Management of small lymph nodes or lesions in dense nodal basins found on Positron Emission Tomography (PET) scans can be challenging to identify, access and locate intraoperatively. Herein we ...describe the first reported case series utilizing pre-operative CT-guided radionuclide-tagged macro-aggregated albumin (TC 99m MAA) for localization and resection of extra-pulmonary PET-avid lymph nodes in pediatric cancer patients.
Pediatric cancer patients (≤21 years) who underwent pre-operative TC 99m MAA localization of suspicious lymph nodes were identified and retrospectively reviewed.
Ten procedures were performed on 10 children at our institution from 2017 to 2021. Median age was 14 13, 18; 70% were male. Primary tumor type was variable. Lymph nodes were in various nodal basins including the axilla, groin, neck, popliteal fossa, retroperitoneum, and mediastinum. Three patients underwent resection of both pulmonary and extra-pulmonary lesions during the same procedure. Median node size was 15 mm (range: 10 mm- 23 cm). In 60.0% of patients the localized lymph nodes of concern were non-palpable at the time of operation. In 90% of the patient, biopsy findings changed the course of disease management.
Pre-operative labeling with TC 99m MAA is a safe and effective technique to facilitate the localization, biopsy, and resection of suspicious lymph nodes found on PET scans in pediatric cancer patients that are located in dense nodal basins. This technique enables accurate resection of small, concerning lymph nodes that might otherwise be difficult to operatively identify and excise; the resultant information can affect the staging and further treatment of these patients.
IV.
•What is currently known about thistopic?○Pre-operative radiolabeling of suspicious pulmonary nodules has been previously described in pediatric oncology patients, though is not yet widely used. Pre-operative radiolabeling has not yet been described to aid in the localization and resection of suspicious extra-pulmonary lymph nodes found on PET scan in pediatric cancer patients.•What new information is contained in this article?○This is the first reported series describing the use of pre-operative radiolabeling of suspicious extra-pulmonary lymph nodes found on PET scan in pediatric cancer patients. This technique enhances the ability to precisely locate and resect small nodes of concern in dense nodal basins.
The impact of Behavioral Health Disorders (BHDs) on pediatric injury is poorly understood. We investigated the relationship between BHDs and outcomes following pediatric trauma.
We analyzed injured ...children (age 5–15) from 2014 to 2016 using the Pediatric Trauma Quality Improvement Program. The primary outcome was in-hospital mortality. Univariable and multivariable analyses compared children with and without a comorbid BHD.
Of 69,305 injured children, 3,448 (5%) had a BHD. These 3,448 children had a median of 1 IQR: 1, 1 BHD diagnosis: ADHD (n = 2491), major psychiatric disorder (n = 1037), drug use disorder (n = 250), and alcohol use disorder (n = 29). A higher proportion of injured children with BHDs suffered intentional and penetrating injury. Firearm injuries were more common for BHD patients (3% vs 1%, p<0.001). Children with BHDs were more likely to have an ISS>25 compared to children without (5% vs 3%, p<0.001). While median LOS was longer for BHD patients (2 1, 3 vs 2 1, 4, p<0.001), mortality was similar (1% vs 1%, p = 0.76) and complications were less frequent (7% vs 8%, p = 0.002). BHD was associated with lower risk of mortality (OR 0.45, 95%CI 0.30, 0.69) after controlling for age, sex, race, trauma type, and injury intent and severity.
Children with BHDs experienced lower in-hospital mortality risk after traumatic injury despite more severe injury upon presentation. Intentional and penetrating injuries are particularly concerning, and future work should assess prevention efforts in this vulnerable group.
Although perimortem delivery has been recorded in the medical literature for millennia, the procedural intent has evolved to the current fetocentric approach, predicating timing of delivery following ...maternal cardiopulmonary arrest to optimize neonatal outcome. We suggest a call to action to reinforce the concept that if the uterus is palpable at or above the umbilicus, preparations for delivery should be made simultaneous with initiation of maternal resuscitative efforts; if maternal condition is not rapidly reversible, hysterotomy with delivery should be performed regardless of fetal viability or elapsed time since arrest. Cognizant of the difficulty in determining precise timing of arrest in clinical practice, if fetal status is already compromised further delay while attempting to assess fetal heart rate, locating optimal surgical equipment, or transporting to an operating room will result in unnecessary worsening of both maternal and fetal condition. Even if intrauterine demise has already occurred, maternal resuscitative efforts will typically be markedly improved following delivery with uterine decompression. Consequently we suggest that perimortem cesarean delivery be renamed “resuscitative hysterotomy” to reflect the mutual optimization of resuscitation efforts that would potentially provide earlier and more substantial benefit to both mother and baby.
The use of transanal proctectomy may have particular advantages for pediatric patients with small pelvic working space. We report short-term outcomes of transanal completion proctectomy (taCP) during ...surgery for inflammatory bowel disease.
All patients (age≤19) underwent taCP from January 1, 2018 to December 31, 2019. Prior total abdominal colectomy (TAC) was performed using a single-incision technique. At operation, patients underwent single-incision laparoscopy with taCP. Patient demographics, pre and perioperative details, and postoperative complications were abstracted.
Seven patients (n = 6) with a median age of 18 years Range: 13–19 were included in this initial series. All patients had a prior TAC with end-ileostomy with taCP occurring a median of 6 Range: 3–89 months after TAC. Six of 7 had a diagnosis of ulcerative colitis (UC) while 1 patient had Crohn's colitis. For patients with UC, taCP was part of an ileal pouch-anal anastomosis with the majority (n = 4) proceeding as a modified-two stage and the remaining (n = 2) a three-stage approach. Single-incision laparoscopy through the prior ileostomy site was used in all IPAA patients. Median operative time was 226 Range: 150–264 minutes with no conversions to more invasive technique. Median hospital length of stay (LOS) was 5 Range: 2–8 days.
In-hospital complications occurred in two patients who had watery diarrhea that prolonged LOS but resolved postdischarge. One patient was readmitted for bowel obstruction that resolved with placement of red rubber catheter at the ileostomy site.
Of the 4 patients with a functioning ileal pouch, 1 patient reported 6–10 bowel movements per day, while 3 others reported ≤5 bowel movements per day. Half (n = 2) reported 1–2 nocturnal bowel movements at their first postoperative visit. No patients reported soiling or leakage, though one patient had a single episode of incontinence.
In this pilot series, transanal proctectomy was effective and safe. Future work should compare traditional MIS completion proctectomy to taCP for applications in pediatric inflammatory bowel disease.
: Case series.
: IV.
High-income countries have increased the use of simulation-based training and assessment for surgical education. Learners in low- and middle-income countries may have different educational needs and ...levels of autonomy but they and their patients could equally benefit from the procedural training simulation provides. We sought to characterize the current state of surgical skills simulation in East, Central, and Southern Africa and determine residents’ perception and future interest in such activities.
A survey was created via collaboration and revision between trainees and educators with experiences spanning high-income countries and low- and middle-income countries. The survey was administered on paper to 76 trainees (PGY2-3) who were completing the College of Surgeons of East, Central, and Southern Africa (COSECSA) Membership of the College of Surgeons examination in Kampala, Uganda in December 2019. Data from paper responses were summarized using descriptive statistics and frequencies.
We received responses from 43 trainees (57%) from 11 countries in sub-Saharan Africa who participated in the examination. Fifty-eight percent of respondents reported having dedicated space for surgical skills simulation training, and most (91%) had participated in some form of simulation activity at some point in their training. However, just 16% used simulation as a regular part of training. The majority of trainees (90%) felt that surgical skills learned in simulation were transferrable to the operating room and agreed it should be a required part of training. Seventy-one percent of trainees felt that simulation could objectively measure technical skills, and 73% percent of respondents agreed that simulation should be integrated into formal assessment. However, residents split on whether proficiency in simulation should be achieved prior to operative experience (54%) and if nontechnical skills could be measured (51%). The most common cited barriers to the integration of surgical simulation into residents’ education were lack of suitable tools and models (85%), funding (73%), and maintenance of facilities (49%).
Residents from East, Central, and Southern Africa strongly agree that simulation is a valuable educational tool and ought to be required during their surgical residency. Barriers to achieving this goal include availability of affordable tools, adequate funding and confidence in the value of the educational experience. Trainees affirm further efforts are necessary to make simulation more widely available in these contexts.
We used interrupted time series (ITS) analysis to determine whether e-scooter shares' introduction in September 2017 increased serious scooter-related injury across the United States.
Using the ...National Electronic Injury Surveillance System, we queried emergency department visits involving motorized scooter-related injuries from January 2010–December 2019. Cases originating where e-scooter shares launched between September 1, 2017–December 1, 2019 (intervention period) were considered exposed. The first month of launch (September 2017) was chosen as the time point for pre- and post-intervention analysis. The primary outcome was change in hospitalizations following scooter injury in association with the month/year launch.
This analysis includes 2754 unweighted encounters, representing 102614 estimated injuries involving motorized scooters nationwide. Hospitals within 20 miles of e-scooter shares also experienced a significant monthly increase of 0.24 scooter-related injury hospitalizations/1000 product-related injury hospitalizations (0.17,0.31) compared to a non-significant change in hospitalizations of 0.02 -0.05,0.09 for control hospitals.
An increase in serious motorized scooter injuries coincides with e-scooter shares’ introduction in the US. Future works should explore effective polices to improve public safety.
•Across US, the estimated number of scooter injuries has increased from 8755 injuries in 2010 to 29330 in 2019.•Time series of hospitals near e-scooter shares demonstrated significant increases in scooter-related hospitalizations.•While scooter-related injuries and hospitalizations increased, the rate of hospitalization did not increase.•As e-scooters become more widely adopted, efforts should examine which policies ensure rider and pedestrian safety.
Background
Comprehensive analysis of trauma care between high-, middle-, and low-income countries (HIC/MIC/LIC) is needed to improve global health. Comparison of HIC and MIC outcomes after damage ...control laparotomy (DCL) for patients is unknown. We evaluated DCL utilization among patients treated at high-volume trauma centers in the USA and South Africa, an MIC, hypothesizing similar mortality outcomes despite differences in resources and setting.
Methods
Post hoc analysis of prospectively collected trauma databases from participating centers was performed. Injury severity, physiologic, operative data and post-operative outcomes were abstracted. Univariate and multivariable analyses were performed to assess differences between HIC/MIC for the primary outcome of mortality.
Results
There were 967 HIC and 602 MIC patients who underwent laparotomy. DCL occurred in 144 MIC patients (25%) and 241 HIC (24%) patients. Most sustained (58%) penetrating trauma with higher rates in the MIC compared to the HIC (71 vs. 32%,
p
= 0.001). Between groups, no differences were found for admission physiology, coagulopathy, or markers of shock except for increased presence of hypotension among patients in the HIC. Crystalloid infusion volumes were greater among MIC patients, and MIC patients received fewer blood products than those in the HIC. Overall mortality was 30% with similar rates between groups (29 in HIC vs. 33% in MIC,
p
= 0.4). On regression, base excess and penetrating injury were independent predictors of mortality but not patient residential status.
Conclusion
Use and survival of DCL for patients with severe abdominal trauma was similar between trauma centers in HIC and MIC settings despite increased penetrating trauma and less transfusion in the MIC center. While the results overall suggest no gap in care for patients requiring DCL in this MIC, it highlights improvements that can be made in damage control resuscitation.
Small bowel obstruction management has evolved to incorporate the Gastrografin challenge. We expanded its use to the emergency department observation unit, potentially avoiding hospital admission for ...highly select small bowel obstruction patients. We hypothesized that the emergency department observation unit small bowel obstruction protocol would reduce admissions, costs, and the total time spent in the hospital without compromising outcomes.
We reviewed patients who presented with small bowel obstruction from January 2015 to December 2018. Patients deemed to require urgent surgical intervention were admitted directly and excluded. The emergency department observation unit small bowel obstruction guidelines were introduced in November 2016. Patients were divided into pre and postintervention groups based on this date. The postintervention group was further subclassified to examine the emergency department observation unit patients. Cost analysis for each patient was performed looking at number of charges, direct costs, indirect cost, and total costs during their admission.
In total, 125 patients were included (mean age 69 ± 14.3 years). The preintervention group (n = 62) and postintervention group (n = 63) had no significant difference in demographics. The postintervention group had a 51% (36.7 hours, P < .001) reduction in median duration of stay and a total cost reduction of 49% (P < .001). The emergency department observation unit subgroup (n = 46) median length of stay was 23.6 hours. The readmission rate was 16% preintervention compared to 8% in the postintervention group (P = .18).
Management of highly selected small bowel obstruction patients with the emergency department observation unit small bowel obstruction protocol was associated with decreased length of stay and total cost, without an increase in complications, surgical intervention, or readmissions.
Readmission rates as high as 20% have been reported after ileal pouch-anal anastomosis (IPAA) in children, with obstruction and dehydration as the most commonly listed reasons. We hypothesized that a ...diverting ileostomy contributes to unplanned readmission after IPAA creation.
Children (age <18) who underwent IPAA creation from January 2007 to August 2018 at two affiliated institutions were reviewed. Patient demographics, operative details, and post-operative length of stay (LOS) were abstracted. Unplanned readmission within 30 days and details on patient readmission were reviewed.
Ninety-three patients (57% female) with a median age of 15 years (range: 18 months-17 years) underwent IPAA. Indications for IPAA included ulcerative colitis (n = 63; 68%), familial adenomatous polyposis (n = 24; 26%), indeterminate colitis (n = 5; 5%), and total colonic Hirschsprung's (n = 1; 1%). Sixty-one (66%) patients were diverted at the time of IPAA creation.
Fourteen patients (15%) were readmitted, and reasons for readmission included bowel obstruction (n = 9; 64%), dehydration (n = 2; 14%), anastomotic leak (n = 2; 14%), and gastrointestinal (GI) bleeding (n = 1; 6%). Patients with a diverting ileostomy at the time of IPAA were more often readmittted than patients who were not diverted (21% vs 3%, p = 0.03). Further, 10 (71%) of the readmitted patients had complications attributable to their ileostomy. In patients readmitted for obstructive symptoms, six (67%) required red rubber catheter insertion for resolution, two (22%) patients required reoperation for obstructions at the level of the stoma, and one (11%) resolved with bowel rest alone.
Readmission following IPAA creation in children is often secondary to preventable issues related to diverting ileostomy. Surgeons should carefully consider the necessity of diversion. When it is necessary, particular attention to fascial aperture size and post-discharge initiatives to reduce dehydration may reduce readmission rates.
Level III.
PDF