Cynthia Reyes

Anatomic and functional abnormalities of the esophagus in infants surviving congenital diaphragmatic hernia

As more infants with congenital diaphragmatic hernia (CDH) survive by means of extracorporeal membrane oxygenation (ECMO), new clinical observations are being made. We report anatomic and functional abnormalities of the esophagus in these infants. Twenty-two of 30 infants with CDH survived. Three of 7 non-ECMO-treated infants and 14 of 17 ECMO-treated infants had an air- or fluid-filled mediastinal mass that was confirmed by an upper gastrointestinal series as ectatic esophagus. Contrast studies demonstrated severe gastroesophageal reflux. Intra-esophageal pH monitoring confirmed significant reflux (Euler scores greater than 50) in 69% of tested patients. Prolonged acid clearance in most patients implied abnormal peristalsis. Hydramnios was correlated to the observed esophageal abnormalities, being present in 13 of 16 infants with an available amniotic history. All patients had symptomatic gastroesophageal reflux managed without antireflux surgery and were discharged 36 +/- 2 days after initiation of feeding. Follow-up (range: 7 to 56 months; mean: 32 months) showed that weight gain in affected children was slower than in those not affected. All but one are asymptomatic. Repeat upper gastrointestinal series shows persistent ectasia but less gastro-esophageal reflux. Gastroesophageal reflux/ectasia is a new observation with CDH. The associated hydramnios may result from proximal foregut obstruction by kinking the gastroesophageal junction with CDH. The radiographic appearance can be quite unusual. Clinical manifestations of gastro-esophageal reflux are manageable without surgery but may account for the observed compromised growth.

Extracorporeal membrane oxygenation causes significant changes in intracranial pressure and carotid artery blood flow in newborn lambs

The effects of ECMO on cerebral dynamics, particularly in the face of asphyxia, are largely unknown. We inquired as to whether carotid artery blood flow (CABF) and intracranial pressure (ICP) were affected by carotid artery/jugular vein ligation, asphyxia, ECMO, and ECMO with asphyxia. Lightly sedated newborn lambs (two to four days old, 3 to 4 kg) in four groups were monitored for mean ICP by an epidural sensor, mean CABF by a flow probe, and mean arterial pressure. Mean values were determined for the duration of each step of the experiment. ECMO was venoarterial at 100 to 120 mL/kg/min. CABF and ICP were measured in group 1 before and after CA/JV ligation; in group 2 during normoxia/normocapnia followed by hypoxia (30 to 40 torr)/hypercapnia (70 to 90 torr); in group 3 before, during, after ECMO while normoxic/normocapnic throughout; and in group 4 as ECMO was begun while hypoxic/hypercapnic. Vessel ligation alone caused no significant CABF/ICP changes. Asphyxia caused physiologic increases in CABF (P less than .03) and ICP (P less than .01). ECMO alone caused a significant decrease in ICP (P less than .003). ECMO with asphyxia caused an even more severe decrease in ICP (P less than .001) combined with augmented CABF (P less than .03). The ICP decrease was limited to the duration of ECMO. Possible explanations include loss of cerebral autoregulation induced by hypoxia/hypercarbia and alterations in cerebral venous drainage necessitated by this method of cardiopulmonary bypass.

Right pneumonectomy syndrome: A lethal complication of lung resection in a newborn with cystic adenomatoid malformation

A newborn girl underwent a right pneumonectomy for cystic adenomatoid malformation. She subsequently developed compression of the trachea and left mainstem bronchus by a combination of aortic arch, pulmonary artery, and ductus arteriosus. She died while planning aortic suspension, and the anatomic relationships were confirmed by autopsy. This problem is potentially treatable by a variety of means.

Intestinal barrier dysfunction in human necrotizing enterocolitis

BACKGROUND Intestinal barrier dysfunction has been implicated in necrotizing enterocolitis (NEC), but has not been directly measured in human NEC. METHODS Small intestines removed during surgery were immediately mounted in an Ussing chamber. mRNA expression of tight junction (TJ) proteins was measured with RT-PCR. RESULTS Fifteen infants were included, 5 with NEC and 10 with other diagnoses. Average transepithelial resistance (TER) was 11.61±1.65Ω/cm2 in NEC specimens, 23.36±1.48Ω/cm2 at resection margin, and 46.48±5.65Ω/cm2 in controls. Average flux of permeability marker mannitol was 0.23±0.06μMol/cm2 per h in NEC, 0.04±0.01 μMol/cm2 per h at resection margin, and 0.017±0.004 μMol/cm2 per h in control tissue (p<0.05). RT-PCR analysis showed marked decrease in mRNA expression of a TJ protein occludin in NEC affected tissue (p<0.03 vs. control). Additionally, mRNA expression of myosin light chain kinase (MLCK), an important regulator of TJ permeability, was increased in NEC specimens. CONCLUSION These studies show for the first time that NEC intestinal tissue have increased intestinal permeability, even at grossly healthy-appearing resection areas. The increase in intestinal permeability in NEC appeared to be related in part to a decrease in occludin and an increase in MLCK expression. LEVEL OF EVIDENCE Level 2.

Repair of a floating sternum with autologous rib grafts and polylactide bioabsorbable struts in an 18-year-old male

Failed regeneration of costal cartilage after open repair of pectus chest wall deformities can result in a floating sternum. A floating sternum can be repaired by insertion of a rib graft between the rib and sternum, and stabilization with a metal strut. The metal implant is usually removed with a second operation. We report use of bioabsorbable struts to stabilize rib grafts during repair of a floating sternum in an 18-year-old male with a failed open repair of pectus carinatum. He had an uncomplicated peri-operative course. One year later, the sternum had a normal appearance and was sturdy. A second operation for removal of hardware was not necessary.

Simple technique for determination of the correct length of percutaneous tunnelled catheters in neonates and children.

A simple technique for determining the correct catheter length in percutaneous tunnelled catheters in infants and young children has been devised that virtually guarantees accurate catheter tip placement. Sixty-six patients, aged newborn to 5 years (mean, 1.6 years) have successfully undergone this technique. It is safe, simple, precise, quick, and cost effective. It requires only a hemostat, a suture, and the supplies provided in the prepackaged catheter kit. This technique should be used whenever a percutaneous technique for accessing the vein is used and fluoroscopy is available.

Implementation of a Clinical Documentation Improvement Curriculum Improves Quality Metrics and Hospital Charges in an Academic Surgery Department

BACKGROUND Accurate clinical documentation (CD) is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation. New requirements have mandated adoption of ICD-10-CM coding systems, adding another layer of complexity to CD. A clinical documentation improvement (CDI) and ICD-10 training program was created for health care providers in our academic surgery department. We aimed to assess the impact of our CDI curriculum by comparing quality metrics, coding, and reimbursement before and after implementation of our CDI program. STUDY DESIGN A CDI/ICD-10 training curriculum was instituted in September 2014 for all members of our university surgery department. The curriculum consisted of didactic lectures, 1-on-1 provider training, case reviews, e-learning modules, and CD queries from nurse CDI staff and hospital coders. Outcomes parameters included monthly documentation completion rates, severity of illness (SOI), risk of mortality (ROM), case-mix index (CMI), all-payer refined diagnosis-related groups (APR-DRG), and Surgical Care Improvement Program (SCIP) metrics. Financial gain from responses to CDI queries was determined retrospectively. RESULTS Surgery department delinquent documentation decreased by 85% after CDI implementation. Compliance with SCIP measures improved from 85% to 97%. Significant increases in surgical SOI, ROM, CMI, and APR-DRG (all p < 0.01) were found after CDI/ICD-10 training implementation. Provider responses to CDI queries resulted in an estimated

Twenty-five years of the James Warden Guest Assistance Program of the Pacific Association of Pediatric Surgeons

4,672,786 increase in charges. CONCLUSIONS Clinical documentation improvement/ICD-10 training in an academic surgery department is an effective method to improve documentation rates, increase the hospital estimated reimbursement based on more accurate CD, and provide better compliance with surgical quality measures.

Selective use of extracorporeal membrane oxygenation in the management of congenital diaphragmatic hernia.

This is a review of twenty-five years of the James Warden Guest Assistance Program of the Pacific Association of Pediatric Surgeons.