Reverse shock index multiplied by the motor component of the Glasgow Coma Scale predicts mortality and need for intervention in pediatric trauma patients.

BACKGROUND: Timely identification of high-risk pediatric trauma patients and appropriate resource mobilization may lead to improved outcomes. We hypothesized that reverse shock index times the motor component of the Glasgow Coma Scale (rSIM) would perform equivalently to reverse shock index times the total Glasgow Coma Scale (rSIG) in the prediction of mortality and the need for intervention following pediatric trauma. METHODS: The 2017-2020 National Trauma Data Bank datasets were used. We included all patients <16 years of age that had a documented prehospital and trauma bay systolic blood pressure, heart rate, and total GCS. We excluded all patients who arrived at the trauma center without vital signs and interfacility transport patients. Receiver operating characteristic (ROC) curves were used to model the performance of each metric as a classifier with respect to our primary and secondary outcomes, and the area under the ROC curve (AUC) was used for comparison. Our primary outcome was mortality prior to hospital discharge. Secondary outcomes included blood product administration or hemorrhage control intervention (surgery or angiography) < 4 hours following hospital arrival and ICU admission. RESULTS: After application of exclusion criteria, 77,996 patients were included in our analysis. rSIM and rSIG performed equivalently as predictors of mortality in the 1-2 (p = 0.05) and 3-5 (p = 0.28) year categories, but rSIM was statistically outperformed by rSIG in the 6-12 (AUC: 0.96 vs. 0.95, p = 0.04) and 13-16 (AUC: 0.96 vs. 0.95, p < 0.01) year-old age categories. rSIM and rSIG also performed similarly with respect to prediction of secondary outcomes. CONCLUSION: rSIG and rSIM are both outstanding predictors of mortality following pediatric trauma. Statistically significant differences in favor of rSIG were noted in some age groups. Because of the simplicity of calculation, rSIM may be a useful tool for pediatric trauma triage. LEVEL OF EVIDENCE: III, Diagnostic Tests or Criteria.

Ingestion of kinetic sand leading to intussusception and bowel obstruction in a child: a case report.

Background: Kinetic sand is a type of play sand that is marketed to children above the age of three years old. It is comprised of sand coated with silicone oil, holding its shape when squeezed or pressed. It is described as a non-toxic, hypoallergenic, safe sand for arts and crafts, and is highly appealing due to its realistic appearance and odor. We present the first reported case of bowel obstruction due to small and large bowel intussusceptions caused by ingestion of kinetic sand leading to hospitalization for medical treatment in a young girl. Case Description: We present a two-year-old female patient with a past medical history of autism, trichotillomania, and pica who presented to our hospital as a transfer for two days of abdominal pain and non-bloody bilious emesis. Radiographic workup included abdominal ultrasound, abdominal X-ray, and computed tomography that revealed both small bowel intussusceptions and colo-colonic intussusception. Fluoroscopic gastrografin enema was performed and yielded free reflux of contrast into the distal ileum. The admitted patient continued to pass the sand with an eventual resolution of abdominal pain. Conclusions: Intussusception is considered a medical emergency and should be treated as soon as possible before potentially fatal complications occur. This report serves to highlight the potential dangers of kinetic sand ingestion and provide guidance for the management of intussusception and bowel obstruction after kinetic sand ingestion in the pediatric population.

Subtotal pyloric obstruction by atypical hypertrophic pyloric muscle in a newborn.

This is a case of a neonate with suspected duodenal atresia on prenatal imaging. However, distal bowel gas was identified postnatally on regular X-rays with a possible pyloric obstructing mass visualised on ultasound. No contrast was visualised passing through the stomach on fluoroscopic studies. Operative evaluation revealed an atypical asymmetric hypertrophic pylorus with exophytic lesions of ectopic glandular tissue. Longitudinal open pyloromyotomy was performed which relieved the gastric obstruction resulting in symptomatic relief without any anatomy altering procedure required.

Retro-psoas appendicitis.

The vermiform appendix (VA) is known to exhibit a wide range of anatomic variability, with clinical presentation correlating with certain known anatomic positioning. To the best of our knowledge, we describe the second known case of a retro-psoas muscle VA variant and the first known case of appendicitis in such a location. Retroperitoneal access was obtained, and the appendix was freed from the intermuscular recess between the psoas and iliacus. The peritoneal defect was primarily repaired, and the patient was discharged on postoperative day 1 in good condition.

Midgut volvulus in a pediatric patient with chronic constipation, congenital intestinal malrotation and internal transmesocolic hernia.

Congenital intestinal malrotation occurs in 1 of 500 newborns and can predispose patients to intestinal volvulus and internal herniation, putting patients at risk for intestinal ischaemia. A male patient in early childhood with a history of severe constipation presented with acute abdominal pain, progressing rapidly to compensated shock. CT scan was suspicious for small bowel ischaemia and superior mesenteric artery compression. He underwent emergency exploratory laparotomy. Intraoperative findings were significant for partial intestinal malrotation with mobile ascending colon and high-riding caecum, and internal herniation with midgut volvulus of the ascending colon through a mesenteric defect in the proximal transverse colon. Derotation of the volvulus, reduction of the internal hernia, resection of necrotic segments of the bowel and a modified Ladd's procedure were performed. Postoperatively, the patient is total parenteral nutrition (TPN) dependent due to short bowel syndrome. A high index of suspicion with prompt imaging is paramount for paediatric patients with symptoms indicating intestinal obstruction.

Substance Abuse and Rural Appalachian Pediatric Trauma in West Virginia.

Introduction: Rural Appalachia is endemic to issues such as substance abuse, poverty, and lack of community support, all of which negatively influence health outcomes. The incidence of pediatric trauma as it relates to substance abuse is of concern in the region, where the rate of positive drug screens in pediatric trauma cases is higher than national average. Methods: The West Virginia statewide pediatric trauma database was analyzed in a retrospective cohort study for the years 2009-2019. Variables of interest included injury severity (assessed using Abbreviated Injury Scale (AIS)), drug screening results, and various measures of patient outcome. Results: The sample was divided into 2009-2016 presentations (n = 3,356) and 2017-2019 presentations (n = 1,182). Incidence of critical (AIS 5) head injuries (p = 0.007) and serious (AIS 3) neck injuries (p = 0.001) increased as time progressed. Days requiring ventilation increased from 3.1 in 2009-2016 to 6.3 in 2017-2019 (p < 0.001). Drug screens were obtained at a rate of 6.9% in 2009-2016 versus 23.3% in 2017-2019 (p < 0.001). Benzodiazepine use increased from 0.8% to 1.8% (p < 0.001), and opioid use increased from 1% to 4.9% (p < 0.001). Conclusion: The increasing severity of pediatric trauma and substance abuse in Appalachia is of significant concern. The use of respiratory drive-depressing drugs has risen, just as the severity of head and neck traumas has increased. These results emphasize the importance of targeted interventions in the rural pediatric population.

Hybrid Single-Port Cholecystectomy of a Pediatric Gallbladder Volvulus.

Gallbladder volvulus is a rare gallbladder pathology that can present in adults but is exceedingly rare in children. The diagnosis itself can be very challenging due to its presentation with signs and symptoms of acute cholecystitis without specific imaging findings. The correct identification and prompt intervention with a cholecystectomy are crucial to improve patient outcomes. In this report, we discuss a pediatric patient who presented with gallbladder volvulus and subsequently underwent novel treatment with a single-port laparoscopic cholecystectomy. The patient is a 12-year-old male of Haitian descent who presented to an outside facility following the onset of persistent, right upper quadrant abdominal pain and recurrent nonbilious emesis. The diagnostic workup included serial abdominal exams, laboratory work, right upper quadrant ultrasounds, and a hepatobiliary iminodiacetic acid (HIDA) scan. The patient then underwent single-port laparoscopic removal of the torsed gallbladder with complete resolution of his symptoms. In this case report, the management and clinical presentation of gallbladder volvulus are discussed in more detail as well as the feasibility of single-port laparoscopic cholecystectomy in the setting of pediatric gallbladder volvulus.

Topical heat shock protein 70 prevents imiquimod-induced psoriasis-like inflammation in mice.

Psoriasis is a chronic inflammatory skin disease with systemic manifestations and potential genetic etiology. The newest treatments utilize antibodies against one of several cytokines known to underlie the inflammatory signaling molecules that produce the skin and systemic symptoms. However, these agents must be regularly injected, and they may compromise the normal responses of the immune system. Furthermore, they do not address the causes of the abnormal immunoregulatory responses of the disease because the etiology is not yet completely understood. In this short-term treatment study, the potential anti-inflammatory activity of an alfalfa-derived Hsp70-containing skin cream (aHsp70) was tested on imiquimod (IMQ)-induced psoriasis-like lesions in wild-type mice. Treatment of the mice with the aHsp70 skin cream simultaneously with the imiquimod application mitigated the induction of psoriatic-like lesions and correlated with altered expression of various skin cytokines.

Novel Modified Seldinger Technique for Gastrojejunal Feeding Tube Placement.

BACKGROUND: Temporary or long-term nutritional support through gastrojejunal (GJ) feeding tubes is a safe and common means of enteral feeding in adults and children. It is indicated in patients with severe gastroesophageal reflux disease, gastric outlet obstruction, or severe gastric dysfunction or gastroparesis. Several techniques for GJ feeding tube placement have been reported. The most technically challenging part of GJ tube placement is the advancement and optimal positioning of the jejunal extension into the proximal jejunum. METHODS: A novel modified Seldinger technique was used for endoscopic placement of a percutaneous low-profile GJ tube (14 French). After gastric access was established, a dilator was advanced under endoscopic vision into the pylorus. Under fluoroscopy, a guidewire was threaded through the dilator into the duodenum. The dilator was then removed, and the GJ tube advanced over the guidewire. RESULTS: A total of 12 patients including 9 pediatric and 3 adult underwent the procedure with no complications. The main indication was gastroparesis with oral intolerance of food. The median operative time was 41.5 minutes. All patients tolerated jejunal tube feeding after surgery. CONCLUSION: The modified Seldinger technique for percutaneous endoscopic GJ tube placement is a safe and efficient procedure in both children and adults. Further studies are necessary to prove its reproducibility in other centers and to compare it to other methods of PEGJ tube placement.

Hybrid Single-Port Cholecystectomy Vs Four-Port Cholecystectomy in Children.

BACKGROUND AND OBJECTIVES: Evidence is increasing that single-port or single-incision laparoscopic cholecystectomy is a safe and feasible alternative for cholecystectomy in children. In this study, we sought to compare the single-port hybrid technique, which we originally reported in 2012, with the conventional 4-port approach, in regards of complications, outcome, operative time and cost. METHODS: A retrospective, single-center comparison of hybrid single-port versus conventional 4-port laparoscopic cholecystectomy was performed in 98 consecutive pediatric patients between January 2010 and October 2014. Patient characteristics, intra- and postoperative outcomes, operative costs, and total hospitalization costs were compared between the 2 approaches using univariate and multivariate analyses. RESULTS: The single-port technique was utilized in 56 (57%) pediatric patients who underwent laparoscopic cholecystectomy. The operative time for single-port procedures was shorter than that of the conventional technique (median, 85 minutes vs 114 minutes; P = .003). Patients with single-port procedures were less likely to have a cholangiogram compared to patients who underwent 4-port cholecystectomy. (9% vs 40%; P < .001). No statistically significant differences between the 2 cohorts were observed for intra- or postoperative outcomes. Although the 2 groups shared nearly the same median duration of hospitalization (22 hours vs 21 hours; P = .70), the single-port group demonstrated a lower total cost of hospitalization (median cost, $7438 vs $8783; P = .030) and lower operative cost (median, $3918 vs $4647; P < .001). CONCLUSION: Hybrid single-port laparoscopic cholecystectomy in children with uncomplicated gallbladder disease is feasible and equally safe, with similar intra- and postoperative outcomes compared with the conventional 4-port approach. It can contribute to global cost reduction because of lower operative and total hospitalization costs.

Intracorporeal hybrid single port vs conventional laparoscopic appendectomy in children.

Transumbilical laparoscopic assisted appendectomy combines laparoscopic single port dissection with open appendectomy after exteriorization of the appendix through the port site. Compared to the conventional three-port approach, this technique provides an alternative with excellent cosmetic outcome. We developed a safe and effective technique to perform an intracorporeal single port appendectomy, using the same laparoscope employed in the extracorporeal procedure. Retrospective review of 71 consecutively performed intracorporeal single port appendectomies and 30 conventional three-port appendectomies in children 6 to 17 years of age. A straight 10-mm Storz telescope with inbuilt 6 mm working channel is used to dissect the appendix, combined with one port-less 2.3 mm percutaneous grasper. Polymer WECK® hem-o-lock® clips are applied to seal the base of the appendix and the appendiceal vessels. No intraoperative complications were reported with the hybrid intracorporeal single port appendectomy or three-port appendectomy. There were two post-operative complications in the group treated with the single port hybrid technique: one intra-abdominal abscess and one surgical site infection. Groups did not differ in age, weight, and types of appendicitis. Operative times were shorter for the hybrid technique (70 vs 79 minutes) but did not differ significantly (P=0.19). This modified technique to a previously described single port extracorporeal appendectomy is easy to master and implement. It provides exposure similar to a three-port laparoscopic appendectomy, while maintaining virtually scarless results and potentially reduces the risk for surgical site infections compared to the extracorporeal technique.

Comparison of Transumbilical Laparoscopically Assisted Appendectomy to Conventional Laparoscopic Appendectomy in Children.

PURPOSE: To compare surgical outcomes of children with appendicitis treated with the transumbilical laparoscopically assisted appendectomy (TULAA) versus the conventional 3-port laparoscopic appendectomy (TPLA). MATERIALS AND METHODS: Retrospective study of pediatric patients with appendicitis treated with TULAA or TPLA between January 2010 and December 2015. Operative time (OT), length of stay, cost, and surgical site infection rate were compared between the 2 groups. RESULTS: Six hundred twenty-five appendectomies were performed [263 TULAA, 362 TPLA: acute (457), gangrenous (39), and perforated (129)]. TULAA had a shorter OT (median, 40 vs. 67 min; P<0.001), a shorter length of stay (median, 20 vs. 23 h; P<0.001), and a lesser cost (median $6266 vs. $8927; P<0.001). Surgical site infection rate was slightly higher in the TULAA group (6% vs. 4%; P=0.19). CONCLUSIONS: TULAA had a shorter OT and was less costly than conventional TPLA. TULAA should be considered as the first surgical approach at treating appendicitis in children.

Transumbilical laparoscopically assisted extracorporeal appendectomy in children and young adults: A retrospective cohort study.

BACKGROUND: To compare surgical outcomes of pediatric patients aged 0-15 with acute appendicitis treated with single-port, transumbilical, extracorporeal laparoscopically assisted appendectomy (SP) with young adult patients aged 16-21. MATERIALS AND METHODS: Single center retrospective chart review in patients 21 years and younger with a pre-operative diagnosis of appendicitis who underwent SP between January 2010 and December 2015. Patients were divided into two groups based on age. Operative time (OT), length of stay (LOS), cost, rates of conversion to standard three-port laparoscopic appendectomy (TP), and rates of infection were compared between the groups. RESULTS: SP was performed in a total of 263 patients: 211 in pediatric patients aged 0-15 and 52 in patients aged 16-21. Age groups did not differ significantly on cost, LOS, operative time, rates of conversion to TP, or rates of infection. CONCLUSIONS: SP has comparable surgical outcomes in adolescent, adult, and pediatric patients.

Umbilical Negative Pressure Dressing for Transumbilical Appendectomy in Childern.

BACKGROUND AND OBJECTIVES: Transumbilical laparoscopic-assisted appendectomy (TULAA) carries a high risk for surgical site infection. We investigated the effect of a bio-occlusive umbilical vacuum dressing on wound infection rates after TULAA for patients with acute appendicitis and compared to it with a conventional 3-port appendectomy with a nonvacuum dressing. METHODS: This study was a retrospective chart review of 1377 patients (2-20 years) undergoing laparoscopic appendectomy for acute appendicitis in 2 tertiary care referral centers from January 2007 through December 2012. Twenty-two different operative technique/dressing variations were documented. The 6 technique/dressing groups with >50 patients were assessed, including a total of 1283 patients. RESULTS: The surgical site infection rate of the 220 patients treated with TULAA and application of an umbilical vacuum dressing with dry gauze is 1.8% (95% CI, 0.0-10.3%). This compares to an infection rate of 4.1% (95% CI, 1.3-10.5%) in 97 patients with dry dressing without vacuum. In the 395 patients who received an umbilical vacuum dressing with gauze and bacitracin, the surgical site infection rate was found to be 4.3% (95% CI, 2.7-6.8%). CONCLUSIONS: Application of an umbilical negative-pressure dressing with dry gauze lowers the rate of umbilical site infections in patients undergoing transumbilical laparoscopic-assisted appendectomy for acute appendicitis.

Choledochal Cyst Disease in a Western Center: A 30-Year Experience.

BACKGROUND: The aim of this study was to report a Western experience in the diagnosis and management of choledochal cyst disease. RESULTS: Sixty-seven patients were identified including 15 children and 52 adults; 76.1 % were females. The median age at diagnosis was 3 [inter-quartile range (IQR) = 6.0-0.7] years for children, and 46 [IQR = 55.6-34.3] years for adults. Forty-eight patients (72 %) were symptomatic. Types of choledochal cyst included: I (n = 49, 73.1 %), II (n = 1, 1.5 %), IV (n = 9, 13.4 %), and V (n = 8, 12 %). The median diameter of the type I choledochal cyst was 35 [IQR = 47-25] mm. All 48 patients underwent excision of cyst with Roux-en-Y hepaticojejunostomy, and eight underwent resection with hepaticoduodenostomy. Six patients underwent liver resection, and five patients underwent orthotopic liver transplantation. Malignancy was concomitant in five adult patients, being identified on preoperative imaging in three cases; and atypia was seen in three additional patients. Early morbidity included Clavien-Dindo classification grades III (n = 7) and II (n = 5), while long-term complications consisted of Clavien-Dindo grades V (n = 5), IV (n = 2), III (n = 18), and II (n = 1). CONCLUSIONS: Presentation and management of choledochal cyst is varied. Malignant transformation is often detected incidentally, and so should be the driving source for resection when a choledochal cyst is diagnosed.

Laparoscopic Extracorporeal Appendectomy in Overweight and Obese Children.

BACKGROUND AND OBJECTIVES: To compare surgical outcomes of overweight and obese patients with acute appendicitis who have undergone single-port extracorporeal laparoscopically assisted appendectomy (SP) with those who have had conventional 3-port laparoscopic appendectomy (TP). METHODS: This single-center retrospective chart review included patients 21 years of age and younger with a preoperative diagnosis of appendicitis who underwent laparoscopic appendectomy from January 2010 through December 2015. Cases of gangrenous and perforated appendicitis were excluded. Subgroup analyses of patients with acute appendicitis were performed. Operative time (OT), length of stay (LOS), and cost were compared between groups stratified by body mass index (BMI) and operative technique. RESULTS: A total of 625 appendectomies were performed-457 for acute appendicitis. Sixty-eight patients were overweight. The SP technique (n = 30) had shorter OT (median minutes, 41 vs 68; P < .001), lower cost (median , $5741 vs $8530; P < .001), and shorter LOS (median hours, 16 vs 19; P = .045) than the TP technique had (n = 38). Seventy patients were obese: 19 were treated with SP and 51 with TP. LOS did not differ significantly between the SP and TP groups, but subjects treated with SP had shorter OT (median minutes, 39 vs 63; P < .001) and lower cost (median, $6401 vs $8205; P = .043). CONCLUSIONS: The SP technique for acute appendicitis was found to have a significantly shorter OT and lower cost in all weight groups. There were minimal differences in LOS. SP should be considered in patients with acute appendicitis, regardless of their weight.