Chinwendu Onwubiko

Contrast enhanced ultrasound for the evaluation of blunt pediatric abdominal trauma

INTRODUCTION Blunt abdominal trauma is a common problem in children. Computed tomography (CT) is the gold standard for imaging in pediatric blunt abdominal trauma, however up to 50% of CTs are normal and CT carries a risk of radiation-induced cancer. Contrast enhanced ultrasound (CEUS) may allow accurate detection of abdominal organ injuries while eliminating exposure to ionizing radiation. METHODS Children aged 7-18years with a CT-diagnosed abdominal solid organ injury underwent grayscale/power Doppler ultrasound (conventional US) and CEUS within 48h of injury. Two blinded radiologists underwent a brief training in CEUS and then interpreted the CEUS images without patient interaction. Conventional US and CEUS images were compared to CT for the presence of injury and, if present, the injury grade. Patients were monitored for contrast-related adverse reactions. RESULTS Twenty one injured organs were identified by CT in eighteen children. Conventional US identified the injuries with a sensitivity of 45.2%, which increased to 85.7% using CEUS. The specificity of conventional US was 96.4% and increased to 98.6% using CEUS. The positive predictive value increased from 79.2% to 94.7% and the negative predictive value from 85.3% to 95.8%. Two patients had injuries that were missed by both radiologists on CEUS. In a 100kg, 17year old female, a grade III liver injury was not seen by either radiologist on CEUS. Her accompanying grade I kidney injury was not seen by one of the radiologist on CEUS. The second patient, a 16year old female, had a grade III splenic injury that was missed by both radiologists on CEUS. She also had an adjacent grade II kidney injury that was seen by both. Injuries, when noted, were graded within 1 grade of CT 33/35 times with CEUS. There were no adverse reactions to the contrast. CONCLUSION CEUS is a promising imaging modality that can detect most abdominal solid organ injuries in children while eliminating exposure to ionizing radiation. A multicenter trial is warranted before widespread use can be recommended. LEVEL OF EVIDENCE Level II; Diagnostic Prospective Study.

The value of official reinterpretation of trauma computed tomography scans from referring hospitals.

INTRODUCTION Historically, computed tomography (CT) scans of injured children obtained at referring emergency departments were not reinterpreted by trauma center radiologists at our institution, creating a dilemma for trauma physicians: rescan, use the outside interpretation, or interpret scans themselves. In 2010, our radiologists began reinterpreting all referring hospital trauma CT scans; this study examines the effect of that change. METHODS Transferred patients who had undergone an abdomen/pelvis CT (CTAP) scan between December 2010 and December 2012 were identified in our trauma registry. Pediatric radiologist reinterpretations were compared to referring hospital radiologist reports. RESULTS We identified 168 patients transferred to our institution with a CTAP. Seventy patients were excluded owing to lack of: complete study, referring hospital interpretation, or reinterpretation. Of the remaining 98 cases, 12 new injuries were identified: 3 splenic and 3 liver injuries, 1 adrenal hematoma, 2 pelvic fractures, 1 spinal fracture, 1 duodenal hematoma and 1 jejunal perforation. Three patients had solid organ injuries upgraded (grade II to III liver laceration; 2 renal lacerations with active extravasation initially missed), and 4 patients downgraded to no injury. CONCLUSION Reinterpretation of referring hospital CT scans by pediatric radiologists is beneficial to appropriate management of pediatric trauma patients with concern for blunt abdominal trauma.

Laparoscopic Gastrojejunostomy Tube Placement in Infants with Congenital Cardiac Disease

INTRODUCTION Gastrojejunostomy (GJ) tubes are an option for durable enteral access for critically ill infants with congenital cardiac disease who struggle with obtaining adequate nutrition. MATERIALS AND METHODS Infants weighing less than 10 kg with cardiac disease who received placement of a laparoscopic GJ tube from November 2011 to January 2015 were reviewed. The operative technique used an umbilical port for the camera and a single stab incision for the gastric access site. After insufflation to 5-8 mm Hg, the stomach was suspended to the abdominal wall, after which a dilator was maneuvered into a postpyloric position using laparoscopic visualization and fluoroscopy, and a glidewire was passed into the duodenum. The GJ tube was then fluoroscopically threaded over the glidewire; final position was confirmed by contrast injection. RESULTS There were 32 laparoscopic GJ tube placement operations performed; 7 (21.9%) of these tubes were standard single-unit GJ tubes, and 25 (78.1%) were low-profile gastrostomy tubes modified with a nasojejunal feeding tube threaded through the feeding port. Median patient age was 3.5 months (range, 0.75-11 months), with a median weight of 4.2 kg (range, 2.4-7.4 kg). Congenital defects were varied, including hypoplastic left heart syndrome and pulmonary vein stenosis. Median operative time was 62 minutes for isolated GJ placement (range, 35-114 minutes). There were three postoperative complications, resulting in a 30-day complication rate of 9.4%. Thirty-day mortality was 9.4% with no mortality related to the operation. CONCLUSIONS Laparoscopic GJ tube placement may be performed safely in infants with cardiac disease and allows these patients to receive adequate nutrition despite intolerance of gastric feeding.

Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis

Introduction The utility of focused assessment with sonography for trauma (FAST) in children is poorly defined with considerable practice variation. Our purpose was to investigate the role of FAST for intra-abdominal injury (IAI) and IAI requiring acute intervention (IAI-I) in children after blunt abdominal trauma (BAT). Methods We prospectively enrolled children younger than 16 years after BAT at 14 Level I pediatric trauma centers over a 1-year period. Patients who underwent FAST were compared with those that did not, using descriptive statistics and univariate analysis; p value less than 0.05 was considered significant. FAST test characteristics were performed using computed tomography (CT) and/or intraoperative findings as the gold standard. Results Two thousand one hundred eighty-eight children (age, 7.8 ± 4.6 years) were included. Eight hundred twenty-nine (37.9%) received a FAST, 340 of whom underwent an abdominal CT. Ninety-seven (29%) of these 340 patients had an IAI and 27 (7.9%) received an acute intervention. CT scan utilization after FAST was 41% versus 46% among those who did not receive FAST. The frequency of FAST among centers ranged from 0.84% to 94.1%. There was low correlation between FAST and CT utilization (r = −0.050, p < 0.001). Centers that performed FAST at a higher frequency did not have improved accuracy. The test performance of FAST for IAI was sensitivity, 27.8%; specificity, 91.4%; positive predictive value, 56.2%; negative predictive value, 76.0%; and accuracy, 73.2%. There were 81 injuries among the 70 false-negative FAST. The test performance of FAST for IAI-I was sensitivity, 44.4%; specificity, 88.5%; positive predictive value, 25.0%; negative predictive value, 94.9%; and accuracy, 85.0%. Fifteen children with a negative FAST received acute interventions. Among the 27 patients with true positive FAST examinations, 12 received intervention. All had an abnormal abdominal physical examination. No patient underwent intervention before CT scan. Conclusion As currently used, FAST has a low sensitivity for IAI, misses IAI-I and rarely impacts management in pediatric BAT. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level II; diagnostic tests or criteria study, level II; therapeutic/care management study, level III.

Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely

BACKGROUND Computed tomography is commonly used to rule out intra-abdominal injury (IAI) in children, despite associated cost and radiation exposure. Our purpose was to derive a prediction rule to identify children at very low risk for IAI after blunt abdominal trauma (BAT) for whom a CT scan of the abdomen would be unnecessary. STUDY DESIGN We prospectively enrolled children younger than 16 years of age who presented after BAT at 14 Level I pediatric trauma centers during 1 year. We excluded patients who presented more than 6 hours after injury or underwent abdominal CT before transfer. We used binary recursive partitioning to derive a prediction rule identifying children at very low risk of IAI and IAI requiring acute intervention (IAI-I) using clinical information available in the trauma bay. RESULTS We included 2,188 children with a median age of 8 years. There were 261 patients with IAI (11.9%) and 62 patients with IAI-I (2.8%). The prediction rule consisted of (in descending order of significance): aspartate aminotransferase >200 U/L, abnormal abdominal examination, abnormal chest x-ray, report of abdominal pain, and abnormal pancreatic enzymes. The rule had a negative predictive value of 99.4% for IAI and 100.0% for IAI-I in patients with none of the prediction rule variables present. The very-low-risk population consisted of 34% of the patients and 23% received a CT scan. Computed tomography frequency ranged from 4% to 96% by center. CONCLUSIONS A prediction rule using history and physical examination, chest x-ray, and laboratory evaluation at the time of presentation after BAT identifies children at very low risk for IAI for whom CT can be avoided.

Acute procedural interventions after pediatric blunt abdominal trauma: A prospective multicenter evaluation

BACKGROUND Pediatric intra-abdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. METHODS We prospectively enrolled children younger than 16 years after BAT at 14 Level I Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared with those who did not receive an intervention using descriptive statistics and univariate analysis; p less than 0.05 was considered significant. RESULTS Two hundred sixty-one (11.9%) of 2,188 patients had IAI. Forty-five (17.2%) IAI patients received an acute procedural intervention (38 operations, seven angiographic embolization). The mean age for patients requiring intervention was 7.1 ± 4.1 years and not different from the population. Most patients (88.9%) with IAI-I were normotensive. IAI-I patients were significantly more likely to have a mechanism of motor vehicle collision (66.7% vs. 38.9%), more likely to present as a Level I activation (44.4% vs. 26.9%), more likely to have a Glascow Coma Scale less than 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical examination (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent computed tomography scan before intervention. Operations consisted of laparotomy (n = 21), laparoscopy converted to open (n = 11), and laparoscopy alone (n = 6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury, including seven angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for solid organ injury (59.2% vs. 7.6%). Postoperative mortality from IAI was 2.6%. CONCLUSION Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course and have excellent clinical outcomes. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.BACKGROUND Pediatric intraabdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. METHODS We prospectively enrolled children <16 years following BAT at 14 Level-One Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared to those who did not receive an intervention using descriptive statistics and univariate analysis; p < 0.05 was considered significant. RESULTS 261 of 2188 patients (11.9%) had IAI. 45 IAI patients (17.2%) received an acute procedural intervention (38 operations, 7 angiographic embolization). The mean age for patients requiring intervention was 7.1+/-4.1 years and not different from the population. The majority of patients with IAI-I were normotensive (88.9%). IAI-I patients were significantly more likely to have a mechanism of MVC (66.7% vs. 38.9%), more likely to present as a level I activation (44.4% vs. 26.9%), more likely to have a GCS < 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical exam (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent CT scan before intervention. Operations consisted of laparotomy (n=21), laparoscopy converted to open (n=11), and laparoscopy alone (n=6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury (SOI), including 7 angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for SOI (59.2% vs. 7.6%). Post-operative mortality from IAI was 2.6%. CONCLUSIONS Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course, and have excellent clinical outcomes. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Primary laparoscopic gastrojejunostomy tubes as a feeding modality in the pediatric population

PURPOSE Outcomes associated with primary laparoscopic gastrojejunal (GJ) tube placement in the pediatric population were evaluated. METHODS A single-institution, retrospective review examined patients undergoing laparoscopic GJ tube placement between June 2011 and December 2014. Outcomes included gastric feeding tolerance, subsequent fundoplication, complications, and mortality. RESULTS Ninety laparoscopic GJ tubes were placed. Median follow-up was 342days (interquartile range [IQR]=141-561days). Median patient age was 5months (IQR=3-11months) and weight was 5.2kg (IQR=4-8.4kg). The most common indications for placement were gastroesophageal reflux (n=85, 94.4%) and/or aspiration (n=40, 44.4%). Most common comorbidities included cardiac (n=34, 37.8%) and respiratory (n=29, 32.2%) diseases. The complication rate was 17.8%, including one case of intestinal perforation. Thirty-four (37.7%) patients transitioned to gastric feeding within 1year; time to conversion was 156days (IQR=117-210days); of those, 18.9% patients transitioned to oral feedings. A fundoplication was later performed in 4 children for persistent reflux. Mortality was 23.3% with no procedural-related deaths. CONCLUSION Primary laparoscopically placed GJ tubes are a reliable means of enteral access for pediatric patients with gastric feeding intolerance. Many of these children are successfully transitioned to gastric and/or oral feedings over time. Further studies are needed to characterize which patients are best served with a GJ tube versus alternatives such as fundoplication. LEVEL OF EVIDENCE III (treatment) TYPE OF STUDY: Retrospective.

The lost art of the splenorrhaphy.

BACKGROUND In the case of the hemodynamically unstable child, splenorrhaphy is preferred to splenectomy to avert postsplenectomy sepsis. However, successful splenorrhaphy requires familiarity with the procedure. We sought to determine how many splenectomies or splenorrhaphies for trauma the average pediatric surgeon can be expected to perform during their career. METHODS The Pediatric Health Information System (PHIS) Database was queried for patients ≤18years coded with an International Classification of Diseases 9th Edition diagnosis code of a splenic injury from 2004 to 2013. Age, gender, grade of splenic injury, and operations performed were extracted. Numbers of pediatric surgeons per hospital were obtained. RESULTS 9567 children were identified. 2.1% underwent a splenectomy and 0.8% underwent a splenorrhaphy. The average surgeon performed 0.6 (SD=0.6) splenectomies and 0.2 (SD=0.4) splenorrhaphies for trauma. If these rates remain constant over time, the average surgeon would perform 1.8 (SD =1.7) splenectomies and 0.6 (SD =1.1) splenorrhaphies for trauma over a 30-year surgical career. CONCLUSION Nonoperative management is associated with a host of benefits, but has resulted in a decrease in the experience level of the pediatric surgeons expected to perform an emergency splenectomy or splenorrhaphy when the unusual occasion arises.