Elizabeth M. Pontarelli

Laparoscopic Adrenalectomy in Children: A Multicenter Experience

INTRODUCTION Laparoscopic adrenalectomy is now being recognized as the standard approach for adrenalectomy for benign lesions in adults. The published experience in children and adolescents has been limited to sporadic small case series. Therefore, we conducted a large multicenter review of children who have undergone laparoscopic adrenalectomy. METHODS After Institutional Review Boards approval, a retrospective review was conducted on all patients who have undergone laparoscopic adrenalectomy at 12 institutions over the past 10 years. Operative times included unilateral adrenalectomy without concomitant procedures. RESULTS About 140 patients were identified (70 males [50%]). Laterality included 76 (54.3%) left-sided lesions, 59 (42.1%) right, and 5 (3.6%) bilateral. Mean operative time was 130.2 ± 63.5 minutes (range 43-406 minutes). The most common pathology was neuroblastoma in 39 cases (27.9%), of which 23 (59.0%) had undergone preoperative chemotherapy. Other common pathology included 30 pheochromocytomas (21.4%), 22 ganglioneuromas (15.7%), and 20 adenomas (14.3%). There were 13 conversions to an open operation (9.9%). Most conversions were because of tumor adherence to surrounding organs, and tumor size was not different in converted cases (P=.97). A blood transfusion was required in 2 cases. The only postoperative complication was renal infarction after resection of a large neuroblastoma that required skeletonization of the renal vessels. At a median follow-up of 18 months, there was only one local recurrence, which was in a patient with a pheochromocytoma. CONCLUSIONS The laparoscopic approach can be applied for adrenalectomy in children for a wide variety of conditions regardless of age with a 90% chance of completing the operation without conversion. The risk for significant blood loss or complications is low, and it should be considered the preferred approach for the majority of adrenal lesions in children.

P-glycoprotein induction by breast milk attenuates intestinal inflammation in experimental necrotizing enterocolitis

P-glycoprotein (Pgp), a product of the multi-drug resistance gene MDR1a, is a broad specificity efflux ATP cassette transmembrane transporter that is predominantly expressed in epithelial tissues. Because mdr1a−/− mice tend to develop spontaneous colitis in bacteria-dependent manner, Pgp is believed to have a role in protection of the intestinal epithelium from luminal bacteria. Here we demonstrate that levels of Pgp in the small intestine of newborn rodents dramatically increase during breastfeeding, but not during formula feeding (FF). In rats and mice, levels of intestinal Pgp peak on days 3–7 and 1–5 of breastfeeding, respectively. The mdr1a−/− neonatal mice subjected to FF, hypoxia, and hypothermia have significantly higher incidence and pathology, as well as significantly earlier onset of necrotizing enterocolitis (NEC) than congenic wild type mice. Breast-fed mdr1a−/− neonatal mice are also more susceptible to intestinal damage caused by the opportunistic pathogen Cronobacter sakazakii that has been associated with hospital outbreaks of NEC. Breast milk, but not formula, induces Pgp expression in enterocyte cell lines in a dose- and time-dependent manner. High levels of ectopically expressed Pgp protect epithelial cells in vitro from apoptosis induced by C. sakazakii. Taken together, these results show that breast milk-induced expression of Pgp may have a role in the protection of the neonatal intestinal epithelium from injury associated with nascent bacterial colonization.

Low doses of Celecoxib attenuate gut barrier failure during experimental peritonitis

The intestinal barrier becomes compromised during systemic inflammation, leading to the entry of luminal bacteria into the host and gut origin sepsis. Pathogenesis and treatment of inflammatory gut barrier failure is an important problem in critical care. In this study, we examined the role of cyclooxygenase-2 (COX-2), a key enzyme in the production of inflammatory prostanoids, in gut barrier failure during experimental peritonitis in mice. I.p. injection of LPS or cecal ligation and puncture (CLP) increased the levels of COX-2 and its product prostaglandin E2 (PGE2) in the ileal mucosa, caused pathologic sloughing of the intestinal epithelium, increased passage of FITC-dextran and bacterial translocation across the barrier, and increased internalization of the tight junction (TJ)-associated proteins junction-associated molecule-A and zonula occludens-1. Luminal instillation of PGE2 in an isolated ileal loop increased transepithelial passage of FITC-dextran. Low doses (0.5–1 mg/kg), but not a higher dose (5 mg/kg) of the specific COX-2 inhibitor Celecoxib partially ameliorated the inflammatory gut barrier failure. These results demonstrate that high levels of COX-2-derived PGE2 seen in the mucosa during peritonitis contribute to gut barrier failure, presumably by compromising TJs. Low doses of specific COX-2 inhibitors may blunt this effect while preserving the homeostatic function of COX-2-derived prostanoids. Low doses of COX-2 inhibitors may find use as an adjunct barrier-protecting therapy in critically ill patients.

Laparoscopic Versus Open Distal Pancreatectomy in the Management of Traumatic Pancreatic Disruption

PURPOSE Traumatic pancreatic transection is uncommon. The role of laparoscopy in the setting of this injury has not been well described. PATIENTS AND METHODS Six large-volume pediatric trauma centers contributed patients <18 years of age who underwent a distal pancreatectomy for traumatic pancreatic transection from 2000 to 2010. RESULTS Twenty-one patients without another indication for emergency laparotomy underwent a distal pancreatectomy for Grade III pancreatic injuries, of which 7 underwent laparoscopic distal pancreatectomy. Mean (±SD) age was 8.6±4.7 years, and 67% were male. There was no difference in the presence of other injuries between the two groups (43% in each group). Computed tomography revealed a transected pancreas in 85% of the laparoscopic patients and 75% of the open group (P=1.0). Mean operative time was 218±101 minutes with laparoscopy compared with 195±111 minutes with the open procedure (P=.7). Median duration of hospitalization was 6 days (range, 6-18 days) in the laparoscopic group compared with 11 days (range, 5-26 days) in the open group (P=0.3). Postoperative morbidity was not different between the two groups (57% versus 21% for laparoscopic versus open, P=.2). CONCLUSIONS Laparoscopy is equivalent to open distal pancreatectomy in children with select traumatic pancreatic injuries.

Recent Developments in Hirschsprung’s-Associated Enterocolitis

Hirschsprung’s-associated enterocolitis (HAEC) continues to be a significant source of morbidity for patients with Hirschsprung’s disease (HD). New clinical and histologic classification systems for HAEC will improve consistency between reports and increase the ability to compare outcomes. A complete understanding of disease pathogenesis is lacking, but evidence suggests that the intestinal microbiota may play a role in the development of HD and HAEC. The benefits of adjunctive therapies, such as anal dilations and botulinum toxin to reduce the incidence of HAEC following corrective endorectal pull-through, remain controversial. Finally, new clinical data have identified an association between HAEC and inflammatory bowel disease and will likely lead to further genetic studies to elucidate the connection between these two disease processes.

Infant head injury in falls and nonaccidental trauma: does injury pattern correlate with mechanism?

ObjectivesNonaccidental trauma (NAT) is most common and most lethal in infants. Falls are the most frequently given explanation for NAT, and head injuries can result from both mechanisms. We hypothesized that infant head injuries from NAT have a distinct injury profile compared to falls. MethodsThe trauma registry and patient records were reviewed from 2004 to 2008. Infants with at least 1 head computed tomography were included. ResultsNinety-nine infants were identified. Falls (67 patients) and NAT (21 patients) were the most common mechanism of injury. Falls had lower injury severity scores, 5 versus 17 compared to NAT (P < 0.001). Nonaccidental trauma patients had injuries to face, chest, abdomen, or extremities much more frequently, 62% versus 3% in falls (P < 0.001). Isolated intracranial hemorrhage was higher in NAT (60% vs. 23%, P = 0.002), whereas isolated skull fracture was higher in falls (42% vs. 5%, P = 0.005). Outcomes for NAT showed longer intensive care unit stays (4 days vs. 1 day; P < 0.001), longer hospital stays (7 days vs. 1 day; P < 0.001), and more intracranial operations (9 vs. 1; P < 0.001). ConclusionsWe recommend that all children younger than 1 year, with an isolated intracranial hemorrhage, have a full NAT work-up. Injury severity score greater than 20, Glasgow Coma Scale less than 13, and extracranial injuries should also increase suspicion of NAT.

Congenital H-type tracheoesophageal fistula: A multicenter review of outcomes in a rare disease

OBJECTIVE To perform a multicenter review of outcomes in patients with H-type tracheoesophageal fistula (TEF) in order to better understand the incidence and causes of post-operative complications. BACKGROUND H-type TEF without esophageal atresia (EA) is a rare anomaly with a fundamentally different management algorithm than the more common types of EA/TEF. Outcomes after surgical treatment of H-type TEF are largely unknown, but many authoritative textbooks describe a high incidence of respiratory complications. METHODS A multicenter retrospective review of all H-type TEF patients treated at 14 tertiary childrens hospital from 2002-2012 was performed. Data were systematically collected concerning associated anomalies, operative techniques, hospital course, and short and long-term outcomes. Descriptive analyses were performed. RESULTS We identified 102 patients (median 9.5 per center, range 1-16) with H-type TEF. The overall survival was 97%. Most patients were repaired via the cervical approach (96%). The in-hospital complication rate, excluding vocal cord issues, was 16%; this included an 8% post-operative leak rate. Twenty-two percent failed initial extubation after repair. A total of 22% of the entire group had vocal cord abnormalities (paralysis or paresis) on laryngoscopy that were likely because of recurrent laryngeal nerve injury. Nine percent required a tracheostomy. Only 3% had a recurrent fistula, all of which were treated with reoperation. CONCLUSIONS There is a high rate of recurrent laryngeal nerve injury after H-type TEF repair. This underscores the need for meticulous surgical technique at the initial repair and suggests that early vocal cord evaluation should be performed for any post-operative respiratory difficulty. Routine evaluation of vocal cord function after H-type TEF repair should be considered. THE LEVEL OF EVIDENCE RATING Level IV.