Internal hernias are difficult to diagnose clinically, and normal cross-sectional imaging has been documented in many patients. Transmesenteric hernias from congenital defects or prior abdominal ...surgery are most common. A 46-year-old previously healthy female presented to the emergency department with acute onset nausea and vomiting eight years after a right ureteral transection during a laparoscopic hysterectomy, with a delayed ureterolysis and reimplantation into the bladder. Rectal contrast CT scan demonstrated a partial large bowel obstruction that was unclear if it was due to an underlying mass, stricture, or internal herniation. The patient was taken for exploratory laparotomy which demonstrated redundant transverse colon herniated under the mobile right ureter; an extended right hemicolectomy was performed. This report describes alteration of retroperitoneal anatomy creating a potential space for colonic herniation and emphasizes that clinical suspicion must remain high for patients presenting with obstructive or partially obstructive symptoms.
Functional lumen imaging probe (EndoFLIP) is a diagnostic technology that assesses esophageal cross-sectional area via impedance planimetry during controlled volumetric distention. The purpose of ...this study is to evaluate the utility of EndoFLIP intraoperatively during laparoscopic esophagomyotomy.
We performed a retrospective cohort study reviewing all patients undergoing EndoFLIP assisted laparoscopic esophagomyotomy for achalasia between January and December 2021 (n = 10). Twenty-two patients with achalasia that underwent traditional laparoscopic esophagomyotomy between July 2014 and September 2019 served as a comparison. Primary outcome evaluated was resolution of symptoms at discharge. Secondary outcomes included change in distensibility index (DI), operative time, length of stay, time to regular diet, and reinterventions.
All patients managed with EndoFLIP assistance had resolution of dysphagia and postprandial vomiting following intervention. Mean change in DI was 5.32 mm2/mmHg with a myotomy length of 3.6 cm. Operative time was shorter in the EndoFLIP cohort (97 min versus 185 min, p = <0.001). Study patients did not undergo an antireflux operation. There was no difference in length of stay or time to soft diet between groups. All patients were discharged on postoperative day 1 tolerating a mechanical soft diet. No acid suppressive medications were prescribed during the observation period. One patient required dilation for recurrent symptoms and one required reoperation for mucosal leak.
EndoFLIP assisted laparoscopic esophagomyotomy results in similar short-term outcomes to traditional surgical technique. EndoFLIP allows for focused myotomy length and a shorter operative time.
Level of evidence: III
There are currently no commonly accepted standardized guidelines for management of cervical vessels at neonatal extracorporeal membrane oxygenation (ECMO) decannulation. This study investigates ...neonatal ECMO decannulation practices regarding management of the carotid artery and internal jugular vein, use of post-repair anticoagulation, and follow-up imaging.
A survey was distributed to the 37 institutions in the Children’s Hospitals Neonatal Consortium. Respondents reported their standard approach to carotid artery and internal jugular vein management (ligation or repair) at ECMO decannulation by their pediatric surgery and cardiothoracic (CT) surgery teams as well as post-repair anticoagulation practices and follow-up imaging protocols.
The response rate was 95%. Pediatric surgeons performed most neonatal respiratory ECMO cannulations (88%) and decannulations (85%), while all neonatal cardiac ECMO cannulations and decannulations were performed by CT surgeons. Pediatric surgeons overwhelmingly ligate both vessels (90%) while CT surgeons typically repair both vessels at decannulation (83%). Of the responding centers that repair, 28% (7) have a standard anticoagulation protocol after neck vessel repair. While 52% (13) of centers routinely image cervical vessel patency at least once post repair, most do not subsequently repeat neck vessel imaging.
Significant practice differences exist between pediatric and CT surgeons regarding the approach to cervical vessels at neonatal ECMO decannulation. For those centers that do repair the vessels there is little uniformity in post-repair anticoagulation or imaging protocols. There is a need to develop standardized cervical vessel management guidelines for neonatal ECMO patients and to study their impact on both short- and long-term outcomes.
IV.
•What is currently known about this topic?At neonatal ECMO decannulation cervical vessels can be managed with ligation or repairLigation may alter cerebral blood flow with potential for hemorrhagic or ischemic eventsRepaired vasculature may become stenotic, aneurysmal, and a risk for strokeCurrently, no guidelines exist for optimizing management of cervical vessels at ECMO decannulation.•What new information is contained in this article?This manuscript presents practice patterns from pediatric and cardiothoracic surgeons at high-volume neonatal ECMO centers regarding surgical management of cervical vessels at ECMO decannulation, including post repair anticoagulation and imaging practices. It includes suggested elements of a protocol for management of these patients.
To evaluate resource utilization in infants discharged with different forms of feeding access.
Retrospective chart review of neonates discharged from 2012 to 2018. Data were collected from the ...medical record and relevant outcomes were compared.
300 patients were sampled. 196 (65%) were discharged on NG feeds, 95 (32%) via GT, and 9 gastrojejunal (GJ 3%). NG-fed infants discharged sooner (mean DOL: NG = 85.4 vs GT = 122.8, p < 0.001). More GT/GJ patients required emergency department (ED) visits for tube complications (GT = 61 vs GJ = 7 vs NG = 42, p < 0.001) and more frequently (mean visits: GT = 1.63 ± 2.33 vs GJ = 4.22 ± 4.44 vs NG = 0.48 ± 1.40, p < 0.001). However, 44 (24%) of the patients discharged on NG later had a GT placed.
Many patients discharged from the NICU can be supported with NG feeds. This may shorten hospital stays and decrease ED visits but select patients will later merit surgical tube placement.
Preoperative malnutrition is associated with increased postoperative morbidity. The perioperative nutrition score (PONS) was developed to identify patients at risk of malnutrition. We sought to ...assess the correlation between preoperative PONS and postoperative outcomes in pediatric inflammatory bowel disease (IBD) patients.
We performed a retrospective cohort study of IBD patients, less than 21 years of age, who underwent elective bowel resection between June 2018 and November 2021. Patients were divided based upon whether they met PONS criteria. The primary outcome was postoperative surgical site infections.
96 patients were included. Sixty-one patients (64%) met at least one PONS criteria, while 35 patients (36%) met none. PONS positive patients more frequently received preoperative TPN supplementation (p < .001). There was no difference in preoperative oral nutritional supplementation between groups. Patients that screened positive for PONS had a longer hospital stay (p = .002), more readmissions (p = .029), and more surgical site infections (p = .002).
Our data highlight the prevalence of malnutrition in the pediatric IBD population. Patients who screened positive had worse postoperative outcomes. Further, very few of these patients received preoperative optimization with oral nutritional supplementation. There is a need for standardization of nutritional evaluation to improve preoperative nutritional status and postoperative outcomes.
III.
Retrospective Cohort.
•Perioperative malnutrition defined by PONS is associated with worse postoperative outcomes in adults.•Malnutrition defined by PONS may be used to screen and optimize preoperative nutrition among pediatric IBD patients.•PONS defined malnutrition is common in pediatric IBD, and those who screen positive had worse perioperative outcomes.
Internal hernias are difficult to diagnose clinically, and normal cross-sectional imaging has been documented in many patients. Transmesenteric hernias from congenital defects or prior abdominal ...surgery are most common. A 46-year-old previously healthy female presented to the emergency department with acute onset nausea and vomiting eight years after a right ureteral transection during a laparoscopic hysterectomy, with a delayed ureterolysis and reimplantation into the bladder. Rectal contrast CT scan demonstrated a partial large bowel obstruction that was unclear if it was due to an underlying mass, stricture, or internal herniation. The patient was taken for exploratory laparotomy which demonstrated redundant transverse colon herniated under the mobile right ureter; an extended right hemicolectomy was performed. This report describes alteration of retroperitoneal anatomy creating a potential space for colonic herniation and emphasizes that clinical suspicion must remain high for patients presenting with obstructive or partially obstructive symptoms.
Pain after Arteriovenous Access Creation Howk, Amy; McAdams, Callie; Heidel, Eric ...
Southern medical journal (Birmingham, Ala.),
04/2022, Letnik:
115, Številka:
4
Journal Article
Recenzirano
Dialysis access creation is a common outpatient procedure that can be completed using general, regional, or local anesthetic techniques. There are few endorsed guidelines regarding opioid-based pain ...control following fistula creation. The purpose of this study was to determine whether utilization of regional anesthesia (RA) is associated with the decreased use of narcotics postoperatively.
We performed a prospective cohort study including all patients undergoing arteriovenous fistula creation with one vascular surgeon from August 2019 to February 2020. Patients were selected for regional versus general anesthesia. Selection for anesthesia type was determined by the primary anesthesiologist. Patients selected for RA underwent supraclavicular brachial plexus block with 30 cm
of 0.5% ropivacaine. Patients were seen in clinic follow-up and completed a questionnaire regarding their postoperative opiate use and pain control.
In the study period, 52 patients underwent arteriovenous fistula creation and completed the follow-up questionnaire. Forty patients received RA. Seventy-five percent of patients sent home with a narcotic prescription filled the prescription. There was a significant difference in postoperative opioid use between the two study groups. Patients who received regional block took on average 3.3 pills totaling 16.5 morphine milligram equivalents, whereas patients who received general anesthesia took on average 6.64 pills totaling 33.2 morphine milligram equivalents (
0.04).
Morbidity and mortality related to opiate use continues to be a public health issue in the United States. This study demonstrates that regional anesthetic techniques in comparison to general anesthesia can result in a significant decrease in postoperative opiate consumption.
During the coronavirus disease 2019 pandemic, trauma presentations to the emergency room decreased across the country. The goal of this study is to analyze the educational impact of coronavirus ...disease 2019 on trauma education and training at a level I trauma center.
Trauma patient presentations were analyzed 6 months before a Tennessee executive stay-at-home order and 6 months after the state executive order. To control for the seasonal trauma volumes, an additional 6 months before the executive order was then analyzed comparing month to month. Total number of presentations, demographics, procedures, airway management, and coronavirus disease 2019 status of patients and residents were analyzed.
The number of trauma presentations were sustained after executive orders at our level I trauma center. There was no significant difference in intubations, central line placements, and chest tube placements before and during the pandemic. Blunt trauma decreased after stay-at-home orders. Of the 36 residents, no residents tested positive during the study period.
Trauma-focused surgical education was not affected at an academic level I trauma center. Understanding that it is region, city, and hospital specific, this study shows that quality trauma education can continue throughout the coronavirus disease 2019 pandemic while keeping trainees safe. Proper airway management, personal protective equipment, social distancing, and coronavirus disease 2019-preventative protocols seem to protect residents from potential harm while allowing them to participate and continue in quality trauma education and training.
The governor of Tennessee issued an order on March 30, 2020, directing Tennesseans to stay home in response to the COVID-19 pandemic. Recent studies demonstrated a decrease in emergency department ...(ED) visits and in trauma during the pandemic. We wanted to see the effect of the COVID-19 pandemic on the East Tennessee trauma population presentation patterns and outcomes. The trauma population at an American College of Surgeons-verified Level-I trauma center in East Tennessee was examined 6 months before and after the stay-home executive order was issued. The data examined included demographic information, patient disposition, complications, and mortality. 7,587 patients were reviewed, with 3,509 (46.3%) patients presenting prior to shelter in place vs 4,078 (53.7%) patients presenting after shelter in place. Following stay-home orders, the trauma population was younger (54.55 vs 51.85, p = .001) and more likely to be male (p = .016). There was a higher rate of penetrating injuries post the stay-home order (p = .001). Patients were more likely to be admitted from the ED (65.4% vs 65.9%, p = .009) and less likely to be discharged home from the ED (30.3% vs 29.3%, p = .009). Admitted patients were less likely to be discharged to a skilled nursing facility (15.4% vs. 10.3%, p < .001) and more likely to be discharged home with services (6.5% vs 10.4%, p < .001). There was no difference in mortality between groups. Trauma volume was sustained during the pandemic. Demographics and dispositions were statistically different. Penetrating trauma increased following stay-home orders, which may prompt preventative measures in future pandemics.
A common recommendation with least‐to‐most prompting is to repeat the discriminative stimulus (SD) with each successive prompt (Cooper, Heron, & Heward, 2007). However, few studies have evaluated ...this recommendation. We compared repeating the SD to presenting the SD once when teaching intraverbal behavior to children with autism. Results showed that both methods produced acquisition, and repeating the SD produced no greater efficiency in acquisition.
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