Ramanath N. Haricharan

Traumatic brain injury is associated with the development of deep vein thrombosis independent of pharmacological prophylaxis.

INTRODUCTION Deep venous thrombosis (DVT) is common among trauma patients. If left untreated it may result in lethal pulmonary thromboembolism. Previous studies have suggested that intracranial hemorrhage serves as an independent risk factor for the development of DVT. These studies were not able to exclude anticoagulation therapy as a confounding variable in their analysis. Our objective was to determine the association of traumatic brain injury (TBI) to the formation of DVT irrespective of the use of anticoagulation therapy. METHODS All patients admitted to an academic level I Trauma Center between 2000 and 2007 with blunt or penetrating injuries were selected for inclusion in this study. Patients who died or who were discharged within 24 hours of admission were excluded in the analysis. TBI was defined as any intraparenchymal hemorrhage or extra-axial intracranial bleeding identified on radiographic imaging or both. Anticoagulation therapy was defined as the uninterrupted use of either subcutaneous lovenox or heparin. Risk ratios and 95% confidence intervals compared the risk of DVT among patients with and without TBI according to the initiation of anticoagulation therapy (no therapy, <24 hours, 24-48 hours, and >48 hours) adjusted for age, gender, race, injury severity, mechanism of injury, spinal injury, and lower extremity fracture. RESULTS Irrespective of the time of initiation of pharmacologic prophylaxis, TBI is independently associated with the formation of DVT. A threefold to fourfold increased risk of DVT formation is consistent across all prophylaxis groups among patients with TBI. CONCLUSION The incidence of DVT among injured patients with TBI is significantly higher than those patients without head injury independent of anticoagulation therapy. Rigorous surveillance to detect DVT among trauma patients with TBI should be undertaken and where appropriate alternate means for pulmonary thromboembolism prevention used.

Older age at diagnosis of Hirschsprung disease decreases risk of postoperative enterocolitis, but resection of additional ganglionated bowel does not.

PURPOSE This study was conducted to determine the effect of age at diagnosis and length of ganglionated bowel resected on postoperative Hirschsprung-associated enterocolitis (HAEC). METHODS Children who underwent endorectal pull-through (ERPT) between January 1993 and December 2004 were retrospectively reviewed. t Test, analysis of variance, Kaplan-Meier, and Coxs proportional hazards analyses were performed. RESULTS Fifty-two children with Hirschsprung disease (median age, 25 days; range, 2 days-16 years) were included. Nineteen (37%) had admissions for HAEC. Proportional hazards regression showed that HAEC admissions decreased by 30% with each doubling of age at diagnosis (P = .03) and increased 9-fold when postoperative stricture was present (P < .01), after controlling for type of ERPT, trisomy 21, transition zone level, and preoperative enterocolitis. Thirty-six children, with age at initial operation less than 6 months, were grouped based on length of ganglionated bowel excised (A [5 cm] and B [>5 cm]). No significant difference in the number of HAEC admissions during initial 2 years post-ERPT was seen between groups A (n = 18) and B (n = 18). The study had a power of 0.8 to detect a difference of 1 admission over 2 years. CONCLUSIONS Children diagnosed with Hirschsprung disease at younger ages are at a greater risk for postoperative enterocolitis. Excising a longer margin of ganglionated bowel (>5 cm) does not seem to be beneficial in decreasing HAEC admissions.

Laparoscopic cholecystectomy for biliary dyskinesia in children provides durable symptom relief.

PURPOSE The purpose of this study was to determine the effectiveness of laparoscopic cholecystectomy in children with biliary dyskinesia. METHODS Reports of children with an abnormal cholecystokinin (CCK)-stimulated HIDA scan between January 2001 and July 2006 who underwent laparoscopic cholecystectomy were reviewed. Postoperatively, a 23-item Likert scale, symptom questionnaire was administered to parents. RESULTS Sixty-four children with chronic abdominal pain and no gallstones on ultrasound had an abnormal CCK-HIDA scan. Twenty-three children (median age, 14 years; 16 girls), with mean (SD) ejection fraction of 17% (8), underwent laparoscopic cholecystectomy and were further analyzed. Preoperatively, these children had right upper quadrant/epigastric pain (78%), nausea (52%), vomiting (43%), and generalized abdominal pain (22%) lasting for a median of 3 months (range, 1 month to 2.5 years). Median postoperative follow-up was 2.7 years. Sixteen (70%) parents completed the questionnaire. Of those who responded, 63% indicated that their children had no abdominal pain, 87% had no vomiting, and 69% had no nausea in the month preceding the questionnaire. Overall, 67% of parents indicated that their childrens symptoms were completely relieved after cholecystectomy, whereas 7% indicated that the symptoms were not relieved. CONCLUSION Laparoscopic cholecystectomy is effective in providing both short-term and long-term improvement of symptoms in children with biliary dyskinesia.

Injury patterns among obese children involved in motor vehicle collisions

PURPOSE The purpose of this study was to compare injury patterns among obese children to their nonobese counterparts involved in motor vehicle collisions. METHODS A nationwide data collection program containing occupant, collision, and injury details from police-reported tow-away crashes between 1997 and 2006 were used. Risk ratios (RRs) and associated 95% confidence intervals (CIs) were adjusted for age, sex, restraint, seat track position, vehicle curb weight, and total velocity change. RESULTS An estimated 9 million children aged 2 to 17 years (20.2% obese) were involved in motor vehicle collisions during the study period. Among 2-to-5-year-olds, obesity increased the risk of severe head (RR, 3.67; 95% CI, 1.03-13.08) and thoracic (2.27; 1.01-5.08) injuries. Among 6-to-9-year-olds, obesity increased risk of thoracic (2.31; 1.08-4.95) and lower extremity (LE) injuries (1.89; 1.03-3.47). Among 10-to-13-year-olds, obesity increased the risk of severe thoracic (1.98; 1.08-3.65) and LE (6.06; 2.23-16.44) injuries. Among 14-to-17-year-olds, obesity increased risk of severe LE injuries (1.44; 1.04-2.00) but decreased risk of abdominal (0.20; 0.07-0.60) and head (0.33; 0.18-0.60) injuries, very similar to the pattern reported in obese adults. CONCLUSION The pattern of obesity-associated injuries changes from a higher risk of head and thoracic injuries among young children to a pattern in late teenagers that is similar to obese adults.

Laparoscopic cholecystectomy for biliary dyskinesia in children: Frequency increasing

PURPOSE The treatment of children with biliary dyskinesia (BD) is controversial. As we recently observed an increasing frequency of referrals for BD in our institution the aim of the study was to re-evaluate the long-term outcome in children with BD. METHODS Children with laparoscopic cholecystectomy (LC) for suspected BD between 8/2006 and 5/2011 were included. A pathologic ejection fraction (EF) was defined as <35%. The long-term effect of cholecystectomy was assessed via a Likert scale symptom questionnaire. RESULTS 82 children (median age 13.5 years, mean BMI 25.8) were included. CCK-HIDA scan was pathologic in 74 children (90.2%). Mean EF was 16.4%. Histology revealed chronic cholecystitis in 48 (58.5%) children and was normal in 30 children (36.5%). The frequency of LC for suspected BD increased by a factor of 4.3 in the last 10 years. Long term follow-up showed that only 23/52 children (44.2%) were symptom-free after LC. Patients with chronic inflammation were more likely to have persistent symptoms (p=0.017). An EF<15% was associated with a resolution of symptoms (p=0.031). CONCLUSION The frequency of LC for suspected BD in our institution has increased significantly during recent years. The long-term efficacy in our cohort was only 44.2%. We believe that laparoscopic cholecystectomy is likely helpful in patients with an EF<15%. However, in children with an EF of 15%-35%, based upon our data, we would highly recommend an appropriately thorough pre-op testing to exclude other gastrointestinal disorders prior to consideration of operative management.

Splenectomy reduces packed red cell transfusion requirement in children with sickle cell disease

PURPOSE The purpose of the study was to measure the effect of splenectomy on packed-cell transfusion requirement in children with sickle cell disease. METHODS Thirty-seven sickle cell children who underwent splenectomies between January 2000 and May 2006 at a childrens hospital were reviewed. Data were collected 6 months preoperatively to 12 months postsplenectomy. Paired t test, analysis of variance, and multivariable regression analyses were performed. RESULTS Of 37 children with median age 11 years (range, 2-18 years), 34 (21 males) had data that allowed analyses. Twenty-six had Hgb-SS, 5 had Hgb-SC, and 3 had Hgb S-Thal. Laparoscopic splenectomy was attempted in 36 and completed successfully in 34 (94% success). The number of units transfused decreased by 38% for 0 to 6 months and by 45% for 6 to 12 months postsplenectomy. Postoperatively, hematocrit levels increased and reticulocytes concurrently decreased with a reduction in transfusion clinic visits. The decrease in transfusion was not influenced by spleen weight, age, or hemoglobin type. Two children had acute chest syndrome (6%), and 1 had severe pneumonia (3%). CONCLUSION Laparoscopic splenectomy can be successfully completed in sickle cell children. Splenectomy significantly reduces the packed red cell transfusion requirement and frequency of clinic visits, in sickle cell children for at least 12 months postoperatively.

Laparoscopic pyloromyotomy: effect of resident training on complications

PURPOSE The purpose of this study was to characterize the safety of laparoscopic pyloromyotomy and examine the effect of resident training on the occurrence of complications. METHODS Five hundred consecutive infants who underwent laparoscopic pyloromyotomy between January 1997 and December 2005 were reviewed and analyzed. RESULTS Laparoscopic pyloromyotomy was successfully completed in 489 patients (97.8%). Four hundred seventeen patients were boys (83%). Intraoperative complication occurred in 8 (1.6%) patients (mucosal perforation, 7; serosal injury to the duodenum, 1). All were immediately recognized and uneventfully repaired. Six patients (1.2%) required revision pyloromyotomy for persistent or recurrent gastric outlet obstruction. There were 7 wound complications (1.4%) and no deaths. Pediatric surgery residents performed 81% of the operations, whereas 16% were done by general surgery residents (postgraduate years 3-4). There was a 5.4-fold increased risk of mucosal perforation or incomplete pyloromyotomy when a general surgery resident rather than a pediatric surgery resident performed the operation (95% confidence interval, 1.8-15.8; P = .003). These effects persisted even after controlling for weight, age, and attending experience. CONCLUSIONS The laparoscopic pyloromyotomy has an excellent success rate with low morbidity. The occurrence of complications is increased when the operation is performed by a general surgery resident, even when directly supervised by pediatric surgical faculty.

Body Mass Index Affects Time to Definitive Closure After Damage Control Surgery

BACKGROUND A growing body of literature demonstrates that irrespective of the mechanism of injury, obesity is associated with significantly worse morbidity and mortality after trauma. Among patients requiring damage control laparotomy (DCL), clinical experience suggests that obesity affects time to definitive closure though this association has never been demonstrated quantitatively. METHODS All patients at an academic Level I trauma center requiring a DCL between January 2002 and December 2006 (N = 148) were included. Information pertaining to demographic, injury, and clinical characteristics was abstracted from patient medical records. The risk of specific complications including pneumonia, renal failure, and sepsis was compared between normal and overweight/obese patients, as measured by body mass index (BMI). The lengths of intensive care unit (ICU) stay and mechanical ventilation as well as time to abdominal closure were also compared. RESULTS The risk of pneumonia, sepsis, and renal failure was 2.05-times, 1.77-times, and 2.84-times higher among overweight patients compared with patients with a normal BMI. The risk of pneumonia, sepsis, and renal failure was 2.01-times, 4.24-times, and 1.85-times higher among obese patients compared with those with a normal BMI. Obese patients also had a significantly longer ICU length of stay (28.7 days vs. 15.1 days; p < 0.0001), longer hospitalization (39.3 days vs. 27.0 days; p = 0.008), and time to definitive closure (8.4 days vs. 3.9 days; p = 0.03) compared with patients with a normal BMI. CONCLUSIONS Among patients requiring DCL, those who are overweight or obese have a prolonged time to definitive closure. These patients also experience a significantly longer ICU course and a higher risk of pneumonia.

Intermediate-term patency of upper arm arteriovenous fistulae for hemodialysis access in children

PURPOSE The goal of this study was to estimate the 2-year cumulative thrombosis-free survival of basilic vein transposition (BVT) and brachiocephalic fistulae in children. METHODS All children who underwent BVT or brachiocephalic fistula construction at a tertiary care childrens hospital from June 2001 to July 2006 were reviewed. Kaplan-Meier analysis, log-rank test, and proportional hazards regression were done. RESULTS Sixteen children (7 girls) with inadequate forearm veins underwent creation of 18 fistulae (12 BVT, 6 brachiocephalic). Median age was 14 (9-19) years. Mean (+/-SE) operative times for BVT and brachiocephalic fistulae were 3.4 (+/- 0.6) hours and 1.9 (+/-0.4) hours, respectively. The overall 2-year cumulative survival rate was 74% (BVT, 66%; brachiocephalic fistula, 83%). Four fistulae failed (1 brachiocephalic, 3 BVT) and 14 fistulae were censored (5, patent fistula; 4, renal transplantation; 2, unrelated death; 1, elective conversion to peritoneal dialysis; 1, surgical ligation of fistula; 1, lost to follow-up). Of 18 fistulae, 6 underwent additional interventions (4, percutaneous angioplasty; 2, surgical thrombectomy). There were no significant differences in survival times based on fistula type, prior transplant status, age, or operative time. CONCLUSIONS Brachiocephalic and BVT fistulae create reliable hemodialysis access for children who have inadequate forearm veins to allow construction of more distal fistulae.