Peripheral vascular bypass with cadaveric arterial allograft in a toddler with femoral mycotic aneurysm.

Mycotic aneurysms are exceedingly rare in the pediatric population. The optimal surgical treatment for children with this disease is unclear as aneurysm resection and vascular reconstruction are uncommonly performed in young children. We present a unique case of a 21-month-old child with a complex cardiac history who presented with limb ischemia and was discovered to have thrombosis of the common femoral and superficial femoral artery. Groin exploration revealed a left common femoral and superficial femoral artery mycotic aneurysm that was successfully repaired with excision of the mycotic aneurysm, external iliac to profunda femoral artery vascular bypass using cryopreserved arterial allograft and femoral vein reconstruction. This case demonstrates successful vascular reconstruction can be performed in a young child with an Aspergillus mycotic aneurysm using cadaveric arterial allograft.

Management of Recurrent Sigmoid Volvulus in the Pediatric Population.

Sigmoid volvulus is a rare etiology of bowel obstruction in the pediatric population that can be easily misdiagnosed, leading to delayed treatment and potential complications. Given that sigmoid volvulus is a common cause of bowel obstruction in the adult population and the significant lack of literature on its management in children, treatment strategies for pediatric patients often follow standardized protocols for adults. We report the case of a 15-year-old boy who presented with recurrent episodes of sigmoid volvulus over a 1-month period. Computed tomography demonstrated a sigmoid volvulus without evidence of ischemia or bowel infarction. Colonoscopy demonstrated a descending megacolon, and bowel transit studies demonstrated normal transit time. Acute episodes were managed conservatively with colonoscopic decompression. After a complete study, laparoscopic sigmoidectomy was performed. This work demonstrates the importance of early recognition and treatment of sigmoid volvulus in the pediatric population to limit recurrent episodes.

Radical Resection of Pediatric Fibrosarcoma Is Not Associated With Survival Benefit: A Nationwide Database Analysis.

INTRODUCTION: Fibrosarcoma is one of the most common nonrhabdomyosarcoma soft tissue sarcomas in the pediatric population. Surgical resection is the cornerstone of treatment; however, optimal factors regarding the extent of fibrosarcoma resection in localized versus regional disease is poorly understood. METHODS: The Surveillance, Epidemiology, and End Results database was queried for patients who are 19 y old or younger with a diagnosis of fibrosarcoma from 1975 to 2016. Kaplan-Meier analyses were performed for disease-specific survival on clinical and pathologic variables. Multivariate analysis was performed based on significant predictors of disease-specific survival. RESULTS: There were 1290 patients (median age 13 [7-17] y) identified with fibrosarcoma. The overall survival rate at 20 y was 93%. Radical resection was performed on 22%, 40%, and 52% of patients with localized, regional, and distant Surveillance, Epidemiology, and End Results disease stage, respectively. Chemotherapy (P < 0.001), radiation (P < 0.001), histology (P < 0.001), and stage (P = 0.004) were significant predictors of increased mortality using univariate Kaplan-Meier analysis. Most patients (86%) with localized or regional stage who underwent radiation had fibrosarcomas of nondermatofibrosarcoma histology (P < 0.001). Dermatofibrosarcoma subtype comprised most radical resections (41%). Excluding distant stage, nondermatofibroma histology (hazard ratio 16.94, 95% confidence interval 3.77-76.01) and regional stage (hazard ratio 8.15, 95% confidence interval 2.93-22.69) were independent prognostic factors of mortality (both P < 0.001). Radical resection was not a significant independent prognostic indicator of survival. CONCLUSIONS: Nondermatofibrosarcoma subtype is independently associated with increased mortality. Although surgery remains the mainstay of treatment, the extent of resection is not a predictor of survival for patients with the localized and regional stage of disease.

Risk factors associated with recent opioid-related hospitalizations in children: a nationwide analysis.

PURPOSE: Identifying at-risk children can provide a crucial opportunity for preventative measures to avoid opioid addiction. This study sought to determine at-risk pediatric patients that were previously hospitalized due to other causes prior to their opioid-related admission. METHODS: The Nationwide Readmissions Database (2010-2014) was queried for children 1-18 years old with an opioid-related hospitalization. Previous admissions (up to 1 year prior) and associated diagnoses were compared. Results were weighted for national estimates. RESULTS: 51,349 opioid-related hospitalizations were identified with an overall in-hospital mortality of 0.8%. Seventeen percent had a previous admission during the same calendar year of which 44% had > 1 and 11% had ≥ 5 prior admissions. Only 4% of prior admissions occurred at a different hospital. Males and females were equally represented, and 82% were ≥ 13 years old. Only 16% of previously admitted patients underwent a major surgical procedure during a previous hospitalization. The most common concomitant diagnoses for patients with prior hospitalizations were drug abuse (37%), chronic pulmonary disease (18%), and depression (10%). CONCLUSION: Opioid-related hospitalizations often occur among children with multiple recent admissions, usually to the same hospital. Most patients do not have a history of cancer or recent surgery to account for their opioid use.

National burden of pediatric abusive injuries: patterns vary by age.

PURPOSE: Child abuse is often unrecognized by healthcare practitioners. This study sought to characterize pediatric abuse injury patterns and associated mortality rates in a nationwide cohort. METHODS: The Kids' Inpatient Database (1997-2012) was queried for patients < 18 years old with a diagnosis of child abuse (utilizing ICD-9 codes for abusive head trauma [AHT], neglect, physical, emotional, sexual, and other abuse). Demographic factors, mortality, and injury patterns were compared with demographic factors using standard statistical tests. RESULTS: > 39,000 children were hospitalized for abuse from 1997 to 2012. The majority were Caucasian (36%), male (51%) and < 4 years old (70%). Most sustained physical abuse (53%), followed by AHT (14%), sexual (9%) and emotional abuse (2%). Multiple injuries were sustained by 44% of patients. Mortality was 4% (n = 1476). Burns (2%) and intrathoracic (2%) injuries had the highest mortality compared to other injuries (21% and 19%, respectively; both P < 0.001). Emotional abuse (5%) and neglect (1%) were highest in those ≥ 13 years old (both P  = 0.001). CONCLUSION: Physical injuries are less common in adolescents (13-18 years) hospitalized for abuse. However, they are more likely to report emotional abuse and neglect, which has not been compared in previous studies. Intrathoracic injuries and AHT are associated with significant mortality.

Geodemographic analysis of pediatric firearm injuries in Miami, FL.

PURPOSE: Firearm injuries (GSW) are a growing public health concern and leading cause of morbidity and mortality among children, yet predictors of injury remain understudied. This study examines the correlates of pediatric GSW within our county. METHODS: We retrospectively queried an urban Level 1 trauma center registry for pediatric (0-18 years) GSW from September 2013 to January 2019, examining demographic, clinical, and injury information. We used a geographic information system to map GSW rates and perform spatial and spatiotemporal cluster analysis to identify zip code "hot spots." RESULTS: 393 cases were identified. The cohort was 877% male, 87% African American, 10% Hispanic, and 22% Caucasian/Other. Injuries were 92% violence-related and 4% accidental, with 63% occurring outside school hours. Mortality was 12%, with 53% of deaths occurring in the resuscitation unit. Zip-level GSW rates ranged from 0 to 9 (per 1000 < 18 years) by incident address and 0-6 by home address. Statistically significant hot spots were in predominantly underserved African American and Hispanic neighborhoods. CONCLUSIONS: Geodemographic analysis of pediatric GSW injuries can be utilized to identify at-risk neighborhoods. This methodology is applicable to other metropolitan areas where targeted interventions can reduce the burden of gun violence among children. TYPE OF STUDY: Retrospective study. LEVEL OF EVIDENCE: Level III.

Unique Case of Congenital Lipomatous Overgrowth With Vascular Malformations, Epidermal Nevi, and Skeletal/Spinal Anomalies Syndrome in a Pediatric Patient.

Vascular malformations are being increasingly identified with associated syndromes caused by sporadically occurring, non-heritable somatic mutations. CLOVES syndrome is a newly recognized constellation of congenital lipomatous overgrowth with vascular malformations, epidermal nevi, and skeletal/spinal anomalies. We report the unique case of CLOVES syndrome diagnosed in a pediatric patient five years after the initial surgical resection of an extensive venolymphatic malformation involving the chest, neck, axilla, and posterior trunk. The lipomatous overgrowths were successfully resected, and subsequent genetic analysis revealed a heterozygous, pathogenic, somatic variant in the PIK3CA gene, confirming our suspicion of CLOVES syndrome.

Incidence of recurrent intussusception in young children: A nationwide readmissions analysis.

BACKGROUND/PURPOSE: Recurrent intussusception following successful nonoperative reduction has previously been reported with a frequency of 8%-12% based on data from individual institutions. Meanwhile, the timing of discharge after successful reduction continues to be debated. Here, we evaluate readmissions for recurrent intussusception in young children using a large-scale national database. METHODS: The National Readmissions Database (2010-2014) was queried to identify young children (age < 5 years) diagnosed with intussusception. We compared procedures performed during the index admission and frequency of readmissions for recurrent intussusception. Results were weighted for national estimates. RESULTS: We identified 8289 children diagnosed with intussusception during an index admission. These patients received definitive treatment with nonoperative reduction alone (43%), surgical reduction (42%), or bowel resection (15%). Readmission for recurrent intussusception was required for 3.7% of patients managed with nonoperative reduction alone, 2.3% of patients that underwent surgical reduction, and 0% of those that underwent bowel resection. Median time to readmission was 4 days after nonoperative reduction, and only 1.5% of these patients experienced recurrence within 48 h of discharge. CONCLUSIONS: Recurrent intussusception may be substantially less common than previously reported. Our findings support the practice of discharge shortly after successful nonoperative reduction. TYPE OF STUDY: Retrospective, prognosis study. LEVEL OF EVIDENCE: III.

Emergency General Surgery-A Misnomer?

Emergency general surgery (EGS) is defined as the urgent assessment and treatment of nontrauma, general surgical emergencies involving adults. Acute surgical emergencies often represent the most common reason for hospital admission with diagnoses, including bowel obstruction and appendicitis. EGS is a growing surgical subspecialty that includes both operative and nonoperative management of acutely ill patients. We sought to assess the burden of nonoperative care in EGS patients at our academic medical center. This study was conducted by retrospective analysis of prospectively collected data from patients entered into the Duke EGS Registry between July 1, 2016 and September 10, 2017. Fifty-six per cent (n = 771) of patients in the Duke EGS Registry (n = 1377) were managed nonoperatively as compared with 44 per cent (n = 606) who were managed operatively. Nonoperative management of disease represents a large subset of EGS and, therefore, needs further investigation to improve processes, outcomes, and standardization of care.