Large rectal diverticulum in the setting of pelvic organ prolapse treated with robotic ventral mesh rectopexy: a case report.

Background: Rectal diverticula are a very rare occurrence compared to diverticula of the colon. They are reported to account for only 0.08% of all diverticulosis. Diverticula of the rectum can be caused by congenital or acquired factors. The majority are asymptomatic, diagnosed incidentally, and require no treatment. The low incidence of rectal diverticulosis may be attributed to the unique anatomical structure and physiological environment of the rectum. However, complications can arise and may necessitate surgical or endoscopic treatment. Case Description: We report the case of a 72-year-old female with a history of diabetes mellitus, hyperlipidemia, and hypothyroidism who presented to the colorectal surgery clinic with symptoms of constipation of nearly a 50-year duration. The patient underwent an anorectal exam under anesthesia which revealed a 3 cm defect in the left levator muscles with herniated rectal wall. A large left lateral rectal diverticulum was diagnosed during the work-up for pelvic organ prolapse on defecography. She underwent robotic assisted ventral mesh rectopexy and recovered uneventfully. After 1 year of follow-up, the patient is asymptomatic, and the control colonoscopy shows no signs of the rectal diverticulum. Conclusions: Rectal diverticula can present in the setting of pelvic organ prolapse and can be safely managed with ventral mesh rectopexy.

Clarifying the volume of estimated need for public health and prevention services within an emergency department population.

OBJECTIVES: Emergency departments (EDs) are called to implement public health and prevention initiatives, such as infectious disease screening. The perception that ED resources are insufficient is a primary barrier. Resource needs are generally conceptualized in terms of total number of ED encounters, without formal calculation of the number of encounters for which a service is required. We illustrate potential differences in the estimated volume of service need relative to ED census using the examples of HIV and hepatitis C (HCV) screening. METHODS: This cross-sectional analysis adjusted the proportion of ED encounters in which patients are eligible for HIV and HCV screening according to a cascade of successively more restrictive patient selection criteria, presuming full implementation of each criterion. Parameter estimates for the proportion satisfying each selection criterion were derived from the electronic health records of an urban academic facility and its ED HIV and HCV screening program during 2 time periods. The primary outcome was the estimated reduction in proportion of ED visits eligible for screening after application of the entire cascade. RESULTS: There were 76,104 ED encounters during the study period. Applying all selection criteria reduced the number of required screens by 97.1% (95% confidence interval, 97.0-97.2) for HIV and 86.1% (95% confidence interval, 85.9-86.3) for HCV. CONCLUSIONS: Using the example of HIV and HCV screening, the application of eligibility metrics reduces the volume of service need to a smaller, more feasible number than estimates from ED census alone. This approach might be useful for clarifying perceived service need and guiding operational planning.

Does radiologic response correlate to pathologic response in patients undergoing neoadjuvant therapy for borderline resectable pancreatic malignancy?

BACKGROUND AND OBJECTIVES: In patients with borderline resectable pancreas cancers, clinicians frequently consider radiographic response as the primary driver of whether patients should be offered surgical intervention following neoadjuvant therapy (NT). We sought to determine any correlation between radiographic and pathologic response rates following NT. METHODS: Between 2005 and 2015, 38 patients at a tertiary care referral center underwent NT followed by pancreaticoduodenectomy for borderline resectable pancreas cancer. Radiographic response after the completion of NT and pathologic response after surgery were graded according to RECIST and Evans' criteria, respectively. RESULTS: Preoperatively, 50% of patients underwent chemotherapy alone and 50% underwent chemotherapy and chemoradiation. Radiographically, one patient demonstrated a complete radiologic response, 68.4% (n = 26) of patients had stable disease (SD), 26.3% (n = 10) demonstrated a partial response, and one patient had progressive. Among patients without radiographic response, 77.7% (n = 21) achieved a R0 resection. Of patients with SD on imaging, 26.9% (n = 7) had Evans grade IIB or greater pathologic response. CONCLUSIONS: Our data indicate that approximately one-fourth of patients who did not have a radiologic response had a grade IIB or greater pathologic response. In the absence of metastatic progression, lack of radiographic down-staging following NT should not preclude surgery.

Early Recurrence and Omission of Adjuvant Therapy after Pancreaticoduodenectomy Argue against a Surgery-First Approach.

BACKGROUND: Sequencing therapy for patients with periampullary malignancy is controversial. Clinical trial data report high rates of adjuvant therapy completion, though contemporary, real-world rates remain incomplete. We sought to identify patients who failed to receive adjuvant therapy and those at risk for early recurrence (ER) who might benefit most from neoadjuvant therapy (NT). METHODS: We retrospectively reviewed medical records of 201 patients who underwent pancreaticoduodenectomy for periampullary malignancies between 1999 and 2015; patients receiving NT were excluded. Univariate and multivariate analyses were performed to identify predictors of failure to receive adjuvant therapy and ER (within 6 months) as the primary end points. RESULTS: The median age at the time of surgery was 65.5 years (interquartile range 57-74 years). The majority of tumors were pancreatic ductal adenocarcinoma (76.6 %), and 71.6 % of patients received adjuvant therapy after resection. Univariate predictors of failure to undergo adjuvant therapy were advanced age, age-adjusted Charlson comorbidity index, operative transfusion, reoperation, length of stay, and 30- to 90-day readmissions (all p < 0.05). Advanced age, specifically among patients >70 years, persisted as a significant preoperative predictor on multivariate analysis (p < 0.01). Patients who failed to receive adjuvant therapy and/or developed ER had significantly worse overall survival rates compared to all other patients (27.8 vs. 9.7 months; p < 0.01). CONCLUSIONS: Approximately one-third of surgery-first patients undergoing pancreaticoduodenectomy at our institution did not receive adjuvant therapy and/or demonstrated ER. This substantial subset of patients may particularly benefit from NT, ensuring completion of multimodal therapy and/or avoiding futile surgical intervention.

Central venous access via external jugular vein in children.

OBJECTIVE: To determine the success rate and complications of using the external jugular (EJ) vein for central venous access in pediatric patients. METHODS: Prospective cohort study of children who underwent attempts at EJ vein central venous access while receiving care in an 11-bed pediatric intensive care unit at an urban children's hospital. RESULTS: Over a period of 15 months, 50 patients had EJ venous cannulation attempts. Central venous access was achieved in 45 patients (90%). Successful central venous access was performed in 4 children (50%) younger than 1 year and in 36 older children (98%). Catheter-tip malposition on chest radiograph required subsequent line manipulation in 2 patients. No complications of pneumothorax or carotid artery puncture occurred during line insertion. The catheters were used for an average of 7.5 days (range, 1-28 days). Catheter malfunction occurred in 4 (1.21/100 catheter-days), and catheter-related bloodstream infections occurred in 2 patients (6.04/1000 catheter-days). No thrombotic complications were clinically detected. CONCLUSIONS: The EJ vein is a viable site for central venous access with a low complication rate in pediatric patients.

Effect of heliox on albuterol delivery by metered-dose inhaler in pediatric in vitro models of mechanical ventilation.

STUDY OBJECTIVE: To determine the effect of varying concentrations of heliox, a mixture of helium and oxygen, on albuterol delivery administered by metered-dose inhaler (MDI) in pediatric mechanically ventilated models. DESIGN: Prospective in vitro laboratory study. SETTING: University-affiliated research laboratory. MODELS: The lungs of a 10-kg infant and 30-kg child receiving humidified pressure-regulated volume-controlled ventilation were simulated. The infant settings were an endotracheal tube (ETT) of 4.0 mm, tidal volume of 150 ml, positive end-expiratory pressure of 2 cm H(2)O, rate of 20 breaths/minute, inspiratory time of 0.7 second; the child settings were an ETT of 6.0 mm, tidal volume of 450 ml, positive end-expiratory pressure of 2 cm H(2)O, rate of 16 breaths/minute, and inspiratory time of 0.8 second. MEASUREMENTS AND MAIN RESULTS: Ten albuterol MDI canisters with chlorofluorocarbon propellants were each actuated once sequentially (total dose 1000 mug) with a commercially available aerosol holding chamber. Albuterol was collected onto a filter proximal to a lung simulator. The filter was rinsed, and concentrations were determined by high-performance liquid chromatography. In the infant model, heliox mixtures of 70:30, 60:40, and 50:50 were compared with nitrogen:oxygen (N(2):O(2)) mixtures in the same ratios. The effect of the 70:30 mixtures was also explored in a child model. Each gas mixture was tested 5 times. At all three ratios, albuterol delivery to the end of the ETT was improved with heliox compared with N(2):O(2) (approximately 7% vs 3-4%, p<0.0001, one-way analysis of variance [ANOVA] with a Bonferroni correction for multiple comparisons). No significant difference was noted in mean percentage albuterol delivery among the varying ratios of heliox studied. By two-way ANOVA, significantly greater albuterol delivery was noted with 70:30 heliox compared with 70:30 N(2):O(2) (7-8% vs 3%, p<0.0001), with no significant difference between the infant and child model (p=0.21). The gas mixture, model, and interaction of the two explained 88% of the variability in mean percentage albuterol delivery. CONCLUSION: Heliox increased albuterol delivery administered by MDI to the end of the ETT in these in vitro pediatric models of mechanical ventilation. Further studies are needed to determine if the improved albuterol delivery with heliox enhances clinical response in infants and children needing mechanical ventilation.

Pediatric extracorporeal membrane oxygenation (ECMO): a review of the first ten years of experience at the Medical University of South Carolina.

ECMO can be life saving in pulmonary emergencies unresponsive to conventional ICU support. ECMO technology and expertise has increased immensely over the last decade. Our experience, and others, has demonstrated that the earlier the referral to an ECMO center, the better chance of survival these patients will have. Our survival results exceed the national average and we have used this therapy in a wide variety of disease processes. Long-term sequelae in survivors are infrequent, as most patients return to normal pulmonary function.

Hemodynamic status after the Norwood procedure: a comparison of right ventricle-to-pulmonary artery connection versus modified Blalock-Taussig shunt.

BACKGROUND: The aim of this study is to compare hemodynamic status, in particular systemic oxygen delivery, in patients undergoing a Norwood procedure with a right ventricle-to-pulmonary artery (RV-PA) versus a modified Blalock-Taussig (mBT) shunt. METHODS: From June 2000 to November 2003, 44 consecutive neonates with hypoplastic left heart syndrome underwent a Norwood procedure. The first 25 patients received an mBT shunt; the subsequent 19 an RV-PA shunt. Hemodynamic data, including mixed venous oxygen saturation, was determined during the first 48 hours after surgery. RESULTS: The mBT and RV-PA shunt patients had no significant differences in systemic oxygen saturation, mixed venous oxygen saturation, arteriovenous oxygen saturation difference, or oxygen excess factor during the first 48 hours. Mixed venous saturation declined to a nadir in both groups at 6 to 12 hours. The RV-PA patients had significantly higher diastolic and mean blood pressures, and lower systolic blood pressure. Mean heart rate, common atrial pressure, and inotrope score did not differ between the two groups. The RV-PA patients received higher fraction of inspired oxygen and minute ventilation to achieve partial pressures of arterial oxygen and carbon dioxide, and pH, similar to mBT patients. Durations of mechanical ventilation, intensive care unit stay, and hospital stay did not differ between mBT and RV-PA patients. Operative survival in the mBT versus RV-PA group was 20 of 25 (80%) versus 17 of 19 (89%; p = 0.7). CONCLUSIONS: Indicators of postoperative systemic oxygen delivery are equivalent in neonates who have undergone a Norwood procedure with an mBT or RV-PA shunt. Both mBT and RV-PA patients undergo similar declines in hemodynamic status 6 to 12 hours after surgery. Any advantages of one approach over the other lie in areas other than systemic oxygen delivery, such as resistance to physiologic insults, or preservation of ventricular function.

Success factors and hurdles in quality improvement in a children's hospital.

A set of nurse/respiratory therapist-driven algorithms developed by a multidisciplinary team with the goal of "liberating" mechanically ventilated pediatric patients more rapidly from the ventilator resulted in sustained improvement over a 47-month period. The difference between expected and observed billed ventilator hour totals was over 22,000 hours (475 hours per month), a 17.5% reduction, which was significant at the P =.03 level by multiple linear regression analysis. Length of stay and mortality rate were unchanged. This difference represents a measure of the unrecognized cost of a nonstandardized approach to the weaning process. This reports reviews this team's success factors and hurdles and offers practical suggestions for pediatric surgeons interested in leading quality improvement initiatives.