Matias Bruzoni

A Prospective Randomized Trial of Ultrasound- vs Landmark-Guided Central Venous Access in the Pediatric Population

BACKGROUND The purpose of this prospective randomized study was to compare landmark- to ultrasound-guided central venous access when performed by pediatric surgeons. The American College of Surgeons advocates for use of ultrasound in central venous catheter placement; however, this is not universally embraced by pediatric surgeons. Complication risk correlates positively with number of venous cannulation attempts. STUDY DESIGN With IRB approval, a randomized prospective study of children under 18 years of age undergoing tunneled central venous catheter placement was performed. Patient accrual was based on power analysis. Exclusion criteria included known nonpatency of a central vein or coagulopathy. After randomization, the patients were assigned to either ultrasound-guided internal jugular vein access or landmark-guided subclavian/internal jugular vein access. The primary outcomes measure was number of attempts at venous cannulation. Secondary outcomes measures included: access times, number of arterial punctures, and other complications. Continuous variables were compared using 2-tailed Students t-test. Discrete variables were analyzed with chi-square. Significance was defined as p < 0.05. RESULTS There were 150 patients enrolled between April 2008 and September 2011. There was no difference when comparing demographic data. Success at first attempt was achieved in 65% of patients in the ultrasound group vs 45% in the landmark group (p = 0.021). Success within 3 attempts was achieved in 95% of ultrasound group vs 74% of landmark group (p = 0.0001). CONCLUSIONS Ultrasound reduced the number of cannulation attempts necessary for venous access. This indicates a potential to reduce complications when ultrasound is used by pediatric surgeons.

Low doses of pamidronate to treat osteopenia in children with severe cerebral palsy: a pilot study

The aim of this study was to test the efficacy of low doses of pamidronate in increasing bone mineral density (BMD) in non-ambulatory children and adolescents with cerebral palsy (CP). Twenty-three non-ambulatory children and adolescents (12 females, 11 males; mean age 10y [SD 5y], range 4y 1 mo-17 y 11 mo) with severe spastic quadriplegic CP and low BMD were recruited from a multidisciplinary clinic. Severity of CP was graded at Level IV (n=10) and Level V (n=13) using the Gross Motor Function Classification System. Patients received intravenous pamidronate (4.12 mg/kg/y, maximum 45 mg/d) every 4 months. Lumbar spine and femoral neck BMD were measured at baseline and after 4 and 12 months. Twelve months after the first dose of pamidronate there was a significant increase in lumbar spine and femoral neck BMD (p<0.01 for both sites) and z scores compared with baseline values (p<0.01 for both sites). Mean BMD z scores increased 1.6 points for femoral neck and 1.9 points for lumbar spine after 12 months of pamidronate treatment. Serum intact parathyroid hormone increased significantly and cross-linked N-teleopeptide of type I collagen decreased significantly at 12 months. No significant side effect was noted. Low doses of pamidronate are well tolerated and significantly increase BMD in non-ambulatory children and adolescents with CP.

Pancreatic incidentalomas: clinical and pathologic spectrum

BACKGROUND Incidental abnormalities are increasingly being detected. The pathology and clinical outcome of patients with pancreatic incidentalomas have not been well characterized. METHODS We reviewed the records of 356 patients with pancreatic abnormalities from August 2001 to June 2007. Clinical and pathologic data were collected for a cohort of patients who had incidental pancreatic lesions detected by imaging modalities. RESULTS Fifty-seven pancreatic incidentalomas were identified. Ninety percent of them were detected by computed axial tomography (CT). The most frequent indications for imaging were genitourinary symptoms and cancer surveillance. Sixty percent of the lesions were solid, and 40% were cystic. Surgical resection was performed in 33 patients. Locally advanced disease was found in six patients, and metastatic disease was found in 9 patients. The most frequent diagnoses were ductal adenocarcinoma, neuroendocrine tumors, and serous cystadenoma. CONCLUSIONS Patients with pancreatic incidentalomas account for a significant patient subgroup. Incidental pancreatic lesions occur frequently and require prompt surgical evaluation.

Management of the primary tumor in patients with metastatic pancreatic neuroendocrine tumor: a contemporary single-institution review.

BACKGROUND Pancreatic nonfunctioning neuroendocrine tumors (PNFNETs) are an uncommon malignancy and often present with metastatic disease. There is a lack of information on the management of the primary tumor in patients who present with unresectable synchronous hepatic metastases. METHODS A retrospective review (2001-2008) of PNFNETs was conducted. Patients were divided into 3 groups: PNFNET without evidence of hepatic metastasis (group A), PNFNET with metastatic disease involving less than 50% of the liver (group B), and PNFNET with metastatic disease involving more than 50% of the liver (group C). Clinical data and outcomes were analyzed. RESULTS Thirty-five patients with PNFNET were identified (group A = 15, group B = 11, group C = 9). Resection of the pancreatic tumor was performed in 26 patients. With a mean follow-up period of 30 months, death from disease progression occurred in 1 patient in group A, none in group B, and in 7 in group C. CONCLUSIONS In selected patients, resection of the primary pancreatic tumor even in the setting of unresectable but limited hepatic metastases may be indicated.

Chest wall reconstruction using implantable cross-linked porcine dermal collagen matrix (Permacol) ☆

BACKGROUND/PURPOSE Chest wall reconstruction in children is typically accomplished with either primary tissue repair or synthetic mesh prostheses. Primary tissue repair has been associated with high rates of scoliosis, whereas synthetic prostheses necessitate the placement of a permanent foreign body in growing children. This report describes the use of biologic mesh (Permacol; Covidien, Mansfield, MA) as an alternative to both tissue repair and synthetic prostheses in pediatric chest wall reconstruction. METHODS A retrospective chart review was performed identifying patients undergoing chest wall reconstruction with biologic mesh at our tertiary referral childrens hospital between 2007 and 2011. Data collection included patient demographics, indication for chest wall resection, number of ribs resected, the administration of postoperative radiation, length of follow-up, postoperative complications, and the degree of spinal angulation (preoperatively and at most recent follow-up). RESULTS Five patients (age, 9.0-21.7 years; mean, 15.4 years) underwent resection for primary chest wall malignancy followed by reconstruction with biologic mesh (Permacol) during the study period. There were no postoperative mesh-related complications, and none of the patients developed clinically significant scoliosis (follow-up, 1.1-2.6 years; mean 1.9 years). CONCLUSION Biologic mesh offers a safe and dependable alternative to both primary tissue repair and synthetic mesh in pediatric patients undergoing chest wall reconstruction.

Transcervical Carotid Stenting with Flow Reversal for Neuroprotection: Technique, Results, Advantages, and Limitations

Carotid angioplasty and stenting are progressively earning a role as a less invasive alternative in the treatment of carotid occlusive disease. The most common approach for carotid artery stenting involves transfemoral access and use of a filter or balloon device for neuroprotection. This approach has limitations related to both the site of access and the method of neuroprotection. Specifically, an aortoiliac segment with advanced occlusive or aneurysmal disease or an anatomically unfavorable or atheromatous arch and arch branches can significantly limit the safety of the retrograde transfemoral pathway to the carotid bifurcation. Additionally, data provided by the use of transcranial Doppler monitoring and diffusion-weighted magnetic resonance imaging in patients undergoing filter- or balloon-protected carotid artery stenting demonstrate that currently available devices are associated with a considerable incidence of cerebral embolization. To address these limitations, we, along with others, have employed a direct transcervical approach for carotid artery stenting that incorporates the principle of flow reversal for neuroprotection. The technique bypasses all of the anatomic limitations of transfemoral access and simplifies the application of flow reversal, which is one of the safest neuroprotection techniques. The purpose of this review is to describe our method of transcervical carotid artery stenting, review the accumulating outcomes data, and discuss the clinical advantages of and indications for this increasingly popular technique.

The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients.

BACKGROUND Hispanics account for over 60% of the U.S. population growth and 25% speak little-to-no English. This language barrier adversely affects both access to and quality of care. Surgical specialties trail other medical fields in assessing the effects of language barriers to surgical clinical care and patient satisfaction. This study was designed to assess the effects of patient-provider language concordance on a pediatric surgery practice. METHODS A surgery-specific, 7-point Likert scale questionnaire was designed with 14 questions modeled after validated patient satisfaction surveys from the literature. Questions concerning provider-patient language concordance, quality of understanding, and general satisfaction were included. Surveys were administered to families of patients in the General Pediatric Surgery Clinic at our institution. Families were categorized into three groups: English-speaking, regardless of race/ethnicity; Spanish-speaking using interpreter services with an English-speaking medical team; and Spanish-speaking communicating directly with a Spanish-speaking medical team (Hispanic Center for Pediatric Surgery, HCPS). One-way analysis of variance was used to test for group differences. RESULTS We administered 226 surveys; 49 were removed due to lack literacy proficiency. Families in the HCPS group reported a higher level of satisfaction than the interpreter and English groups (p<0.01). The HCPS group also indicated improved understanding of the information from the visit (p<0.001). Spanish-speaking only families felt that communicating directly with their health care team in their primary language was more important than their English-speaking counterparts (p<0.001). CONCLUSIONS In a pediatric surgery clinic, language concordant care improves patient satisfaction and understanding for Hispanic families in comparison to language discordant care. Other clinics in other surgery sub-specialties may consider using this model to eliminate language barriers and improve patient satisfaction and understanding of surgical care.

Single-site umbilical laparoscopic splenectomy.

Laparoscopic splenectomy was first described in children in 1993. Since then, it has become a commonly performed procedure in children because of reduced discomfort and hospitalization and significantly improved cosmesis compared with the open approach. With the advent of single-site laparoscopic surgery, it is only natural that this approach be used for splenectomy. This article will describe the reasons that the single-site approach might be useful for splenectomy and also the technique used at the authors institution. Moreover, a brief review of the current literature in children will be presented.

A modification of the laparoscopic transcutaneous inguinal hernia repair to achieve transfixation ligature of the hernia sac.

BACKGROUND/PURPOSE The proposed benefits of laparoscopic inguinal hernia repair in the pediatric population include less postoperative pain, smaller scars, and easier access to the contralateral groin. This is countered by slightly higher recurrence rates reported in some series. These differences are attributable to variation in the laparoscopic technique, surgeon experience, and certain anatomic features. We describe a modification of the laparoscopic-assisted transcutaneous hernia repair that achieves transfixation ligature of the hernia sac and that may further reduce recurrence. METHODS Institutional review board approval was obtained, and a retrospective chart review of all patients undergoing repair of symptomatic hernias using this new technique was carried out. Data collection included demographics, laterality of hernia, operative time, recurrence rate, and complications. RESULTS Twenty-one patients (age 1-144 months) underwent hernia repair between October 2009 and October 2010 using a novel technique of transcutaneous transfixation ligature of the neck of the hernia sac. The mean operative time was 18 minutes (8-35 minutes). Follow-up was from 1 to 12 months. There was no intraoperative or postoperative complication and no recurrences to date. CONCLUSION The technique described is a modification of the existing laparoscopic-assisted transcutaneous inguinal hernia repair that more closely approximates the criterion standard open repair. The technique addresses some prevailing concerns with the initially described method of transcutaneous repair, and short-term outcomes are positive. Long-term outcomes remain to be defined.

Less Invasive Pedicled Omental-Cranial Transposition in Pediatric Patients With Moyamoya Disease and Failed Prior Revascularization

BACKGROUND: Patients with moyamoya disease and progressive neurological deterioration despite previous revascularization pose a major treatment challenge. Many have exhausted typical sources for bypass or have ischemia in areas that are difficult to reach with an indirect pedicled flap. Omental-cranial transposition has been an effective, but sparingly used technique because of its associated morbidity. OBJECTIVE: We have refined a laparoscopic method of harvesting an omental flap that preserves its gastroepiploic arterial supply. METHODS: The pedicled omentum can be lengthened as needed by dividing it between the vascular arcades. It is transposed to the brain via skip incisions. The flap can be trimmed or stretched to cover ischemic areas of the brain. The cranial exposure is performed in parallel with pediatric surgeons. We performed this technique in 3 pediatric patients with moyamoya disease (aged 5-12 years) with previous superficial temporal artery to middle cerebral artery bypasses and progressive ischemic symptoms. In 1 patient, we transposed omentum to both hemispheres. RESULTS: Blood loss ranged from 75 to 250 mL. After surgery, patients immediately tolerated a diet and were discharged in 3 to 5 days. The ischemic symptoms of all 3 children resolved within 3 months postoperatively. Magnetic resonance imaging at 1 year showed improved perfusion and no new infarcts. Angiography showed excellent revascularization of targeted areas and patency of the donor gastroepiploic artery. CONCLUSION: Laparoscopic omental harvest for cranial-omental transposition can be performed efficiently and safely. Patients with moyamoya disease appear to tolerate this technique much better than laparotomy. With this method, we can achieve excellent angiographic revascularization and resolution of ischemic symptoms. ABBREVIATIONS: MCA, middle cerebral artery SPECT, single-photon emission computed tomography STA, superficial temporal artery TIA, transient ischemic attack