Evaluating Skeletal Maturity at Time of Surgical Correction of Pectus Excavatum Based on Medial Clavicle Epiphyseal Ossification.

BACKGROUND: Surgical correction of pectus excavatum (SCOPE) is dependent upon chest wall pliability with optimal timing prior to complete skeletal maturation. Measures of skeletal maturity are not readily available for operative planning; therefore, surgeons use age as proxy despite patient-specific rates of skeletal maturation. We aimed to determine whether preoperative skeletal maturity is associated with postoperative pain as surrogate for chest wall pliability. METHODS: Children ≤18 years who underwent SCOPE from 2020 to 2022 were retrospectively identified. Preoperative CT within 3 months of procedure was reviewed by 2 radiologists and 1 surgeon. Skeletal maturity was determined by Schmeling-Kellinghaus classification which stages secondary epiphyseal ossification of the medial clavicle. Inter-rater reliability was evaluated. Schmeling-Kellinghaus stage and postoperative pain were compared. RESULTS: Of twenty-eight records reviewed, 57% were Schmeling-Kellinghaus stage 1. High inter-rater reliability was identified (inter-radiologist: kappa = .95, P < .001, all raters: kappa = .78, P < .001). Median age at operation was 15.5 years (interquartile range: 14.8-16.0) and increased with skeletal maturity (P < .001). When comparing stage 1 (n = 16) to >1 (n = 12), stage 1 had lower maximum pain scores (P < .001), total morphine equivalents (P < .001), and benzodiazepine use (P < .001) after surgery. CONCLUSIONS: The Schmeling-Kellinghaus classification system is a valid proxy of skeletal maturity that can be applied with high inter-rater reliability. SCOPE during stage 1 was found to have less postoperative pain and narcotic use than more mature stages. This is proof of concept that skeletal maturity should be considered when determining optimal timing of surgical correction. Future research will evaluate the impact of skeletal maturity on postoperative outcomes.

Prevalence of intrarenal reflux in pediatric patients on contrast-enhanced voiding urosonography.

BACKGROUND: Intrarenal reflux may be seen with vesicoureteral reflux (VUR) when contrast from the pelvocalyceal system extends into tubules in the parenchyma. Because intrarenal reflux has been associated with scarring, detecting intrarenal reflux may influence management to avoid renal damage. OBJECTIVE: Our objective was to evaluate the prevalence of intrarenal reflux identified on contrast-enhanced voiding urosonography (ceVUS) and its association with sex, age, grade of VUR, location in kidney and stage of bladder filling or voiding. MATERIALS AND METHODS: CeVUS studies performed from August 2019 through July 2020 with VUR were retrospectively reviewed by two pediatric radiologists. They independently graded VUR and assessed for intrarenal reflux, noting its location and stage of bladder filling or voiding during which it occurred. The presence and location of scarring was also recorded. RESULTS: One hundred and six ceVUS exams were reviewed with 211 kidneys evaluated (one solitary kidney). Patients were ages 2 weeks to 12 years (mean: 1.8 years) with 71 females (67%) and 35 males (33%). Grades 2 to 5 VUR were detected in 165 kidneys with intrarenal reflux seen in 42 (25.4%). Intrarenal reflux was present in 1 of 40 kidneys (2.5%) with grade 2, 10 of 67 (14.9%) with grade 3, 25 of 47 (53.2%) with grade 4 and 6 of 11 (54.5%) with grade 5 VUR. Intrarenal reflux occurred during voiding in 31 of 42 kidneys (73.8%) and was seen most often in the lower pole (71.4%) with significant association between intrarenal reflux and interpolar renal scarring (odds ration [OR] 3.92; 95% confidence interval [CI] 1.49, 10.32; P-value 0.01). CONCLUSION: Intrarenal reflux was often seen on ceVUS, with the highest frequency occurring in young patients with grades 4 and 5 VUR and during voiding. Radiologists should have a high index of suspicion for intrarenal reflux on ceVUS, especially in young children with high-grade VUR.

Assessment of distal ureteral and ureterovesical junction visualization on contrast-enhanced voiding urosonography.

BACKGROUND: Contrast-enhanced voiding urosonography (CEVUS) uses intravesically administered microbubble contrast to detect vesicoureteral reflux (VUR) and urethral anomalies with ultrasound. Multiple studies have suggested CEVUS can replace voiding cystourethrogram (VCUG) as a radiation-free alternative. Analysis of the ureterovesical junction and ureters on VCUG documenting the ureterovesical junction position, ureteral duplication, periureteral diverticula and ureteroceles is important as anatomical variations may affect management and surgical approach. OBJECTIVE: Our purpose was to assess distal ureteral and ureterovesical junction region visualization in children with VUR detected on CEVUS. MATERIALS AND METHODS: CEVUS studies performed between June 2018 and March 2019 with reported VUR were retrospectively reviewed by two pediatric radiologists to confirm VUR and to qualitatively assess the ureterovesical junction region for each renal moiety using a 3-point scale for clear, limited or absent visualization of the distal ureter, ureterovesical junction, ureteral duplication, periureteral diverticula and ureteroceles. RESULTS: Thirty-four studies with VUR on CEVUS were identified. Sixty-seven renal moieties were evaluated including a solitary kidney in one child. VUR was detected in 52 moieties by reader 1 and in 53 by reader 2. A single moiety with discrepancy between readers regarding VUR was excluded from statistical analysis. No diverticula were detected by either reader and one ureterocele was detected by both readers. Visualization of the ureterovesical junction was described as clear in 5/52, limited in 14/52 and absent in 33/52 refluxing renal moieties by reader 1 and as clear in 12/52, limited in 20/52 and absent in 20/52 by reader 2. The ureterovesical junction was clearly visualized in 5/52 (9.6%) by reader 1 and 12/52 (23.1%) by reader 2. The Kappa value of -0.29 (confidence interval [CI] -0.25, 0.21) reveals a lack of agreement between the readers for clear versus limited or absent ureterovesical junction visualization. Distal ureteral visualization was described as clear in 14/52, limited in 16/52 and absent in 22/52 refluxing renal moieties by reader 1 and as clear in 27/52, limited in 7/52 and absent in 18/52 by reader 2. The distal ureter was clearly visualized in 14/52 (26.9%) by reader 1 and 27/52 (51.9%) by reader 2. The Kappa of 0.43 (CI 0.22, 0.64) reveals moderate agreement between the readers for clear versus limited or absent distal ureteral visualization. Duplication of the renal collecting system was identified in 13/52 refluxing kidneys by reader 1 and 11/52 refluxing kidneys by reader 2. Visualization of ureteral duplication was described as clear in 9, limited in 4 and absent in 39 of 52 refluxing renal moieties by reader 1 and as clear in 9, limited in 2 and absent in 41 by reader 2. Ureteral duplication was clearly visualized in 9/52 (17.3%) by reader 1 and 9/52 (17.3%) by reader 2. Kappa of 0.87 (CI 0.68, 1) reveals high agreement between the readers for clear versus limited or absent identification of ureteral duplication. CONCLUSION: The distal ureter and ureterovesical junction region frequently are not clearly visualized in refluxing renal moieties on CEVUS. Awareness of this limitation is important as there may be implications when evaluating patients for surgical management of VUR.

Staged imaging pathway for the evaluation of pediatric appendicitis.

PURPOSE: Despite significant radiation exposure involved with computed tomography (CT) in evaluation of pediatric appendicitis, its use is still widespread. The goal of this study was to assess the effect of a staged imaging pathway for appendicitis to significantly decrease CT use while maintaining diagnostic accuracy. METHODS: Chart review was performed for patients evaluated for appendicitis over a 12-month period prior to and after pathway implementation. RESULTS: There was a significant decrease in CT use as initial imaging after implementation of the pathway; 87.1-13.4 % for evaluations positive for appendicitis (decrease 84.6 %, p < 0.0001) and 82.6-9.2 % for evaluations negative for appendicitis (decrease 88.9 %, p < 0.0001). Use of CT during any point in the evaluation decreased from 91.7 to 25.1 % (decrease 72.6 %, p < 0.0001). The negative appendectomy rate was similar; 5.4 % prior, 4.9 % post (p = 0.955). The missed appendicitis rate did not statistically change; 1.1 % prior, 3.7 % post (p = 0.523). The perforation rate was not statistically altered; 6.5 % prior; 9.8 % post (p = 0.421). 350 less patients underwent CT during the year following the pathway. CONCLUSIONS: The staged imaging pathway resulted in a marked decrease in children exposed to CT without compromising diagnostic accuracy.