge after the Nuss procedure using intercostal nerve cryoablation, intercostal nerve blocks, and a perioperative ERAS pain protocol

BACKGROUND

The Nuss procedure for pectus excavatum has historically been associated with significant postoperative pain, which has been the major factor contributing to hospital length of stay (LOS).

METHODS

A single-institution, prospective study of 40 consecutive patients undergoing Nuss bar placement for pectus excavatum between November 2019 and January 2021 was conducted to assess the effectiveness of a multimodality pain management protocol. All patients received T3-T8 intercostal nerve cryoablation (INC), T3-T8 bupivacaine intercostal nerve blocks, Exparel at the skin incisions, and management with a perioperative analgesia regimen that minimized narcotic usage. The primary outcome was LOS. Secondary outcomes included opioid use, pain scores, and time to sensory recovery.

RESULTS

37/40 patients (92.5%) were discharged home on postoperative day (POD) 1, and 3/40 (7.5%) were discharged on POD 2 (mean LOS = 1.1 days). The median average postoperative pain score was 2/10. After eliminating IVPCA from our protocol, total oral morphine equivalent (OME) decreased by 73% (55.5 mg to 15 mg) with no change in pain scores or discharge timing.

CONCLUSIONS

INC combined with bupivacaine intercostal nerve blocks and a pre- and post-hospital analgesia protocol facilitated discharge one day after the Nuss procedure, achieved excellent pain control, and eliminated the need for intravenous opioids.

Congenital bronchobiliary fistula in association with right-sided congenital diaphragmatic hernia

A case of congenital bronchobiliary fistula is reported in conjunction with another congenital anomaly, right-sided congenital diaphragmatic hernia. The liver was herniated through the diaphragmatic defect into the right chest where a fistula tract was identified from the surface of the liver to the right mainstem bronchus. The patient was treated successfully.

Thoracic outlet syndrome in a child--transaxillary resection of anomalous first rib

Thoracic outlet syndrome (TOS) is extremely rare in children. Only several pediatric cases have been reported, and all presented with neurologic symptoms. The authors report on a 6-year-old boy with an asymptomatic left subclavian artery aneurysm caused by compression of the subclavian artery by an anomalous first rib with poststenotic aneurysmal dilatation. This was successfully managed by transaxillary resection of the anomalous rib. This represents the youngest reported case of TOS and the first description of a vascular manifestation of TOS in the pediatric population. Access to the costoscalene triangle utilizing a transaxillary approach was straightforward and afforded excellent exposure, even in a child.

Thoracic outlet syndrome with subclavian aneurysm in a very young child: the complementary value of MRA and 3D-CT in diagnosis

Thoracic outlet syndrome (TOS) is rare in childhood. In adults, TOS results in compression of the neurovascular bundle (branches of the brachial plexus and the subclavian artery), but more than 95% of cases present solely with neurologic compression. We present a case of TOS in a very young child and describe the rare finding of subclavian artery compression and post-stenotic aneurysm. The clinical features, imaging workup, and surgical findings are discussed. The combination of three-dimensional MR angiography and CT was of great value in diagnosis and surgical planning.

Intussusception

Intussusception is the invagination of one portion of the intestine into another and is the most common form of intestinal obstruction in infants. This report reviews the clinical presentation and diagnostic and treatment options available for intussusception. The etiologies of childhood intussusception are discussed. Details and literature review are provided on the advantages and disadvantages of ultrasonography, barium enema, air contrast enema, and surgery in the diagnosis and treatment of intussusception.

Impact of sonography on the diagnosis and treatment of acute lower abdominal pain in children and young adults

OBJECTIVE

Our purpose was to evaluate the impact of sonographic data on clinical physicians' diagnostic confidence and their treatment of children and young adults with acute lower abdominal pain.

SUBJECTS AND METHODS

Senior surgical and emergency department staff completed questionnaires before and after abdominal sonography was performed on 94 of 101 consecutive children and young adults with acute lower abdominal pain, pelvic pain, or both. Physicians who were unaware of sonographic data stated the most likely diagnosis and their level of confidence in their diagnosis and then formulated clinical plans. After they were given sonographic data, physicians again stated the most likely diagnosis, estimated their level of confidence, and formulated revised treatment plans.

RESULTS

Sonographic data resulted in revised clinical diagnoses in 52% of the patients. Overall, the gain in diagnostic confidence for the entire study population was 33% (95% confidence interval [CI], 27-38%; p < .0001). The impact on the physicians' confidence was greater in those children and young adults whose diagnoses changed after sonography (mean increase in physicians' confidence, 48.3%; 95% CI, 47-75%). In patients whose diagnoses were not changed after sonography, the mean increase in physicians' confidence was 17.6% (95% CI, 11-24%; p < .0001 [analysis of variance]). Physicians used sonographic data to change initial treatment plans in 43 patients (46%). Of these 43 patients, a lower intensity of care was given to 30 patients (70%) and a higher intensity to 13 patients (30%).

CONCLUSION

Sonographic data frequently changed initial clinical diagnoses, thus increasing diagnostic confidence and changing clinical treatment decisions in the setting of acute lower abdominal pain in children and young adults.

Insulin-like growth factor-I gene expression in three models of accelerated lung growth

BACKGROUND/PURPOSE

We have learned previously that in utero tracheal ligation reverses the structural and physiological effects of surgically created congenital diaphragmatic hernia. In addition, we have discovered that postnatal lung growth similarly can be accelerated using liquid-based airway distension with perfluorocarbon. Another model of accelerated lung growth is that of compensatory growth seen after neonatal pneumonectomy. In all of these models, growth has occurred because of an increase in alveolar number rather than enlargement of preexisting alveoli. However, the molecular mechanisms underlying these processes remain unknown. The purpose of this study was to determine if gene expression could be altered by changes in physical forces in the prenatal and postnatal lung.

METHODS

The three models of accelerated lung growth studied were the following: (1) The prenatal group, consisted of fetal lambs (n = 12) that underwent the surgical creation of a left diaphragmatic hernia at 90 days' gestation. Six of these animals also underwent simultaneous tracheal ligation. (2) The PFC group consisted of five neonatal animals that underwent isolation of the superior segment of the right upper lobe, with intrabronchial distension with perfluorocarbon to 7 to 10 mm Hg pressure for a 3-week period. (3) The postpneumonectomy group consisted of four neonatal animals that underwent left pneumonectomy. In the fetal study, lungs were retrieved at term (130 days), and in the postnatal study, lungs were retrieved 3 weeks after initial intervention. In all cases, RNA was extracted from snap-frozen lung samples and Northern blot analysis performed.

RESULTS

Insulinlike growth factor-I, insulinlike growth factor-II, and vascular endothelial growth factor gene expression were analyzed by densitometry. Insulinlike growth factor-I gene expression was found to be decreased in association with experimental diaphragmatic hernia (P = .005), but restored to normal with tracheal ligation. Insulinlike growth factor-I gene expression was significantly increased in both postnatal models of accelerated lung growth (P = .022, P = .016). No significant differences were found in insulinlike growth factor-II or vascular endothelial growth factor gene expression.

CONCLUSIONS

The authors conclude from these preliminary data that (1) insulin like growth factor-I gene expression is reduced in experimental fetal diaphragmatic hernia and restored to normal by tracheal ligation, and (2) insulinlike growth factor-I gene expression is increased in both the liquid-based airway distension and postpneumonectomy models of accelerated postnatal lung growth. The authors speculate that all of these manipulations exploit a natural pathway essential for normal lung growth.

Continuous intrapulmonary distension with perfluorocarbon accelerates neonatal (but not adult) lung growth

BACKGROUND/PURPOSE

We have previously demonstrated that experimental fetal tracheal ligation reverses the structural and physiological effects of pulmonary hypoplasia associated with congenital diaphragmatic hernia. The purpose of this study was to determine if lung growth could be similarly accelerated postnatally by continuous liquid-based intrapulmonary distension.

METHODS

Ten neonatal lambs were divided into two experimental groups. Five neonatal animals underwent a right thoracotomy with isolation of the anterior superior segment of the right upper lobe. A pressure monitoring catheter was introduced and perfluorocarbon (PFC) was instilled into the segment. Animals were subjected to a 21-day distention period with continuous maintenance of 7 to 10 mm Hg intrabronchial pressure. Five other neonatal animals used as age- and weight-matched controls were killed immediately after distension with PFC to 7 to 10 mm Hg. To evaluate the effect of age on postnatal growth, identical procedures were performed on seven mature sheep. Four adult animals underwent a 21-day distension with PFC, and three animals were killed immediately after PFC distension.

RESULTS

Neonatal animals who underwent distension showed a significant acceleration of lung growth based on right upper lobe volume to body weight ratio (P = .0019), total alveolar number (P = .003), and total alveolar surface area (P = .006), when compared with controls. Alveolar growth was attributed to an increased alveolar number rather than increased alveolar size based on a normal histological appearance, normal airspace fraction (P = NS), and normal alveolar numerical density (P = NS). In contrast, no significant differences in lung growth or maturation indices were present in adult animals.

CONCLUSIONS

From this preliminary data we conclude: (1) Liquid-based airway distension does accelerate postnatal lung growth, (2) lung architecture remains normal during this period of accelerated growth, (3) adult sheep do not respond to liquid-based airway distension with lung growth, and (4) prolonged exposure to intrapulmonary PFC appears to be safe. We speculate that stretch is the stimulus for lung growth because there are no known growth factors present in PFC.

Experimental fetal tracheal ligation and congenital diaphragmatic hernia: a pulmonary vascular morphometric analysis

The authors have previously shown that fetal tracheal ligation (TL) reverses the pulmonary hypoplasia in experimental diaphragmatic hernia (DH) by accelerating fetal alveolar growth. The purpose of this study was to determine if growth of the accompanying macroscopic and microscopic pulmonary vasculature is also accelerated. Eighteen fetal lambs were divided into three experimental groups: diaphragmatic hernia (DH), DH and simultaneous tracheal ligation (DH/TL), and sham-operated controls (C). Animals were delivered near term, the lungs retrieved, and pulmonary capillary growth (5 to 50 microns in diameter) evaluated by standard morphometric techniques. Capillary ultrastructure was evaluated by electron microscopy. Nine additional fetal lambs of the same gestational age were equally divided into the same three groups and their lungs analyzed by pulmonary arteriography for evaluation of large vessel growth (< 100-microns diameter). Computer digital analysis of angiogram lung slices showed that the total area of large vessels was increased in DH/TL lungs when compared with DH lungs and decreased in DH lungs when compared with C lungs (P = .003); however, the ratio of large vessel area per unit of lung area was similar in all groups. Microscopic morphometry of the capillary bed showed that the total number of capillaries was increased in DH/TL lungs over both DH and C lungs (P = .0001); however, the number of capillaries per alveolus (cap/alv) was similar in all groups. In DH/TL lungs, electron microscopy showed normal capillary wall structure and normal thickness of the capillary-alveolar interface, whereas in DH lungs, capillary structure was abnormal and the capillary-alveolar interface was thickened.(ABSTRACT TRUNCATED AT 250 WORDS)

Lung development

Human lung development is divided into five stages: embryonic, pseudoglandular, canalicular, saccular, and alveolar. The boundaries between these stages are not sharp; rather, overlap occurs between various gestational ages and individuals. The anatomic and morphological characteristics of each stage are described; general principles of lung development and cytodifferentiation of type I and type II pneumocytes are discussed. The complex phenomenon of lung development incorporates two processes--lung growth and lung maturation. Although these processes are developmentally related, they appear to be separately controlled. Lung growth seems to be influenced primarily by physical factors such as intrathoracic space, lung liquid volume and pressure, and amniotic fluid volume among others. Special attention is given to fetal lung liquid dynamics and the effects of its manipulation on lung growth, particularly by tracheal occlusion. Lung maturation has two components--structural and biochemical (ie, surfactant). Structural lung maturation appears to be regulated by physical factors. Physical factors that produce hypoplasia produce structurally immature lungs, whereas physical factors that produce hyperplasia produce structurally mature lungs. Biochemical maturation appears to be hormonally regulated by several endocrine organs (pituitary, adrenal, thyroid) and a host of endocrine factors including corticotropin, cortisol, thyroid hormones, and others.

Experimental fetal tracheal ligation reverses the structural and physiological effects of pulmonary hypoplasia in congenital diaphragmatic hernia

Infants with congenital diaphragmatic hernia (DH) and profound pulmonary hypoplasia are currently unsalvageable. The authors previously demonstrated that tracheal ligation (TL) accelerates fetal lung growth and reverses the pulmonary hypoplasia of fetal nephrectomy. The purpose of this study was to determine if the pulmonary hypoplasia of experimental DH could be similarly reversed and, if so, whether the resulting lungs would show better function than those of their DH counterparts. Eighteen fetal lambs were divided into three experimental groups of six animals each. In group 1, DH was created at 90 days' gestation. In group 2, DH was created at 90 days' gestation and TL performed during the same operation. Group 3 consisted of sham-operated controls. These animals were delivered near full-term, and their lungs analyzed by standard morphometric techniques. Ten additional fetal lambs were divided into two experimental groups of five animals each. In group 4, DH was created at 90 days' gestation. In group 5, DH was created at 90 days' gestation and TL performed 20 days later, at 110 days' gestation. These animals were pressure-ventilated via tracheostomy over a 2-hour period in which PaO2, PaCO2, and compliance were measured. Intratracheal pressure (ITP) was measured at the time of delivery in all groups. Upon retrieval, DH animals had abdominal viscera in the chest and small lungs; in contrast, DH/TL animals had the herniated viscera reduced from the chest by enlarged lungs. DH/TL lungs showed markedly increased growth, with significant increases in lung volume:body weight ratio (LV:BW; P = .0001), alveolar surface area (ALV.SA; P = .0001), and alveolar number (ALV#) (P = .0001) when compared with those of the DH or control group. This growth was associated with a normal maturation pattern based on histological appearance, normal airspace fraction, and normal alveolar numerical density. ITP in the DH/TL group was increased when compared with that of DH and control animals (P = .0001). Total lung DNA and protein were both elevated in the DH/TL animals (P = .0001). However, the DNA:protein ratio remained normal, suggesting lung growth had occurred through cell proliferation, not by hypertrophy. When ventilated over a range of settings, DH/TL lungs were more compliant (P = .0001) and achieved higher PaO2s (P < .003) and lower PaCO2s (P = .0001) than their DH counterparts. From these data, the authors conclude: (1) Experimental fetal DH produces hypoplastic lungs that are not capable of adequate gas exchange with conventional ventilation.(ABSTRACT TRUNCATED AT 400 WORDS)

Experimental fetal tracheal ligation prevents the pulmonary hypoplasia associated with fetal nephrectomy: possible application for congenital diaphragmatic hernia

Pulmonary hypoplasia has a definite clinical impact in a variety of congenital diseases such as renal dysplasia and congenital diaphragmatic hernia. These diseases have in common inadequate growth and development of fetal lungs. Previous reports have demonstrated increased lung growth with in utero tracheal ligation. The purpose of this study was to determine if lung growth can be accelerated in the setting of experimental pulmonary hypoplasia. Ninety-five-day gestation fetal sheep were divided into four experimental groups: nephrectomy, nephrectomy with tracheal ligation, tracheal ligation alone, and sham-operated control animals. Animals were delivered near term and their lungs inflation fixed at 25 cm H2O. Total alveolar number (Alv#), total alveolar surface area (AlvSA), and lung volume to body weight ratios (LV:BW) were determined for apical and basilar segments of each animal and then averaged. Total lung DNA and protein content were also analyzed. The nephrectomy group had smaller lungs than control animals with decreased Alv#, AlvSA, and LV:BW. In contrast, nephrectomy with tracheal ligation produced large lungs which had increased Alv#, AlvSA, and LV:BW when compared with both the nephrectomy and the control group (P < .01). Total lung DNA and protein concentrations were both markedly elevated in the tracheally obstructed groups. However, the DNA/protein ratios remained constant in all four groups, suggesting that lung growth had occurred through cell multiplication. Photomicrographs of the lung demonstrated a histologically immature appearance in the nephrectomy group and a histologically mature appearance in the tracheally obstructed groups.(ABSTRACT TRUNCATED AT 250 WORDS)