Optimizing throughput of babies with infantile hypertrophic pyloric stenosis

BACKGROUND

Definitive surgical care is often delayed in hypertrophic pyloric stenosis (HPS). Our aim is to evaluate the effect modifiable factors in preoperative HPS management have on efficiency of care.

METHODS

A retrospective review of all patients undergoing pyloromyotomy for HPS at two US children's hospitals between 2008 and 2018 was performed.

RESULTS

406 patients were included in the study. The majority (310, 76 ​%) were adequately resuscitated and ready for surgery upon diagnosis in the ER. However, only 133 patients (43 ​%) had surgery on the day of admission. Patients diagnosed between 12pm and 6pm were more likely to have surgery the next day than those diagnosed before noon (67 ​% vs 33 ​%, p ​< ​.001), which correlated with a longer length of stay (32 vs 47 ​h, p ​< ​.001).

CONCLUSION

The majority of patients presenting with HPS can safely undergo same day surgery. Delaying surgery due to an afternoon diagnosis is common, and leads to a modifiable increased total length of stay.

Laparoscopic Repair of Pediatric Femoral Hernias

Background: Current rates of reported pediatric femoral hernias remain exceedingly low, with their incidence reported to be <1%. The mainstay of repair has traditionally been through an open approach, and pediatric surgeons remain reluctant to repair otherwise. Owing to its rarity, consensus regarding management remains absent. Because of this, we present a scoping review on the use of laparoscopy and minimally invasive techniques to repair pediatric femoral hernias. Methods: A scoping literature review was performed using PubMed, Embase, Scopus, and Web of Science for related articles (keywords). Full-text articles and abstracts were then reviewed for relevance using inclusion and exclusion criteria with data extracted from each piece. Results: The search identified 268 articles published from 1992 to 2023. Eleven articles met our inclusion criteria. After reviewing their content, a total of 87 patients were identified. Of these, 42 laparoscopic repairs were reported. Three primary laparoscopic surgical techniques were described, with no recurrence reported. Conclusion: Laparoscopy remains a viable tool in diagnosing and managing femoral hernias. Various technically feasible options for laparoscopy and minimally invasive techniques have been described with excellent results and limited recurrence. However, given the quality of the data, further studies are needed to investigate the long-term durability of such repairs.

Medium-Term Outcomes of the Godoy Burnia Repair: Durability of a Sutureless Laparoscopic Inguinal Hernia Repair in Girls

Background: Several methods to repair pediatric inguinal hernias utilizing a minimally invasive technique have been developed over the decades. These methods often involve passage of suture through the peritoneum at the level of the inguinal ring. We previously described the Godoy Burnia, a laparoscopic, sutureless, cautery-only inguinal hernia repair (IHR), and this follow-up study provides longer term data for this emerging surgical technique. Methods: After institutional review board approval, a single-centered retrospective review was performed of female pediatric patients with Godoy Burnia repair from 2014 to 2021. Demographics, operative details, and outcomes were reviewed. Technique: Through a single umbilical incision, a 3 mm port and camera and 3 mm Maryland dissector are placed into the abdomen. The Maryland dissector grasps the hernia sac, everts it, and brings it into the abdomen. Electrocautery is applied to allow scarring and closure of the inguinal ring. Results: Sixty-nine hernia repairs were performed on 44 patients with ages 5 days to 16 years (average 3.9 years) and weighing 2-70 kg (average 16 kg). Average follow-up was 52.8 months, and average operative times were 14/16 minutes for unilateral/bilateral repair, respectively. Twenty-two percent of hernias were found at time of another surgery and repaired. One recurrence (1.45%) in a 16-year-old patient, and 2 patients with other short-term complications. Conclusions: Godoy Burnia, a single-incision, sutureless, laparoscopic IHR in girls, is an acceptable alternative surgical technique with a low complication and recurrence rate. The longer follow-up in this study demonstrates the durability of the repair in most age groups, and decreased operative times suggest a favorable learning curve.

The Evolving Effectiveness of Biologics in Avoiding Surgery in Children With Ulcerative Colitis: At what Nutritional Cost?

BACKGROUND

Pediatric ulcerative colitis (UC) treatment has changed dramatically with the introduction of multiple biologics. The goal of this study was to determine the effectiveness of these new biologics on achieving remission, nutritional impact, and eventual need for surgery in children.

METHODS

We retrospectively analyzed hospital records of UC patients (ages 1-19) seen at a pediatric gastroenterology clinic between January 2012 andAugust 2020. Patients were divided into groups: 1) medically without biologics or surgery; 2) patients treated with one biologic; and 3) patients treated with multiple biologics 4)patients that underwent colectomy.

RESULTS

There were 115 UC patients with a mean follow-up of 5.9 ± 3.7 years (1 month-15.3 years). PUCAI score at diagnosis was mild in 52 patients (45%), moderate in 25 (21%), and severe in 5 (4.3%). PUCAI score for 33 patients (29%) could not be calculated. There were 48 (41.3%) in group 1 with 58% remission, 34 (29.6%) in group 2 with 71% remission, 24 (20.8%) in group 3 with 29% remission, and only 9 (7.8%) in group 4 with 100% remission. The majority (55%) of surgical patients had colectomy within the first year of diagnosis. BMI improved after surgery (P = 0.001). The change from one biologic to others did not improve nutrition over time.

DISCUSSION

New biologics are changing the landscape in maintaining remission from UC. The current need for surgery is much lower than previously published studies. In medically refractive UC, nutritional status only improved after surgery. Addition of another biologic for medically refractory ulcerative colitis in order to avoid surgery must take into account the positive impact surgery has on nutrition and disease remission.

Identifying barriers to resident robotic console time in a general surgery residency through a targeted needs assessment

Robotic-assisted general surgery is experiencing exponential growth. Despite our institution's high volume, residents often graduate with inadequate console experience. Our aim was to identify the educational needs of residents and perceived barriers to residents' console time from both attendings and residents. Separate surveys were created and distributed to robotic surgery faculty and general surgery residents at our institution. Questions were a variety of modalities and focused on the robotic surgery experience at our institution, including barriers to resident console time from both attending surgeon and resident perspectives. Although residents' interest in robotic surgery exceeded that of open and laparoscopic surgery, confidence in their robotic skills was low compared to the other modalities. The top barriers to participating in robotic cases according to residents included minimal or no previous console time with the attending, lack of simulator time, and being required to perform bedside assistant duties. Faculty reported resident preparedness, prior robotic skill demonstration, simulator time, case complexity, and their own confidence as significant factors influencing resident console time. Using these results, we concluded that the design and implementation of a formal robotic surgery curriculum should incorporate simulation-based opportunities for residents to practice their skills, improve confidence, and increase console experience. In addition, simulation opportunities for faculty should also be considered to allow for improvement and maintenance of robotic surgical skills.

The novel application of an emerging device for salvage of primary repair in high-risk complex esophageal atresia

INTRODUCTION

Preservation of native esophagus is a tenet of esophageal atresia (EA) repair. However, techniques for delayed primary anastomosis are severely limited for surgically and medically complex patients at high-risk for operative repair. We report our initial experience with the novel application of the Connect-EA, an esophageal magnetic compression anastomosis device, for salvage of primary repair in 2 high-risk complex EA patients. Compassionate use was approved by the FDA and treating institutions.

OPERATIVE TECHNIQUE

Two approaches using the Connect-EA are described - a totally endoscopic approach and a novel hybrid operative approach. To our knowledge, this is the first successful use of a hybrid operative approach with an esophageal magnetic compression device.

OUTCOMES

Salvage of delayed primary anastomosis was successful in both patients. The totally endoscopic approach significantly reduced operative time and avoided repeat high-risk operation. The hybrid operative approach salvaged delayed primary anastomosis and avoided cervical esophagostomy.

CONCLUSION

The Connect-EA is a novel intervention to achieve delayed primary esophageal repair in complex EA patients with high-risk tissue characteristics and multi-system comorbidities that limit operative repair. We propose a clinical algorithm for use of the totally endoscopic approach and hybrid operative approach for use of the Connect-EA in high-risk complex EA patients.

Warning Labels and High-Powered Magnet Exposures

BACKGROUND AND OBJECTIVES

High-powered magnets are among the most dangerous childhood foreign bodies. Consumer advocates and physicians have called for these products to be effectively banned, but manufacturers assert warning labels would sufficiently mitigate risk.

METHODS

Subjects from Injuries, Morbidity, and Parental Attitudes Concerning Tiny High-powered Magnets (IMPACT of Magnets), a retrospective, multicenter study of children with high-powered magnet exposures (ie, ingestion or bodily insertion), were contacted. Consenting participants responded to a standardized questionnaire regarding the presence and utility of warning labels, magnet product manufacturer, and attitudes around risk.

RESULTS

Of 596 patients in the IMPACT study, 173 parents and 1 adult patient were reached and consented to participate. The median age was 7.5 years. Subjects reported not knowing if a warning label was present in 60 (53.6%) cases, whereas 25 (22.3%) stated warnings were absent. Warnings were present in 28 (24.1%) cases but only 13 (46.4%) reported reading them. A manufacturer was identified by families in 28 (16.1%) exposures; 25 of these were domestic and 27 had warnings. Subjects reported knowing magnets were dangerous in 58% of the cases, although 44.3% believed they were children's toys and only 6.9% knew high-powered magnets were previously removed from the United States market.

CONCLUSIONS

Over 90% of subjects from the IMPACT study didn't know if warning labels were present or failed to read them if they were, whereas almost half believed high-powered magnets were children's toys. Warning labels on high-powered magnet products are, therefore, unlikely to prevent injuries in children.

Value of robotic surgery simulation for training surgical residents and attendings: a systematic review protocol

INTRODUCTION

Robotic surgery is a method of minimally invasive surgery performed through small incisions using a remote robotic console. Surgical residents and attendings participate in simulation training to be able to effectively perform robotic surgery using wet labs, dry labs and virtual reality platforms. Our objective is to identify the effectiveness of robotic simulation on novice robotic surgeons. This review will answer our review question: To what extent are robotic simulations for training novice robotic general surgery residents and attendings associated with improved outcomes in comparison with no simulation training?

METHODS AND ANALYSIS

A comprehensive search of PubMed, Embase, the Cochrane Library and Web of Science was performed. The studies were then determined to meet initial screening criteria by one individual for abstract and title with full text screening performed by two authors independently and in duplicate. Narrative themes will be collected, analysed and summarised where possible.

ETHICS AND DISSEMINATION

There is no Institutional Review Board approval required given that the work is carried out on previously published papers. The final manuscript and results will be presented and published at an academic conference and peer -reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021274090.

Intraoperative uses of near-infrared fluorescence spectroscopy in pediatric surgery: A systematic review

BACKGROUND

The application of near infrared spectroscopy (NIRS) imaging in surgery is growing. This study aimed to systematically review the literature to summarize the intraoperative uses of NIRS in pediatric surgery.

METHODS

A PRISMA-compliant literature search was conducted in PubMed, Embase, Scopus, and Web of Science from inception to February 2020. Title/abstract and then full-text screening were performed. The Oxford centre for Evidence Based Medicine tool (OCEBM) was used to evaluate the level of evidence of included studies.

RESULTS

Reviewers identified 53 articles. Of which, 34 studies (64.2%) were case-series and 11 (20.8%) were case reports. Most of the studies (n = 45, 84.9%) were level 4 on the OCEBM tool. The most common uses of NIRS were to visualize the biliary tree and to identify primary and metastatic malignant tissues. Other applications include assessment of perfusion of tissues including bowel anastomoses, and lymphatic surgery. Several advantages of the introduction of NIRS in pediatric surgery exist including having the potential to reduce operative time and intra/post-operative complications. Moreover, NIRS helps in detecting malignant tissues that can be missed by conventional imaging. However, NIRS has important limitations such as difficulty in identification of the biliary tree in obese patients or inflamed gallbladder, detection of small deeply localized malignant tissues, as well as the high cost.

CONCLUSIONS

NIRS is a promising modality that can be used intraoperatively to augment different pediatric surgical procedures. NIRS has important advantages and limitations compared to conventional surgery, however, more studies are required to evaluate its outcomes and cost-effectiveness.

LEVEL OF EVIDENCE

IV.

Endoluminal Silicone-Covered Stenting in Children: Novel Applications and Lessons Learned

BACKGROUND

Silicone-covered endoluminal stents have been applied to various hollow visceral disorders in adult patients with varying success. Efficacy of retrievable endoluminal stenting in children is less well-established.

PURPOSE

The purpose of this study was to evaluate our experience with evolving applications of endoluminal silicone-covered stenting in children.

RESEARCH DESIGN

Eight children 19 years and younger having silicone-covered stent placement for various indications at a single institution (2014-2021) were reviewed retrospectively.

RESULTS

Eight patients received a total of 26 silicone-covered stents. Four stent placements (15.4%) were associated with a direct adverse event. To resolve the endoluminal disorder, four patients received multiple stents or further intervention. When evaluating novel applications, clinical benefit was noted for one patient with vaginal atresia, and another after ileal pouch anal anastomosis disruption.

CONCLUSION

This experience highlights the broad and innovative applications for endoluminal silicone-covered natural orifice stenting in children. Acute processes respond well and rapidly to stenting, although chronic, established fistula may require additional manipulations or surgery.

High-Powered Magnet Exposures in Children: A Multi-Center Cohort Study

BACKGROUND AND OBJECTIVES

High-powered magnets were effectively removed from the US market by the Consumer Product Safety Commission (CPSC) in 2012 but returned in 2016 after federal court decisions. The United States Court of Appeals for the 10th Circuit cited imprecise data among other reasons as justification for overturning CPSC protections. Since then, incidence of high-powered magnet exposure has increased markedly, but outcome data are limited. In this study, we aim to describe the epidemiology and outcomes in children seeking medical care for high-powered magnets after reintroduction to market.

METHODS

This is a multicenter, retrospective cohort study of patients aged 0 to 21 years with a confirmed high-powered magnet exposure (ie, ingestion or insertion) at 25 children's hospitals in the United States between 2017 and 2019.

RESULTS

Of 596 patients with high-powered magnet exposures identified, 362 (60.7%) were male and 566 (95%) were <14 years of age. Nearly all sought care for magnet ingestion (n = 574, 96.3%), whereas 17 patients (2.9%) presented for management of nasal or aural magnet foreign bodies, 4 (0.7%) for magnets in their genitourinary tract, and 1 patient (0.2%) had magnets in their respiratory tract. A total of 57 children (9.6%) had a life-threatening morbidity; 276 (46.3%) required an endoscopy, surgery, or both; and 332 (55.7%) required hospitalization. There was no reported mortality.

CONCLUSIONS

Despite being intended for use by those >14 years of age, high-powered magnets frequently cause morbidity and lead to high need for invasive intervention and hospitalization in children of all ages.

Recurrence after laparoscopic high ligation in adolescents: A multicenter international retrospective study of ten hospitals

PURPOSE

Inguinal hernia repairs are among the most common operations performed by pediatric surgeons. Laparoscopic high ligation is a popular technique, but its recurrence rate in adolescents is unknown. We hypothesized that recurrence after laparoscopic high ligation in adolescents would be similar to open repair (1.8%-6.3%).

METHODS

We evaluated adolescent patients (12-18 years old at the time of surgery) who underwent laparoscopic high ligation across eleven hospitals. At least six months postoperatively, they were contacted by telephone for follow-up. Variables analyzed included demographics, operative details, recurrence, and other complications.

RESULTS

A total of 144 patients were enrolled. One hospital (n=9) had a recurrence rate of 44.4%, compared to 3.0% (4/135) for the other hospitals. By accounting for 50.0% of recurrences, it represented a statistical outlier and was excluded, leaving 135 patients for analysis. The median age was 14 years, and 63.7% were male. Recurrence with the excluded center was 5.6% (8/144). Use of absorbable suture (OR 42.67, CI 4.41-412.90, p<0.01) and braided suture (OR 12.10, CI 1.54-95.25, p=0.02) was weakly associated with recurrence. Recurrence was not significantly different from published results.

CONCLUSION

Laparoscopic high ligation of adolescent inguinal hernias has a recurrence rate similar to open repair when performed by experienced surgeons.

TYPE OF STUDY

Prognosis study (retrospective study) LEVEL OF EVIDENCE: Level II.

Cost-Effective Approach to the Laparoscopic Appendectomy : Balancing Disposable Instrument Cost With Operative Time

BACKGROUND

Surgeons can help reduce health care spending by selecting affordable and efficient instruments. The laparoscopic appendectomy (LA) is commonly performed and can serve as a model for improving health care cost.

METHODS

We retrospectively reviewed all adult patients who underwent LA for non-perforated appendicitis from March 2015 to November 2017. Our objective was to determine which combination of disposable instruments afforded the lowest total operative cost without compromising postoperative outcomes.

RESULTS

In total, 1857 consecutive patients were reviewed from 2 hospitals. After determining the 8 most commonly utilized combinations of disposable instruments, 846 patients were ultimately analyzed. The combination of a LigaSure, Endoloop, and an EndoBag (LEB) had the shortest median operative time (25 minutes, P < .001) and lowest median total operative cost ($1893, P < .001).

CONCLUSIONS

The LEB instrument combination rendered the shortest operative time, lowest total operative cost, and can be used to maximize surgical value during LA.

Implementation of a pediatric trauma cervical spine clearance pathway

PURPOSE

Pediatric cervical spine injuries are rare events. Missed injuries must be weighed against radiation exposure and excess resource utilization in a young population. A universal pediatric cervical spine clearance algorithm does not exist. The study objective is to determine if care improved after the implementation of a standardized cervical spine clearance pathway by evaluating imaging rates, length of stay, speciality consultation, and injury detection.

METHODS

A multidisciplinary group reviewed relevant literature to develop an algorithm for cervical spine clearance in pediatric trauma patients. We reviewed patient charts 15 months before and after implementation. Categorical comparisons were tested with Chi-square. A p value less than 0.05 was considered statistically significant.

RESULTS

The pre- and post-implementation groups were homogenous when comparing demographics, mechanism and severity of injury. Using the cervical spine clearance pathway, patients received fewer plain cervical spine radiographs (34% vs 16%), fewer spine speciality consults (28% vs 13%), and more patients were cleared clinically (44% vs 62%) (p < 0.05). There were 2 (1.7%) documented injuries in the pre-implementation group and 3 (3%) documented injuries in the post-implementation group. There were no missed injuries.

CONCLUSIONS

Use of a standardized pathway allows more patients' cervical spines to be cleared clinically and better utilizes resources without compromising patient care.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Care Management Study.

Paraduodenal hernias in children: Etiology, treatment, and outcomes of a rare but real cause of bowel obstruction

•

Paraduodenal Hernia has rarely been reported in the pediatric age group.

•

Paraduodenal Hernia is a rare cause of intestinal obstruction and is often misdiagnosed.

•

CT-scan is the gold standard mean for diagnosis in most cases.

•

Paraduodenal Hernia must be kept in mind as a possible cause of intestinal obstruction.

Introduction

Paraduodenal Hernia (PDH) is the most common variant of internal hernia and occurs most often in males during their 4^th–6^th decades of life. PDH in pediatric age group has rarely been reported in literature with only five cases of age up to 10 years were reported. PDH is a rare cause of intestinal obstruction, which may lead to subsequent strangulation and perforation of the bowel.

Presentation of case

We reported a 1.5 year-old male child presented with intestinal obstruction. The patient experienced abdominal pain, vomiting and irritability. Abdominal x-ray showed distal intestinal obstruction which was discovered to be a result of left PDH incidentally during the surgery. In addition, we performed a literature search using PubMed to identify the published cases of PDH. We also compared our case with the characteristics of all reported PDHs in toddlers and children up to 10 years of age in a concise table.

Discussion

Despite its congenital origin, PDH has been reported in childhood age group in very rare occasions rendering the accurate incidence of PDH in infancy and childhood unknown. PDHs can be asymptomatic or can present most commonly with recurrent upper abdominal pain. Diagnosis is quite difficult in the absence of symptoms but could be achieved using a computed tomography (CT-scan) in non-emergency symptomatic patients. Surgical repair is mandatory to avoid potential complications.

Conclusion

As PDH can lead to major and life threatening complications, it must remain in our minds as a possible cause of intestinal obstruction.

Preoperative esophagogastroduodenoscopy in patients without reflux symptoms undergoing laparoscopic sleeve gastrectomy: utility or futility?

Aim

To evaluate the value of esophagogastroduodenoscopy (EGD) as a preoperative investigation in individuals without symptoms of Gastro-Esophageal Reflux Disease (GERD) who will undergo laparoscopic sleeve gastrectomy (LSG).

Materials and methods

After Institutional Review Board approval was obtained, patients scheduled for LSG were prospectively enrolled in the study between January 2016 and March 2018. Patients with symptoms of GERD were excluded from the study. Participants were randomly allocated to two groups: individuals who underwent EGD before the surgery as a usual routine investigation (Group A), and individuals who were scheduled without preoperative EGD (Group B). Patient demographics, endoscopic findings, endoscopic biopsy results, and histopathological findings of the resected parts of the stomach after LSG were analyzed and recorded. Additionally, operative characteristics and outcomes, and follow up findings were recorded and analyzed with appropriate statistical methods.

Results

A total of 219 individuals without symptoms of GERD underwent LSG were enrolled. Group A included 111 individuals (25 males and 86 females). Group B comprised 108 individuals (20 males and 88 females). The mean age and mean Body Mass Index (BMI) were similar in both groups. From Group A, 86 out of 111 individuals (77.5%) had no pathology identified on EGD, while 21 individuals (18.9%) were found to have areas of gastric erythema and biopsies showed active gastritis. All LSG operations were performed without any major complication. After one year, all individuals were assessed for the presence of symptomatic GERD and no significant difference was found between the two groups.

Conclusion

Preoperative EGD may not be mandatory for asymptomatic GERD individuals undergoing LSG as post-operative complications and early follow up for GERD symptoms are not significantly different. Further prospective studies with longer follow up are needed to evaluate the role of EGD in individuals undergoing LSG.

Postoperative intestinal intussusception in children, an easily missed culprit of postoperative intestinal obstruction: Case series and literature review

•

Most of our patients presented in the first two weeks after the primary operation and managed successfully with operative manual reduction with no postoperative complications.

•

Postoperative intestinal intussusception secondary to surgical reduction of ileocolic intussusception is an exceedingly rare cause of postoperative intestinal obstruction.

•

Usually, postoperative intestinal intussusception is misdiagnosed as postoperative adhesive obstruction.

•

Postoperative intestinal intussusception is challenging in diagnosis and needs a very high index of suspicion.

•

By keeping the possibility of POI in mind, one can easily diagnose it and prevent its consequences.

Background

Postoperative intestinal intussusception (POI) is a rare cause of intestinal obstruction with POI after surgical reduction of ileocolic intussusception being an extremely rare variant. POI was reported to follow many abdominal and non-abdominal operations. A late diagnosis can risk ischemia and necrosis. POI also increases the morbidity and mortality, rendering an early diagnosis and prompt management as lifesaving.

Methods

We reviewed the medical charts retrospectively for the last ten years for patients with POI at Palestine Red Crescent Society Hospital, Hebron, Palestine. We reviewed the literature and presented the characteristics of the most reported cases of POI following surgical reduction of ileocolic intussusception.

Results

We presented three cases of ileoileal POI and one case of ileocolic POI followed different primary operations. All but one patient presented in the first two weeks. The delayed presentation came two months after revision of a prolapsed colostomy. All patients managed successfully with operative manual reduction with no postoperative complications. Initially, we had struggles in the diagnosis of POI largely due to a low suspicion for this rare entity, but thereafter we kept POI in mind and managed the after-coming cases in an expeditious manner.

Conclusion

Frequently, POI is misdiagnosed as postoperative adhesive obstruction. POI is challenging in diagnosis and needs a very high index of suspicion, mainly due to its rarity and atypical presentation. By keeping the possibility of POI in mind, one can easily diagnose it and prevent its consequences.

Esophageal caustic injuries in pediatrics: a sobering global health issue

Caustic material ingestion by children is considered a global healthcare issue, especially in low-to-middle income countries. The aim of this article was to review the epidemiology, prevention, and management of caustic material ingestion in pediatric patients, comparing low-to-middle income countries with high-income countries. We conducted an English literature review using PubMed with the following keywords: (caustic OR corrosive) AND ingestion AND (pediatric OR pediatric). Our search retrieved 253 citations; all abstracts were screened by the authors, and 52 articles were finally included in our review. Prevention is key in tackling this issue, but legislation is scarce in low-to-middle income countries. Diagnosis of caustic ingestion is mostly achieved using flexible endoscopy, computed tomography, and endoscopic ultrasound, but access is limited in low-to middle income countries and diagnosis is often delayed. After stabilizing patients, the mainstay of treatment is graded endoscopic dilatation, and rarely, esophageal replacement. We concluded that caustic ingestion represents a serious condition where prevention is the key. Once a child suffers an injury, rapid and careful evaluation of the injury with endoscopy, and a course of close observation and dilations if needed, will often avoid esophageal replacement. When necessary, the stomach is the best first option if it is viable, followed by the colon, and finally, the jejunum.

Benefits of a family-centered approach to pediatric induction of anesthesia

BACKGROUND/PURPOSE

We initiated a pediatric surgical program including a caregiver for the induction of anesthesia. We measured preoperative midazolam administration, preoperative time, induction time, and program satisfaction.

METHODS

Families with children undergoing surgery during the study period were included. Preoperative midazolam administration, preoperative time, and induction time were compared between participants and controls. Satisfaction surveys were given to participating caregivers and staff.

RESULTS

The rate of preoperative midazolam use decreased from 41% (392/964) to 13% (16/118) among participants vs controls (p < 0.0001). After linear regression analysis, this difference persisted as an adjusted odds ratio of 0.29 (95% CI = 0.16-0.52). Preoperative and induction times (minutes) were similar between groups (76.2 vs 82.2, 13.8 vs 16.2, p = nonsignificant). Based on 5-point Likert surveys, the program was rated as "beneficial" or "very beneficial" to the patient by caregivers (99.2%) and staff (77.5%). Caregivers stated it "reduced" or "greatly reduced" anxiety for them (87.1%) and their child (93.2%).

CONCLUSIONS

Opponents of similar programs suggest familial presence slows care and is disruptive. Our program decreased utilization of preoperative anxiolytics with no effect on operating room efficiency. Both hospital staff and participants felt the program was beneficial to the patient. Perceived caregiver and child anxiety was reduced.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

A Novel Nonelectrosurgical Technique for Incising the Pylorus in Laparoscopic Pyloromyotomy

OBJECTIVE

Since the loss of the protected arthrotomy knife several years ago, pediatric surgeons have struggled to find a safe, reliable, and inexpensive way to incise the pyloric serosa before spreading the muscle. The most widely accepted method of cutting the serosa is with electrocautery, although some still question its safety. We introduce a novel technique of incising the serosa with a percutaneously inserted needle without the use of electrocautery.

DESCRIPTION

In this case series, we describe the experience of a single surgeon with a novel technique of incising the serosa. A retrospective chart review was conducted between January 2012 and September of 2015. In 6 patients, the serosal incision on the pylorus was made using a percutaneously inserted 18 gauge needle to cut the serosa and the superficial hypertrophied muscle fibers. As the body of the needle is not sharp, it protects the mucosa from being lacerated as the incision is carried out given a fixed depth of cut.

RESULTS

The last 6 patients with hypertrophic pyloric stenosis underwent this technique. There were no conversions to open. In addition, there were no perforations and no complications related to the alteration in technique.

CONCLUSIONS

Although many manufacturers pursue both disposable and nondisposable solutions to this problem, we believe this is a safe, reliable, and very inexpensive solution to this simple problem.

Primary tracheal schwannoma a review of a rare entity: current understanding of management and followup

BACKGROUND

Neurogenic tumors of the tracheobronchial tree are extremely rare and include neurofibroma and schwannoma. We report a case of primary recurrent tracheal schwannoma causing obstructive airway symptoms.

CASE PRESENTATION

A 60-year-old man presented with obstructive airway symptoms due to recurrent tracheal schwannoma. Due the recurrence, size of the tumor and low surgical risk, the patient was treated with tracheal resection.

CONCLUSION

Primary endotracheal neurogenic tumors are extremely rare, but one should consider them in the differential diagnosis of persistent upper airway symptoms. While endoscopic therapies recur nearly a quarter of the time, surgical resections do not have any recorded recurrences.

In Pursuit of the Most Cost-Effective Pediatric Laparoscopic Appendectomy: The Effect of Disposable Instrument Choice on Operative Time and Surgeon-Controllable Cost

BACKGROUND

There is a movement toward cost savings in healthcare worldwide. Surgeons can affect two main cost variables in an operation (controllable cost): disposables and time. Our hypothesis is that increasing disposable costs do not change outcome or operative time, but simply increases controllable cost.

METHODS

We retrospectively reviewed patients younger than the age of 18 years undergoing laparoscopic appendectomies for nonperforated appendicitis from January 2013 to November 2016. Data obtained included demographic information in addition to intraoperative details, including disposables used and associated cost, resident participation, operative time, and final pathology. Patients were excluded if perforation was present as confirmed by operative findings or pathology (Kansas City definition). Patients were also excluded if concurrent procedures were performed during the appendectomy.

RESULTS

We reviewed 918 patients and excluded 288 for a total of 690. Disposable cost, operative time, and complications were compared between cases with a resident present and those without. Residents did not increase the use of disposables, but did increase operative time and therefore the total controllable cost. Transumbilical laparoscopic-assisted technique was significantly faster with lower controllable cost when compared with all other methods. Using disposable trocars with an endostapler was the second fastest and second lowest controllable cost and retained a significant difference when compared with most other methods. Endoloop methods did not show overall controllable cost savings versus the vast majority of methods.

CONCLUSIONS

To maximize controllable cost savings, we recommend a transumbilical laparoscopic-assisted appendectomy or a standard three-port laparoscopic appendectomy, with disposable trocars and the endostapler.

MEK mediates the novel cross talk between TNFR2 and TGF-EGFR in enhancing vascular endothelial growth factor (VEGF) secretion from human mesenchymal stem cells

BACKGROUND

Bone marrow mesenchymal stem cells (MSCs) may mediate their beneficial effects by paracrine mechanisms. Recently, we reported that tumor necrosis factor-alpha (TNF-alpha) increased the release of vascular endothelial growth factor (VEGF) from human MSCs and augmented transforming growth factor-alpha (TGF-alpha)-stimulated VEGF secretion. However, it is unknown whether TNF-alpha stimulates VEGF production via TNF receptor 1 (TNFR1) or 2 (TNFR2) and the mechanism by which TNF-alpha augments TGF-alpha (a ligand of epidermal growth factor receptor, EGFR) stimulated VEGF production. We hypothesized that the ablation of TNFR2 would decrease TNF-alpha-stimulated and/or TGF-alpha- stimulated VEGF production via MEK-dependent mechanisms.

METHODS

MSCs transfected with TNFR1, TNFR2, or GAPDH siRNA were stimulated with TNF-alpha and/or TGF-alpha for 24 h. VEGF levels in the supernatant were determined by enzyme-linked immunosorbent assay (ELISA). A Western blot analysis was performed to measure the activation of MEK and ERK and the expression of TNFR1 and TNFR2.

RESULTS

TNF-alpha or TGF-alpha increased VEGF secretion in cells transfected with GAPDH or TNFR1 siRNA. The combination of TNF-alpha and TGF-alpha increased VEGF production. TNF-alpha and/or TGF-alpha stimulation increased phospho-MEK and phospho-ERK in cells transfected with TNFR1 siRNA. Conversely, the effects of TNF-alpha and/or TGF-alpha on MSC VEGF production were significantly decreased, and MEK/ERK activation was negated in cells transfected TNFR2 siRNA.

CONCLUSION

TNFR2 plays a vital role in the effects of TNF-alpha and TGF-alpha on MSC VEGF production. The activation of MEK was implicated in this novel cross talk between TNFR2 and TGF-alpha-EGFR in regulating the production of VEGF in human MSCs.

Percutaneous endoscopic gastrostomy buttons in children: superior to tubes

BACKGROUND

There is a paucity of literature comparing outcomes of percutaneous endoscopic gastrostomy (PEG) tubes vs PEG buttons. Primary PEG buttons offer an advantage of being a single-step low-profile enteral access device with potentially fewer complications.

METHODS

A retrospective review of patients undergoing PEG tubes and buttons (January 2006-August 2007) was performed. Power analysis demonstrated that 105 patients in each group were needed. Patient characteristics were collected in each group and evaluated by chi(2) and t tests. P values of less than .05 were considered significant.

RESULTS

A total of 223 children having undergone PEG (110 tubes, 113 buttons) were identified. No differences were found in operative time, intraoperative complications, clogging, breakage, infections, emergency department visits, or hospital readmissions. However, children undergoing PEG button placement were more likely to spend only one night in the hospital vs PEG tube (60% vs 25%, respectively; P < .001). In addition, PEG buttons had fewer dislodgements (4 vs 15; P < .05).

CONCLUSION

The PEG buttons are less likely to become dislodged than PEG tubes. Infection rates were not found to be different between groups. Children with PEG buttons were more likely to be discharged earlier than children with PEG tubes. Primary PEG buttons are clinically comparable to PEG tubes with less concern for dislodgements.

Preoperative prediction of need for fundoplication before gastrostomy tube placement in children

PURPOSE

Percutaneous endoscopic gastrostomy (PEG) tube placement is a common procedure performed for children with oral aspiration and failure to thrive. The concurrent presence of gastroesophageal reflux (GER) may be difficult to diagnose in these children and may dictate the need for an antireflux procedure. The purpose of this study was to review our preoperative evaluation of children undergoing PEG placement to better elucidate preoperative factors that may require eventual fundoplication.

METHODS

A retrospective review at a tertiary care, children's hospital between May 2002 and August 2007 was performed of patients undergoing PEG placement. Patients were identified through database search by operative procedure codes. Patient groups were defined as those undergoing PEG alone (group 1) and those requiring fundoplication after prior PEG (group 2). Comparison of patient demographics and radiologic qualitative results of GER was analyzed using chi(2) analysis, with significance determined at P < .05.

RESULTS

A total of 863 patients underwent PEG placement over this 64-month period. A sampled cohort of patients undergoing PEG over a year comprised group 1. Forty-four patients (5.1%) underwent Nissen fundoplication after prior PEG placement (group 2). Patient demographics were similar between the groups. Comparison of comorbid conditions and qualitative indicators of GER between the groups showed only cerebral palsy had a significantly higher associated risk of GER that required antireflux surgery. Preoperative clinical assessment had a 95% positive predictive value in identifying children who required only PEG.

CONCLUSIONS

Despite the high predictive value of individualized clinical assessment in the ultimate decision for gastrostomy without need of fundoplication, further studies are needed to determine whether children with conditions such as cerebral palsy may require a concurrent antireflux surgery at the time of gastrostomy.

Fistula in ano in infants: who recurs?

INTRODUCTION

Fistula in ano is a common malady in infancy. However, relatively little literature is devoted to it. Our aim was to describe the natural history and identify predictors of which children will ultimately recur.

METHODS

A retrospective review of patients less than 3 years old undergoing anal fistulotomy was performed between May 2002 and November 2007 at a tertiary children's hospital. Demographics, preoperative, operative, and postoperative characteristics were collected in each group and evaluated by biostatistical analysis. P values <0.05 were considered significant.

RESULTS

A total of 92 children undergoing anal fistulotomy were identified. The median age was 6 months. Twelve children (13%) had recurrences and two of the 12 had multiple recurrences. Children who had recurrences were older (12.9 vs. 7.5 months, P < 0.05) and were more likely to have a previous abscess (20 vs. 6%, P < 0.05). In addition, children with recurrences had pus noted at the time of surgery more than children who did not recur (23 vs. 8%, respectively, P < 0.05). There were no major complications.

CONCLUSIONS

Fistula in ano in infants is a relatively benign process with most children having no serious sequelae. However, a not insignificant portion (13%) of children developed recurrences. Older children who developed fistulas were more likely to have a recurrence than younger, and children who had previous episodes of perianal abscess or pus noted at the time of surgery were more likely to recur.

Stem cells as a potential future treatment of pediatric intestinal disorders

All surgical disciplines encounter planned and unplanned ischemic events that may ultimately lead to cellular dysfunction and death. Stem cell therapy has shown promise for the treatment of a variety of ischemic and inflammatory disorders where tissue damage has occurred. As stem cells have proven beneficial in many disease processes, important opportunities in the future treatment of gastrointestinal disorders may exist. Therefore, this article will serve to review the different types of stem cells that may be applicable to the treatment of gastrointestinal disorders, review the mechanisms suggesting that stem cells may work for these conditions, discuss current practices for harvesting and purifying stem cells, and provide a concise summary of a few of the pediatric intestinal disorders that could be treated with cellular therapy.

VEGF is critical for stem cell-mediated cardioprotection and a crucial paracrine factor for defining the age threshold in adult and neonatal stem cell function

Bone marrow mesenchymal stem cells (MSCs) may be a novel treatment modality for organ ischemia, possibly through the release of beneficial paracrine factors. However, an age threshold likely exists as to when MSCs gain their beneficial protective properties. We hypothesized that 1) VEGF would be a crucial stem cell paracrine mediator in providing postischemic myocardial protection and 2) small-interfering (si)RNA ablation of VEGF in adult MSCs (aMSCs) would equalize the differences observed between aMSC- and neonatal stem cell (nMSC)-mediated cardioprotection. Female adult Sprague-Dawley rat hearts were subjected to ischemia-reperfusion injury via Langendorff-isolated heart preparation (15 min equilibration, 25 min ischemia, and 60 min reperfusion). MSCs were harvested from adult and 2.5-wk-old neonatal mice and cultured under normal conditions. VEGF was knocked down in both cell lines by VEGF siRNA. Immediately before ischemia, one million aMSCs or nMSCs with or without VEGF knockdown were infused into the coronary circulation. The cardiac functional parameters were recorded. VEGF in cell supernatants was measured via ELISA. aMSCs produced significantly more VEGF than nMSCs and were noted to increase postischemic myocardial recovery compared with nMSCs. The knockdown of VEGF significantly decreased VEGF production in both cell lines, and the pretreatment of these cells impaired stem cell-mediated myocardial function. The knockdown of VEGF in adult stem cells equalized the myocardial functional differences observed between adult and neonatal stem cells. Therefore, VEGF is a critical paracrine mediator in facilitating postischemic myocardial recovery and likely plays a role in mediating the observed age threshold during stem cell therapy.

Barium appendicitis after upper gastrointestinal imaging

BACKGROUND

Barium appendicitis (BA) is a rarely seen entity with fewer than 30 reports in the literature. However, it is a known complication of barium imaging.

OBJECTIVE

To report a case of BA in a patient whose computed tomography (CT) scan was initially read as foreign body ingestion.

CASE REPORT

An 18-year-old man presented with right lower quadrant pain after upper gastrointestinal imaging 2 weeks prior. A CT scan was obtained of his abdomen and pelvis that revealed a finding that was interpreted as a foreign body at the area of the terminal ileum. A plain X-ray study of the abdomen revealed radiopaque appendicoliths. Pathology confirmed the diagnosis of barium appendicitis.

CONCLUSIONS

BA is a rare entity and the pathogenesis is unclear. Shorter intervals between barium study and presentation with appendicitis usually correlate with fewer complications.

Sex steroids and stem cell function

Gender dimorphisms exist in the pathogenesis of a variety of cardiovascular, cardiopulmonary, neurodegenerative, and endocrine disorders. Estrogens exert immense influence on myocardial remodeling following ischemic insult, partially through paracrine growth hormone production by bone marrow mesenchymal stem cells (MSCs) and endothelial progenitor cells. Estrogens also facilitate the mobilization of endothelial progenitor cells to the ischemic myocardium and enhance neovascularization at the ischemic border zone. Moreover, estrogens limit pathological myocardial remodeling through the inhibitory effects on the proliferation of the cardiac fibroblasts. Androgens also may stimulate endothelial progenitor cell migration from the bone marrow, yet the larger role of androgens in disease pathogenesis is not well characterized. The beneficial effects of sex steroids include alteration of lipid metabolism in preadipocytes, modulation of bone metabolism and skeletal maturation, and prevention of osteoporosis through their effects on osteogenic precursors. In an example of sex steroid-specific effects, neural stem cells exhibit enhanced proliferation in response to estrogens, whereas androgens mediate inhibitory effects on their proliferation. Although stem cells can offer significant therapeutic benefits in various cardiovascular, neurodegenerative, endocrine disorders, and disorders of bone metabolism, a greater understanding of sex hormones on diverse stem cell populations is required to improve their ultimate clinical efficacy. In this review, we focus on the effects of estrogen and testosterone on various stem and progenitor cell types, and their relevant intracellular mechanisms.

TGF-alpha increases human mesenchymal stem cell-secreted VEGF by MEK- and PI3-K- but not JNK- or ERK-dependent mechanisms

Transforming growth factor-alpha (TGF-alpha) may be an important mediator of wound healing and the injury response. Human bone marrow mesenchymal stem cells (MSCs) release VEGF as a potentially beneficial paracrine response; however, it remains unknown whether TGF-alpha stimulates the production of VEGF from MSCs and, if so, by which mechanisms. We hypothesized that TGF-alpha would increase human MSC VEGF production by MAP kinase kinase (MAPKK/MEK), phosphatidylinositol 3-kinase (PI3-K)-, ERK, and JNK-dependent mechanisms. To study this, MSCs were cultured and divided into the following groups: 1) with vehicle; 2) with various stimulants alone: TGF-alpha, TNF-alpha, or TGF-alpha+TNF-alpha; 3) with individual kinase inhibitors alone (two different inhibitors for each of the following kinases: MEK, PI3-K, ERK, or JNK); and 4) with the above stimulants and each of the eight inhibitors. After 24-h incubation, a TGF-alpha dose-response curve demonstrated that low-dose TGF-alpha (500 pg/ml) suppressed MSC production of VEGF compared with vehicle (502 +/- 16 pg/10(5) cells/ml to 332 +/- 9 pg/10(5) cells/ml), while high-dose TGF-alpha (250 ng/ml) significantly increased MSC VEGF production (603 +/- 24 pg/10(5) cells/ml). High-dose TGF-alpha also increased TNF-alpha-stimulated release of VEGF from MSCs. MSCs exposed to TGF-alpha and/or TNF-alpha also demonstrated increased activation of PI3-K, JNK, and ERK. The TGF-alpha-stimulated production of VEGF by MSCs and the additive effect of TNF-alpha and TGF-alpha on VEGF production were abolished by MEK and PI3-K inhibition, but not ERK or JNK inhibition. Our data suggest that TGF-alpha increases VEGF production in MSCs via MEK- and PI3-K- but not ERK- or JNK-dependent mechanisms.

TNFR1 signaling resistance associated with female stem cell cytokine production is independent of TNFR2-mediated pathways

End-organ ischemia is a common source of patient morbidity and mortality. Stem cell therapy represents a novel treatment modality for ischemic diseases and may aid injured tissues through the release of beneficial paracrine mediators. Female bone marrow mesenchymal stem cells (MSCs) have demonstrated a relative resistance to detrimental TNF receptor 1 (TNFR1) signaling and are thought to be superior to male stem cells in limiting inflammation. However, it is not known whether sex differences exist in TNF receptor 2 (TNFR2)-ablated MSCs. Therefore, we hypothesized that 1) sex differences would be observed in wild-type (WT) and TNFR2-ablated MSC cytokine signaling, and 2) the production of IL-6, VEGF, and IGF-1 in males, but not females, would be mediated through TNFR2. MSCs were harvested from male and female WT and TNFR2 knockout (TNFR2KO) mice and were subsequently exposed to TNF (50 ng/ml) or LPS (100 ng/ml). After 24 h, supernatants were collected and measured for cytokines. TNF and LPS stimulated WT stem cells to produce cytokines, but sex differences were only seen in IL-6 and IGF-1 after TNF stimulation. Ablation of TNFR2 increased VEGF and IGF-1 production in males compared with wild-type, but no difference was observed in females. Female MSCs from TNFR2KOs produced significantly lower levels of VEGF and IGF-1 compared with male TNFR2KOs. The absence of TNFR2 signaling appears to play a greater role in male MSC cytokine production. As a result, male, but not female stem cell cytokine production may be mediated through TNFR2 signaling cascades.

Differential IL-6 and VEGF secretion in adult and neonatal mesenchymal stem cells: role of NFkB

Stem cells have shown promise for the treatment of end organ ischemia. NFkB has been demonstrated to regulate growth factor secretion in human adult bone marrow stem cells (aBMSCs). We hypothesized that: (1) NFkB is an important mediator in aBMSC and neonatal BMSC (nBMSC) VEGF and IL-6 secretion; and (2) inhibition of NFkB will result in a decrease of VEGF and IL-6 in nBMSCs. BMSCs were plated and exposed to TNF (50 ng/ml) or LPS (100 ng/ml), with or without NFkB or IKK inhibition. VEGF and IL-6 were measured via ELISA in 24-h supernatants. Inhibition of NFkB and IKK both demonstrated a decrease in VEGF (p<0.05) in aBMSCs but not nBMSCs. The LPS-stimulated nBMSC with IKK inhibition group was the only exception which demonstrated a decrease in VEGF secretion. However, both NFkB inhibition caused both aBMSCs and nBMSCs to produced less IL-6 after LPS stimulation (p<0.05). Only aBMSCs' secretion of IL-6 decreased with NFkB and IKK inhibition when stimulated with TNF (p<0.05) differing only when TNF-stimulated nBMSCs were inhibited with IKK. VEGF and IL-6 secretion in aBMSCs is dependent on the classic NFkB pathway. However, neonatal BMSC VEGF and IL-6 secretion is stimulant-specific and utilization of the NFkB pathway is more complex.