Graeme Pitcher

Outcomes of plastic closure in gastroschisis.

BACKGROUND Gastroschisis is a congenital abdominal wall defect in which the intestines develop outside the abdomen and are exposed to amniotic fluid. When the defect is small, lymphatic, venous, and intestinal obstruction may occur and contribute to the formation of intestinal edema, atresia, ischemia, and a thick inflammatory peel. Treatment requires early coverage of abdominal contents either by primary closure or by the placement of temporary Silastic silo followed by abdominal wall closure. Currently, both traditional suture closure and the sutureless plastic closure are being employed to repair the gastroschisis defect. The goal of the current study is to evaluate plastic closure. We predict no difference will be found in clinical outcomes between plastic closure and traditional suture closure. METHODS A retrospective review of 80 patients treated between 2000 and 2009 was performed. Plastic closure was used in 52 (65%) and traditional suture closure in 28 (35%) babies. The surgical procedure was determined by surgeon preference. Of the 31(39%) babies who required silos, 15 (19%) were treated with plastic closure and 16 (20%) underwent traditional closure. We collected the following demographic data and clinical progression data. Using SAS 9.2 (SAS Institute Inc, Cary, NC), we conducted linear regression, logistic regression, and time to event models to compare the following outcomes: days on ventilator, days to start enteral feeds, days to reach goal enteral feeds, days on total parenteral nutrition, hospital charges, duration of stay, mortality, and complications. RESULTS The mean duration of follow-up was 11.4 months. Patients spent an average of 6 days on the ventilator. There were 2 mortalities. A multivariate analysis demonstrated that no differences were found between the 2 closures with most of the outcomes; however, when compared with traditional suture closure, those babies treated with plastic closure spent 4 days fewer days on the ventilator (P < .01). Those babies who underwent suture closure were more likely to have an infection or sepsis (odds ratio, 5.15; P < .001). When the entire cohort was considered, no significant difference was found between plastic and suture closure in time to start feeds, time to reach goal feeds, time on parenteral nutrition, hospital charges, duration of stay, or complications. Ventral hernias were noted in 46 (58%) patients, 32 (62%) after plastic closure and 14 (50%) after suture closure (P = .32). Hernia repair was required in 16 (20%) patients, 11 (21%) after plastic closure, and 5 (18%) after traditional repair (P = .32). In the silo cohort, children treated with plastic closure required 7.5(P < .01) fewer days to start enteral feeds than those treated with suture closure. CONCLUSION Plastic closure of abdominal wall defects in gastroschisis is effective both as a primary procedure and after silo placement. A multivariate analysis shows plastic closure to be associated with fewer days of mechanical ventilation and less likelihood of developing infection or sepsis.

Segmental resection for the treatment of congenital pulmonary malformations

PURPOSE The purpose of this study was to compare clinical outcomes of segmental resection to lobectomy as increasing antenatal diagnosis of congenital pulmonary malformations has led to a shift in surgical management. METHODS A retrospective institutional review for patients undergoing surgical excision of congenital pulmonary malformations was performed. RESULTS Sixty-two patients with congenital pulmonary malformations were reviewed between 2001 and 2012. Forty-five were included for analysis. Malformations were subdivided into two groups, including congenital lobar emphysema (CLE) (n=11, 24%) and intrapulmonary (IP) lesions (n=34, 76%). Nineteen (56%) IP patients underwent segmental resection, and 15 (79%) were performed thoracoscopically without conversion to thoracotomy. None of these patients had recurrent disease. Lobectomy was performed in 11 (100%) CLE and 15 (44%) IP patients, and the majority were by thoracotomy. Median hospital stay was longer for the lobectomy group at 7days when compared to the segmentectomy group at 2days (p<0.001). There was not a difference in complication rate (21% vs. 19%, p=1.000) or in median number of chest tube days (2 vs. 3days, p=0.079) for segmentectomy versus lobectomy patients. CONCLUSIONS Segmental resections of congenital pulmonary malformations can be performed safely while conserving healthy lung tissue.

Outcome of antegrade continent enema (ACE) procedures in children and young adults

OBJECTIVE Intractable incontinence affects a large number of children and young adults in the US. The goal of this study is to evaluate the long-term outcomes of surgical access for administration of antegrade continence enemas (ACE) in affected children and young adults. METHODS Patients who underwent surgical procedure to enable administration of ACE from 1994 to 2011 were retrospectively reviewed. Data collected included patient demographics, primary diagnosis, surgical technique, conduit used, complications, follow-up duration, and social continence. RESULTS Sixty eighty patients underwent surgery to enable ACE; mean follow up was 61 months. Enteral conduit (EC) was performed in 19 patients, tube cecostomy catheters (CC) in 49. Meningomyelocele was diagnosed in 60% of patients. Mean age was 11 (1.67-53) years. Complications included tube dislodgement (43%), granulation tissue (46%), site infection (13%), leakage (32%), break in the tube (6%) and tract stenosis (6%). Complete social continence was achieved in 68%, partial continence was achieved in 29%, and no benefit was achieved in 3% of patients. The rate of complications and incontinence resolution following CC was 78% and 66%, and following EC 89% and 74%. The differences were not statistically significant. CC patients developed granulation tissue more frequently (53%) and leaks of fecal material less frequently (20%) compared to EC patients (26% and 53%) (p < 0.05 and < 0.01). Although children 7 years or younger developed more overall complications (94%) than older patients (69%; p < 0.05), there was not a significant difference in the frequency of any one complication or in the rate of continence, between the two groups. Multivariate analysis showed that EC is three times more likely to be complicated by fecal leakage. CC patients are at greater risk to develop granulation tissue (p < 0.05). CONCLUSIONS Most patients achieved social continence and improved hygiene with the aid of ACE. Younger children also benefited greatly from institution of ACE. CC was associated with fewer major complications such as leak of fecal contents than EC but required regular tube changes.

Link for Injured Kids: A Patient-Centered Program of Psychological First Aid After Trauma

Objective Injury, the most common type of pediatric trauma, can lead to a number of adverse psychosocial outcomes, including posttraumatic stress disorder. Currently, few evidence-based parent programs exist to support children hospitalized after a traumatic injury. Using methods in evaluation and intervention research, we completed a formative research study to develop a new program of psychological first aid, Link for Injured Kids, aimed to educate parents in supporting their children after a severe traumatic injury. Methods Using qualitative methods, we held focus groups with parents and pediatric trauma providers of children hospitalized at a Level I Childrens Hospital because of an injury in 2012. We asked focus group participants to describe reactions to trauma and review drafts of our intervention materials. Results Health professionals and caregivers reported a broad spectrum of emotional responses by their children or patients; however, difficulties were experienced during recovery at home and upon returning to school. All parents and health professionals recommended that interventions be offered to parents either in the emergency department or close to discharge among admissions. Conclusions Results from this study strongly indicate a need for posttrauma interventions, particularly in rural settings, to support families of children to address the psychosocial outcomes in the aftermath of an injury. Findings presented here describe the process of intervention development that responds to the needs of an affected population.

Bronchial Compression and Tracheosophageal Fistula Secondary to Prolonged Esophageal Foreign Body

Introduction: Foreign body ingestion is a common pediatric problem that can have a delayed presentation, as presented herein. Case Report: We present the case of a 15-year-old female who developed bronchial compression and an acquired tracheoesophageal fistula secondary to a longstanding esophageal foreign body. Discussion: There are several challenges in diagnosis and management of this unusual situation. We review the literature regarding prolonged retention of foreign bodies and the challenges in diagnosis in the developmentally disabled child. Conclusion: Providers must have a high suspicion for foreign bodies in the case of unusual symptoms present in children with neurodevelopmental delays.

The Thoracic Inlet Index in patients with tracheal obstruction caused by chest wall deformity: Validation in patients and age-matched controls

AIM We present a novel index for evaluating severity of airway-threatening thoracic inlet compromise in childhood. Two indices were validated in three cases and sixty asymptomatic controls. METHODS We developed an index to determine severity of thoracic inlet narrowing. Two different measurement methods were evaluated: Thoracic Inlet Index (TII) was determined at the site of greatest airway compromise at the level of the innominate artery crossing the anterior trachea and TII (anatomic) using purely skeletal measurements, both determined from thoracic CT scan. We sought to validate both indices to determine which was more predictive of the risk of airway compromise. Three patients who presented with life threatening airway compromise were compared to sixty age matched asymptomatic controls obtained from the trauma registry. RESULTS The mean TII in controls was 3.89. The TII was consistent at various ages. In patients, mean TII was 12.16 (range of 11.31-12.95). For TII the difference between controls and symptomatic patients was highly significant (P=0.0012). The mean TII (anatomic) in controls was 3.5. The TII (anatomic) was less consistent when evaluated in different age groups. In patients mean TII (anatomic) was 6.32 (range 5.38-7.59). For TII (anatomic), the difference between controls and symptomatic patients was also significant (P=0.0474) but did not discriminate as well as the functional index. CONCLUSIONS The TII measured at the level of the innominate artery crossing on thoracic CT scan appears to be the most useful. A level of greater than 10 was highly predictive of airway compromise in our patient group.

Pediatric Inguinal Hernia Repair

Pediatric inguinal hernia repair is performed for patent processus vaginalis with hydrocele or hernia. This chapter lists the indications, essential steps, common technical variations, and complications of the procedure. A detailed template operative dictation note is included.

Commentary: preoperative evaluation in cryptorchidism.

Two articles in this issue explore the authors’ experience with the preoperative investigation and diagnosis of boys with undescended testes. Both of these articles come from surgeons working in relatively resource-challenged environments. Dr. Ekenze and his colleagues present data from a Nigerian teaching hospital, reporting that, in their experience, preoperative ultrasound is invaluable for differentiating patients whose orchidopexies can be achieved by a standard groin approach from those whom they believe are best approached by an extensive muscle-cutting operation to mobilize the intra-abdominal testis [1]. Dr. Zakaria and colleagues approach the problem from a different perspective and evaluate the utility of performing the examination with the patient under anesthesia [2]. Both draw the conclusion that their approach adds utility to the investigation of the boy with an impalpable undescended testis.

Paediatric Surgery, Mark Davenport and Agostino Pierro (eds)

When one considers the number of children in our communities it is a testament to their robust good health that pediatric surgical pathology occurs so uncommonly and in classical well-described categories of usually rare conditions. In academic pediatric surgical centers around the world, students and junior doctors encounter children with surgical diseases, often learning about the various conditions case by case as they see the various pathologies for the first time. In developing countries and nonacademic environments, nurses, doctors, and general surgeons will occasionally have to treat a child with a surgical problem and will need simple and concise practical guidance. This book is aimed at filling that niche in the literature on the subject. At a lightweight 4 9 7 inches with a strong plastic-laminated cover in cheerful colors, it would happily travel in the pocket of a student or trainee for the duration of his or her rotation in pediatric surgery. However,

Patient education and recall regarding postsplenectomy immunizations

75 for a small book of this nature is more than one would expect to pay, and this may be a deterrent to many potential buyers who would ‘‘need it only for one rotation.’’ Also, the essential ‘‘Britishness’’ of the book will certainly lessen its appeal on the side of the Atlantic on which it was, paradoxically, published. Its endorsement by the British Association of Paediatric Surgeons is all well and good, but the inclusion of a table of all the past presidents of the association will only serve to amuse most modern readers and remind them of a surgical hubris from years gone by. A truly international book with a broader representation of authors and a more global view of pediatric surgical problems would surely have served readers and the editors’ interests better. The editors are to be commended for succeeding in creating a book which in my opinion is a very good blend of the concise portability that you would expect in a vade mecum and this book’s substantial content. Useful and mainly contemporary references are carried at the end of each section. The spectrum of chapters is comprehensive, including all the usual subjects, as well as urology, cardiac surgery, and some neurosurgery. There is an informative chapter on fetal screening, as well as a useful précis of neonatal medicine. The general considerations chapter refreshingly includes topics such as consent, ethics and withdrawal of care, and even leads the reader to useful electronic resources. However, chapters covering common conditions such as appendicitis and intussusception are so brief as to almost limit their usefulness. A serious omission is the lack of a chapter on head injury, which is presented in a brief half-page in the already severely curtailed chapter on neurosurgery; further, there is no mention of the management of raised intracranial pressure. Criticisms of editorial form include the lack of uniform formatting and writing style between chapters— light-hearted and illustrated with historical vignettes in places and business-like and concise in others. The idea of providing text boxes containing a slogan or quotation as an aide memoir is inconsistently applied, but it is effective in some of the chapters. The use of the inside covers for useful tables providing guidance for fluid management is an excellent device, and one that might be expanded to include some of the vital tables now scattered through the text. Overall I think this little book would be a worthwhile addition to every surgical trainee’s library. It fills a glaring gap in the present literature; but I imagine, like almost everything in these times of hardscrabble consumerism, that it could be better and cheaper! G. J. Pitcher (&) Division of Pediatric Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA e-mail: graeme-pitcher@uiowa.edu URL: www.uihealthcare.com