Background The purpose of this prospective randomized study was to compare landmark- to ultrasound-guided central venous access when performed by pediatric surgeons. The American College of Surgeons ...advocates for use of ultrasound in central venous catheter placement; however, this is not universally embraced by pediatric surgeons. Complication risk correlates positively with number of venous cannulation attempts. Study Design With IRB approval, a randomized prospective study of children under 18 years of age undergoing tunneled central venous catheter placement was performed. Patient accrual was based on power analysis. Exclusion criteria included known nonpatency of a central vein or coagulopathy. After randomization, the patients were assigned to either ultrasound-guided internal jugular vein access or landmark-guided subclavian/internal jugular vein access. The primary outcomes measure was number of attempts at venous cannulation. Secondary outcomes measures included: access times, number of arterial punctures, and other complications. Continuous variables were compared using 2-tailed Student's t -test. Discrete variables were analyzed with chi-square. Significance was defined as p < 0.05. Results There were 150 patients enrolled between April 2008 and September 2011. There was no difference when comparing demographic data. Success at first attempt was achieved in 65% of patients in the ultrasound group vs 45% in the landmark group (p = 0.021). Success within 3 attempts was achieved in 95% of ultrasound group vs 74% of landmark group (p = 0.0001). Conclusions Ultrasound reduced the number of cannulation attempts necessary for venous access. This indicates a potential to reduce complications when ultrasound is used by pediatric surgeons.
Background
Nonalcoholic fatty liver disease (NAFLD) is prevalent in children with obesity and is definitively diagnosed with liver biopsy. However, the utility of routine biopsy during adolescent ...bariatric surgery remains unknown. We describe the usefulness of routine versus selective intraoperative liver biopsy in adolescents undergoing bariatric surgery.
Methods
A retrospective review of adolescents who received bariatric surgery at our institution between 2007 and 2018 was performed. Prior to 2014, all patients routinely received intraoperative liver biopsy. After 2014, biopsy was performed selectively on an individual basis for transaminitis or clinical concern. Demographic, biochemical, and histopathologic data were compared between patients who underwent routine, selective, or no biopsy.
Results
There were 77 patients who received bariatric surgery during the study period: 32 underwent routine biopsy, 13 selective biopsy, and 32 no biopsy. Selective liver biopsy was more likely to show pathologic evidence of fibrosis (84.6% versus 31.2%,
p
= 0.000) and steatosis (100.0% versus 59.4%,
p
= 0.003), and higher mean NAFLD activity score compared with routine biopsies (4.4 versus 2.1,
p
= 0.001). Patients with steatosis had significantly higher preoperative fasting insulin (41.4 versus 21.1 mIU/L,
p
= 0.000), and patients with fibrosis had significantly higher glycated hemoglobin (6.1% versus 5.5%,
p
= 0.033) and alanine aminotransferase (81.5 versus 52.7 mg/dL,
p
= 0.043). There were no biopsy complications or changes in management due to biopsy results.
Conclusions
Routine intraoperative liver biopsy during adolescent bariatric surgery possesses questionable benefit, as it does not appear to impact short-term postoperative management. Prospective, longitudinal studies are needed to better understand the meaningfulness of liver histopathology in this population.
Abstract Background Sutureless gastroschisis repair involves covering the abdominal wall defect with the umbilical cord or a synthetic dressing to allow closure by secondary intention. No randomized ...studies have described the outcomes of this technique. Our objective was to prospectively compare short-term outcomes of sutureless versus sutured closure in a randomized fashion. Study Design We recruited patients who presented with gastroschisis between 2009 and 2014 and were randomized into either sutureless or sutured treatment groups. Patients with complicated gastroschisis (stricture, perforation, ischemia) were excluded. Pre-defined ventilation, feeding and dressing changes protocols were instituted. Primary outcomes were time to extubation and time to full feeds. Secondary outcomes included time to discharge and rate of complications. Data were analyzed using Fisher’s exact or T-tests using a p value<0.05. Factors associated with increased time to discharge were estimated using multivariate analyses. Results Thirty-nine patients were enrolled, 19 to sutureless and 20 to sutured repair. There was no statistical difference in time to extubation (sutureless 1.89 vs sutured 3.15 days, p=0.061). The sutureless group had a significant increase in mean time to full feeds (45.1 vs 27.8 days, p=0.031) and mean time to discharge (49.3 vs 31.4 days, p=0.016). Complication rates were similar in both groups. Multivariate regression modeling showed that an increase in time to discharge was independently associated with sutureless repair, feeding complications, and sepsis. Conclusions Sutureless repair of uncomplicated gastroschisis can be performed safely, however, it was associated with a significant increase in time to full feeds and time to discharge.
•What is currently known about this topic?•Short bowel syndrome is the most common cause of intestinal failure among children. Children with ultrashort bowel syndrome have < 10 % of their expected ...length of bowel and are unlikely to achieve enteral autonomy with current therapy. There are no described surgical techniques that specifically treat ultrashort bowel syndrome.•What new information is contained in this article?•We describe a new technique for the surgical treatment of ultrashort bowel syndrome, ileal tube lengthening to employ distraction enterogenesis. In a description of 4 patients who underwent ileal tube lengthening, we report 1.75 cm or 45 % growth over a month without any major complications.
Ultrashort bowel syndrome is a rare, but morbid surgical problem without effective treatment. Recent clinical analysis has demonstrated the critical influence of ileal length on ultimate enteral autonomy. Surgical techniques to increase ileal length in nondilated bowel do not exist. We describe a novel technique to lengthen ileum in children with ultrashort bowel syndrome.
Beginning in May 2021 prospective candidate children were identified. Candidacy for ileal tube lengthening included diagnosis of ultrashort bowel syndrome, intact ileocecal valve with remnant ileum, and proximal intestinal stoma or draining gastrostomy. Informed consent was obtained. Following laparoscopic lysis of adhesions, a balloon catheter was inserted through a left flank stab incision and into the lumen of the remnant ileum around a purse string suture. Cecopexy was performed in the right-lower quadrant. Clips were used to mark the cecum and the proximal extent of ileum. The catheter length was fixed externally at the completion of the procedure. Serial x-rays were used to measure distraction effect while increasing tension was applied to the catheter over the subsequent weeks. Ileal tube lengthening was performed until the end of the catheter was reached or the tube was dislodged. A contrast study was performed at the completion of lengthening. Intestinal length at time of restoration of continuity and clinical outcomes were recorded.
Four infants were enrolled from May 2021-July 2023. Diagnoses leading to ultrashort bowel syndrome were mesenteric teratoma, necrotizing enterocolitis, and multiple intestinal atresia. At the time of restoration of intestinal continuity, a median of 1.75 cm (45 %) additional ileal length was achieved at a median of 25.5 days. There were no serious complications following ileal tube lengthening and no additional operative interventions were required.
Ileal lengthening through internal distraction is a feasible surgical intervention to salvage ileum for infants with ultrashort bowel syndrome. Ileal tube lengthening may result in distraction enterogenesis, providing a novel intervention to increase intestinal length.
IV (Case series without comparison group).
Esophageal lung is rare bronchopulmonary foregut malformation where a main stem bronchus is connected anomalously to the esophagus. We present a challenging diagnostic workup of a 14-month-old who ...was referred following multiple complicated hospitalizations for recurrent respiratory distress.
A male infant born at 37 weeks was noted to be hypoxemic at birth and subsequently diagnosed with right-sided pulmonary hypoplasia, absent right main stem bronchus, a left-sided non-obstructive pulmonary artery sling, and possible tracheal stenosis via computed tomographic angiography (CTA). After a stay in the neonatal intensive care unit for persistent hypoxemia, he was discharged home on oxygen. At 4.5 months, the patient developed severe respiratory distress requiring extracorporeal membrane oxygenation, which was complicated by a stroke. During this admission, repeat CTA showed a broncho-esophageal fistula, concerning for esophageal lung. The patient was seen in consultation at our institution at 14 months given persistent respiratory insufficiency. He underwent repeat endoscopy with our multi-disciplinary Aerodigesive Clinic, confirming mild tracheal stenosis and esophageal lung. A right pneumonectomy was recommended. During the pneumonectomy, the right bronchus was confirmed to originate from the distal esophagus on endoscopy. Intraoperative bronchoscopy showed a patent central airway and left bronchopulmonary tree. The patient recovered well post-operatively without complications and was discharged home on room air.
Diagnosing esophageal lung can be difficult and requires thorough evaluation of the adjacent anatomy, oftentimes requiring multidisciplinary evaluation with multiple radiologic and endoscopic modalities.
•Currently, IRA is offered in a minority of adult referral centers in selective patients with no perianal or small intestinal involvement. Considering the lifelong duration of the disease, the ...pediatric population would arguably benefit significantly from this approach but the amount of literature in the pediatric population is very limited.•Ileorectal anastomosis (IRA) after colectomy should be considered for medically refractory isolated Crohn's colitis in selected patients.•A larger prospective study is necessary to identify patient eligibility timing of IRA, and post-operative surveillance strategy before recommendation of IRA as a standard treatment.
The classic operation for medically refractory Crohn's pancolitis is colectomy with end ileostomy. Ileorectal anastomosis (IRA) in this setting has not been well studied in children. In this study, we review our experience and outcomes with IRA in children with severe Crohn's Disease (CD).
A single-center retrospective study was performed by reviewing the patient charts between 2017 and 2022. Before colectomy, disease severity was assessed by poor response to biologic medication and corticosteroids, the presence of serious comorbidities and history of C. difficile infection (CDI). Proctoscopy was done before IRA, and rectal histopathology at the time of IRA was reviewed. Postoperative complications, time from colectomy to anastomosis, and number of bowel movements were recorded.
6 patients with pancolitis underwent laparoscopic total colectomy with end ileostomy and subsequent IRA. All patients were refractory to biologics and/or steroids. 4 patients had history of CDI. Mean age at the time of surgery was 16 ± 1 years. Postoperative course was complicated by AKI in 1 patient, pancreatitis in 1 patient, and rectal bleeding in 2 patients. A mean 274±130 days elapsed between colectomy and IRA. There were no complications or recurrent flares after IRA over the mean 356 ± 227 days follow-up. Patients had a mean of 5 bowel movements/day after IRA.
IRA should be considered after colectomy for medically refractory CD in selected patients. A larger prospective study is necessary before recommendation for IRA as standard treatment.
N/A
Background This report describes a rare surgical case of an intraabdominal mass in a middle-aged patient 40 years after imperforate anus repair. Case presentation A 44-year-old Latino male with ...history of repaired anorectal malformation presented with recurrent urinary tract infections and rectal prolapse with bothersome bleeding and fecal incontinence. During his preoperative evaluation, he was initially diagnosed with a prostatic utricle cyst on the basis of magnetic resonance imaging findings, which demonstrated a cystic, thick-walled mass with low signal contents that extended inferiorly to insert into the distal prostatic urethra. However, at the time of surgical resection, the thick-walled structure contained an old, firm fecaloma. The final pathology report described findings consistent with colonic tissue, suggesting a retained remnant of the original fistula and diverticulum. Conclusions Although rare, persistent rectourethral fistula tracts and rectal diverticula after imperforate anus repair can cause symptoms decades later, requiring surgical intervention. This is an important diagnostic consideration for any adult patient with history of imperforate anus. Keywords: Case report, Imperforate anus, Rectourethral fistula, Posterior sagittal anorectoplasty, Robotic procedure
Background
Spleen-preserving distal pancreatectomy has been described lately in order to reduce the risks associated with splenectomy. The aim of this study is to report a series of open and ...laparoscopic distal pancreatectomies with splenic vessel preservation.
Methods
From June 2001 to April 2007, 11 spleen-preserving distal pancreatectomies were performed, utilizing open and laparoscopic techniques. The main variables recorded were demographics, intra- and postoperative complications, and final pathology results.
Results
All 11 spleen-preserving distal pancreatectomies were performed successfully. Laparoscopic resection was possible in seven patients. Postoperative morbidity consisted of one pancreatic fluid collection. The overall incidence of pancreatic leak was 18%. The final pathology revealed serous cystadenoma in 36% of the cases, neuroendocrine tumor in two cases, three mucinous cystadenomas, one carcinoid tumor, and one intrapancreatic spleen. With a median follow-up of 26 months, no splenic vein thrombosis was detected.
Conclusions
Open or laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation is a feasible and safe procedure. In selected cases of cystic lesions and low grade neoplasms, distal pancreatectomy with splenic preservation is possible.
Introduction Survival for infants with gastroschisis in developed countries has improved dramatically in recent decades with reported mortality rates of 4–7%. Conversely, mortality rates for ...gastroschisis in sub-Saharan Africa remain as great as 60% in contemporary series. This study describes the burden of gastroschisis at the major pediatric hospital in Zimbabwe with the goal of identifying modifiable factors influencing gastroschisis-related infant mortality. Methods We performed a retrospective cohort study of all cases of gastroschisis admitted to Harare Children's Hospital in 2013. Univariate and multivariate analyses were performed to describe infant, maternal, and geographic factors influencing survival. Results A total of 5,585 neonatal unit admissions were identified including 95 (1.7%) infants born with gastroschisis. Gastroschisis-related mortality was 84% ( n = 80). Of infants with gastroschisis, 96% ( n = 91) were born outside Harare Hospital, 82% ( n = 78) were born outside Harare Province, and 23% ( n = 25) were home births. The unadjusted odds of survival for these neonates with gastroschisis were decreased for low birth weight infants (<2,500 grams; odds ratio OR, 0.15; 95% CI, 0.05–0.51), preterm births (<37 weeks gestational age; OR, 0.06; 95% CI, 0.01–0.50), and for those born to teenage mothers (<20 years of age; OR, 0.05; 95% CI, 0.01–0.46). There was also a trend toward decreased odds of survival for home births (OR, 0.16; 95% CI, 0.02–1.34) and for those born outside Harare Province (OR, 0.35; 95% CI, 0.10–1.22). Conclusion Gastroschisis-related infant mortality in Zimbabwe is associated with well-known risk factors, including low birth weight, prematurity, and teenage mothers. However, modifiable factors identified in this study signify potential opportunities for developing innovative approaches to perinatal care in such a resource-constrained environment.
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