Incontinence-Associated Dermatitis: State of the Science and Knowledge Translation.

This review of the literature updates and considers the evidence on incontinence-associated dermatitis (IAD). Best practice strategies for the management of skin damage from IAD (both prevention and treatment) are provided. A mnemonic to help clinicians translate IAD evidence into practice is introduced. Workplace experiences supplement this evidence synthesis. Approaches to assist in translation of this knowledge and evidence into practice are also provided.

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.

Robotic pulmonary resections in children: series report and introduction of a new robotic instrument.

Thermal sealing devices, such as the LigaSure (ValleyLab-Tyco Healthcare; Boulder, CO) or Gyrus PK (Gyrus ACMI, Maple Grove, MN) are minimally invasive instruments that can be used to seal the pulmonary parenchyma in pediatric lung resections. But these devices were only available in laparoscopic form, and no robotically similar instruments were manufactured. This handicaps the surgeon at the console, because these nonrobotic instruments must be manipulated and used by the bedside assistant instead of the console surgeon. In July 2006, the robotic Gyrus PK was introduced for the da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA). In this paper, we present our initial experience in performing robotic pulmonary resections in infants and children, including all cases before and after the robotic Gyrus PK was introduced.

A "plastic" sutureless abdominal wall closure in gastroschisis.

BACKGROUND/PURPOSE: Several techniques are described for closure of the gastroschisis abdominal wall defect. The authors describe a technique that allows for spontaneous closure that is simple, cosmetically appealing, and minimizes intraabdominal pressure after bowel reduction. METHODS: Under either general anesthetic or analgesia with sedation, the gastroschisis bowel is decompressed, and the bowel is primarily reduced. The gastroschisis defect is covered with the umbilical cord tailored to fit the opening, and 2 Tegaderm (3M Healthcare, MN) dressings reinforce the defect ("plastic closure"). Intragastric pressure is monitored during and after the procedure. If primary reduction is not possible, the bowel is reduced daily via a spring-loaded silo (Bentec Medical, CA). After reduction of the bowel, the defect is allowed to close spontaneously using the "plastic closure" technique. The authors prospectively treated a cohort of patients with gastroschisis that included simple to complex cases using this technique. RESULTS: Ten children with gastroschisis were treated; 6 of these children had a primary reduction and simple closure of their defect using the "plastic closure." In the remaining 4 children, the plastic closure was used either primarily or secondarily to silo placement, despite the need for repair of complex intestinal anomalies. The average times to first feeding and discharge were 12.5 and 28.3 days, respectively. Six of the 10 children (60%) had small umbilical hernias, and only 1 underwent operative repair at 13 months of age. CONCLUSIONS: The plastic closure of gastroschisis is simple, safe, and cosmetically appealing. Intraabdominal pressures are well controlled, and the umbilical position remains centrally located in this sutureless technique. Umbilical defects can occur but are observed for spontaneous closure like most primary umbilical hernias.