Nonoperative management of blunt liver and spleen injury in children: evaluation of the ATOMAC guideline using GRADE

BACKGROUND: Nonoperative management of liver and spleen injury should be achievable for more than 95% of children. Large national studies continue to show that some regions fail to meet these benchmarks. Simultaneously, current guidelines recommend hospitalization for injury grade + 2 (in days). A new treatment algorithm, the ATOMAC guideline, is in clinical use at many centers but has not been prospectively validated. METHODS: A literature review conducted through MEDLINE identified publications after the American Pediatric Surgery Association guidelines using the search terms blunt liver trauma pediatric, blunt spleen trauma pediatric, and blunt abdominal trauma pediatric. Decision points in the new algorithm generated clinical questions, and GRADE [Grading of Recommendations, Assessment, Development, and Evaluations] methodology was used to assess the evidence supporting the guideline. RESULTS: The algorithm generated 27 clinical questions. The algorithm was supported by six 1A recommendations, two 1B recommendations, one 2B recommendation, eight 2C recommendations, and ten 2D recommendations. The 1A recommendations included management based on hemodynamic status rather than grade of injury, support for an abbreviated period of bed rest, transfusion thresholds of 7.0 g/dL, exclusion of peritonitis from a guideline, accounting for local resources and concurrent injuries in the management of children failing to stabilize, as well as the use of a guideline in patients with multiple injuries. The use of more than 40 mL/kg or 4 U of blood to define end points for the guideline, and discharging stable patients before 24 hours received 1B recommendations. CONCLUSION: The original American Pediatric Surgery Association guideline for pediatric blunt solid organ injury was instrumental in improving care, but sufficient evidence now exists for an updated management guideline.(AU)

Pulmonary hypertension predicts mortality in infants with omphalocele.

OBJECTIVE: The objective of this study was to identify predictors of mortality in infants with omphalocele. METHODS: Medical records of infants with omphalocele born between January 1992 and June 2012, with follow-up toDecember 2012, were retrospectively reviewed. Survivors and non-survivors were compared. Evidence for pulmonary hypertension was sought between the second and seventh day after birth. All included infants had increased right ventricular pressures (RVP >40 mmhg) on echocardiogram on the second day of life with increased oxygen requirements, therefore, the finding of increased pressure was not considered a result of the transitional circulation. Logistic regression was used to evaluate the importance and independence of various factors. RESULTS: Of 51 infants whose records were reviewed, 13 died (25%) and 38 survived (75%). The median time to death was 34 days (range: 4 -408 days). The median follow-up time for those who died was 1.5 years (range: 0.01-15 years) and for survivors was 2.6 years (range: 0.08-15 years). Logistic regression revealed that respiratory insufficiency at birth (OR: 14.8; 95% CI: 2.5-85.0) and pulmonary hypertension (OR: 6.4; 95% CI: 1.1-39.0) were independently associated with mortality. CONCLUSION: Respiratory insufficiency after birth and pulmonary hypertension are independent predictors of mortality in infants with omphalocele.

Incidence, diagnosis, and outcomes of vocal fold immobility after esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) repair.

BACKGROUND: The diagnosis of vocal fold paralysis in an infant is a devastating finding that may require a permanent tracheotomy. The incidence of congenital vocal fold paralysis is unknown, but it is thought to be more common in infants with anatomic anomalies in the aero-digestive system. Vocal fold paralysis after surgical repair of esophageal atresia and tracheoesophageal fistula is a rare finding often diagnosed after multiple failed extubations. Currently infants do not routinely undergo documentation of vocal fold motion prior to esophageal atresia repair. We report here on our experience with this rare complication. METHOD: A retrospective review was done of patients with esophageal atresia and/or tracheoesophageal fistula from 1985 to 2009. Patient demographics, operative techniques, and outcomes were collected. RESULTS: 150 patients were identified. Mean age at surgical intervention was 12 ± 33 days. Otolaryngology service was consulted for 13% of patients with postoperative failure. Awake fiberoptic laryngoscopy identified 3% of patients with vocal fold paralysis. Bilateral vocal fold paralysis was found in 3 patients, and 2 patients had unilateral vocal fold paralysis. Patients with bilateral paralysis were treated with tracheotomy; unilateral paralysis was treated expectantly. CONCLUSION: In this study, 3% of patients were diagnosed with vocal fold paralysis after esophageal atresia repair. The etiology of vocal fold paralysis in this study is difficult to assess. Pre-operative fiberoptic laryngoscopy is recommended to identify children with congenital vocal fold paralysis prior to surgical intervention, especially in those requiring revision surgery.

Management of anterior mediastinal masses in children.

BACKGROUND: Children with anterior mediastinal masses are at risk for life-threatening airway compromise during anesthesia, and can present a diagnostic and management challenge for pediatric surgeons. METHODS: We performed a retrospective chart review of all children presenting with an anterior mediastinal mass from 1994-2009. Parameters studied included demographics, historical and physical findings at diagnosis, radiographic evidence of airway compression, diagnostic studies, diagnosis, and complications. RESULTS: There were 26 patients with anterior mediastinal masses over a 15-year period. The mean age was 11.3 years, and there were no gender differences. The diagnoses were lymphoma (62%, 16/26), leukemia (15%, 4/26), and other (23%, 6/26). Diagnosis was made by CBC/peripheral smear in 2/4 patients with leukemia, by bone marrow biopsy in 2/4 patients with leukemia, by thoracentesis in 3/16 patients with lymphoma, by lymph node biopsies in 6/16 patients with lymphoma, and by biopsy of a mediastinal mass in 7/16 patients with lymphoma and in 6/6 patients with other diagnoses. Radiographic evidence of airway compression was seen in 62% (16/26) of children. Only 12% (3/26) had a tracheal cross-sectional area (TCA) <50%. Correlation of symptoms with anatomical airway obstruction or complications was poor. Pulmonary function studies were obtained in 38%, 10/26 children. Only 2 children had a PEFR (peak expiratory flow rate) <50% predicted. This data also correlated poorly with anatomical airway obstruction or complications. 3 patients had anesthesia-related complications: one desaturation during induction prior to median sternotomy, one with significant desaturation and bradycardia during biopsy under local anesthesia with minimal sedation, and one with prolonged (5 days) mechanical ventilation after general anesthesia. 2 of these patients had a TCA <50%, and 2 had SVC obstructions. There were no anesthesia-related deaths, and the overall survival was 85% (22/26). CONCLUSION: Anterior mediastinal masses in children should be approached in a step-wise fashion with multi-disciplinary involvement, starting with the least invasive techniques and progressing cautiously. The surgeon should have a well-defined and preoperatively established contingency plan if these children require general anesthesia for diagnosis.

Outcome of congenital diaphragmatic hernia repair depending on patch type.

INTRODUCTION: Patch repair of a congenital diaphragmatic hernia is associated with a much higher rate of recurrence than when primary repair is feasible. The biosynthetic options for the repair materials continue to expand. We therefore reviewed our experience to benchmark complication rates as we progress with the use of new materials. METHODS: A retrospective review was conducted of all patients who underwent repair of congenital diaphragmatic hernia from January 1994 to May 2009. RESULTS: Of the 155 patients included in the study, 101 patients had primary closure and 54 received a diaphragmatic patch. The rates of recurrence, Small Bowel Obstruction (SBO), and subsequent abdominal operation were all significantly higher in the group of patients requiring patch repair. There were 3 types of patch repairs: 37 patients received a SIS patch, 12 had a nonabsorbable patch, and 5 received an AlloDerm patch. The incidence of SBO in patients with a nonabsorbable mesh was 17% and was associated with a 50% recurrence rate and 67% re-recurrence rate. SIS was associated with 19% incidence of SBO, a recurrence rate of 22% and a 50% re-recurrence rate, whereas AlloDerm had a 40% incidence of SBO, 40% recurrence rate, and 100% re-recurrence rate. DISCUSSION: As we move towards the next generation of materials, these data do not justify the continued comparison with nonabsorbable patches. We do not have enough comparative data to define a superior biosynthetic material, but we plan to use our data on SIS to benchmark our experience with future generation materials.

Review of the technical variants in the repair of pectus excavatum.

INTRODUCTION: Many technical variations have been introduced for the surgical correction of pectus excavatum (PE). The authors reviewed the literature to provide a detailed overview of the general principles of pectus excavatum repair, bar insertion and removal techniques. MATERIALS AND METHODS: A comprehensive review of the literature was undertaken. RESULTS: A summary of the different approaches and techniques of pectus excavatum repair, bar insertion and removal is presented. Various procedures, their advantages and disadvantages, the techniques employed and associated complications are discussed in depth. CONCLUSION: Pectus excavatum repair has undergone many changes since its first description. Despite previous descriptions of evolving procedures, comparative overviews of surgical variations, outcomes after pectus bar insertion and removal techniques are rare in the literature. The authors reviewed the literature to summarize the previous and current understanding of techniques and highlight the variations.

Bowel obstruction after treatment of intra-abdominal tumors.

BACKGROUND: Tumors of the solid viscera are one of the most common types of pediatric malignancies. Due to the intra-abdominal location of many of these neoplasms, laparotomy and/or bowel resection are often necessary, predisposing patients to postoperative intestinal obstruction. Additionally, chemotherapy and radiation therapy may lead to acute and chronic bowel injury, also potentially predisposing these patients to postoperative bowel obstruction. We reviewed our data over an eleven-year period to identify the incidence of obstruction as well as factors associated with its development. METHODS: A retrospective data analysis of all patients diagnosed with intra-abdominal Wilms' tumor, rhabdomyosarcoma, neuroblastoma, and Hodgkin's and non-Hodgkin's lymphoma in a single institution from 1997 to 2007 was conducted. Data collected included demographic factors, operations, incidence of small bowel obstruction (SBO) and the use of adjuvant or neoadjuvant chemoradiation therapy. Patients who developed SBO were compared to those who did not develop obstruction. Data comparisons were analyzed statistically using Fisher's exact test, 2-tailed Student's t-Test, or chi-square proportional analysis with significance reported for p<0.05. RESULTS: A total of 291 patients were identified during the study period. Mean age at diagnosis was 8.1+/-5.8 years. Males accounted for 57% of all patients. Tumor distribution was as follows: Wilms' tumor: 56 (19%); non-Hodgkin's lymphoma: 71 (24%); Hodgkin's lymphoma: 64 (22%); rhabdomyosarcoma: 32 (11%); and neuroblastoma: 68 (24%). There were a total of 12 bowel obstructions in 11 patients (3.7%). Mean follow-up for all patients was 3.6+/-2.7 years. Children with bowel obstruction were more likely to be male (4.5:1, p=0.061) and younger (4.2 years versus 8.1 years; p=0.087). Wilms' tumor accounted for 45% of patients with bowel obstruction, but made up only 19% of the study population. The incidence of bowel obstruction in patients with Wilms' tumor was 8.9% compared to an overall incidence of 3.8% (p=0.043). CONCLUSION: Bowel obstruction is relatively uncommon after intra-abdominal malignancies in children. Wilms' tumor, rhabdomyosarcoma and Burkitt's lymphoma appear to be associated with the highest risk of bowel obstruction.

A review of venovenous and venoarterial extracorporeal membrane oxygenation in neonates and children.

The use of extracorporeal membrane oxygenation (ECMO) has increased since its inception. As this modality gained wider acceptance, its application in a variety of disease states has increased. The initial use of ECMO required cannulation of both the carotid artery and internal jugular vein (VA ECMO). Ligation of the carotid artery and concern regarding potential long-term sequelae prompted the development of the single cannula venous only (VV ECMO) technique. Various reports in the literature have compared VV ECMO and VA ECMO. We present a review of the literature with regard to both physiology and clinical application.

The progressive development of pyloric stenosis: a role for repeat ultrasound.

INTRODUCTION: Patients presenting in the first 3 months of life with nonbilious emesis are commonly studied by ultrasound. A negative study effectively rules out pyloric stenosis. However, the development of pyloric stenosis is a progressive and dynamic process. The rate of hypertrophy to the point of meeting diagnostic criteria is unknown and there is no data published in the literature regarding the role of repeat ultrasound in patients with persistent symptoms. During a prospective, randomized trial we identified 3 patients with negative ultrasounds who subsequently were diagnosed and treated for pyloric stenosis. We present this series as an illuminating depiction of the development of muscle hypertrophy in patients with pyloric stenosis. METHODS: Patients with pyloric stenosis and repeat ultrasound were identified from our prospective, randomized trial. All patients had sonographic pyloric measurements obtained at our institution. Data included patient age upon presentation, ultrasound-defined pyloric parameters, operation, and outcome. RESULTS: Three patients were identified with a negative ultrasound with a pyloric thickness ranging from 0.8 mm to 2.5 mm. Subsequent thickness on repeat ultrasound ranged from 3.5 to 6.2 mm. The rate of hypertrophy ranged from 0.17 mm/day to 0.5 mm/day. CONCLUSIONS: A negative pyloric sonogram may be due to the fact that the patient is in the very initial stages of development of pyloric stenosis. Caregivers should counsel parents to return if symptoms persist and there should be a low threshold for repeat ultrasound in these patients.

Laparoscopic gastric bypass after failed open horizontal stapled gastroplasty.

The number of people in the population who have undergone an operative procedure for morbid obesity is likely to rise steadily as the awareness and popularity of bariatric surgery continues to develop. As this number increases, the number of patients with long-term failures and complications from these procedures will also rise. Although previous operations, particularly open procedures, normally deter surgeons from choosing a laparoscopic approach, the evolving technical skill of laparoscopic surgeons should allow for the reconsideration of these inhibitions. In this case, we present of laparoscopic Roux-en-Y gastric bypass on a 48-year-old woman who had undergone horizontal gastric stapling 20 years prior to presentation.

Hepatic control of perfusate homeostasis during normothermic extrocorporeal preservation.

BACKGROUND: We investigated the ability of the isolated porcine liver to maintain acid-base homeostasis in the perfusate and the impact of ischemia-reperfusion injury without or with extracorporeal perfusion. METHODS: Harvested livers were either stored for 24 hours in cold University of Wisconsin solution or preserved by continuous, normothermic, oxygenated sanguineous perfusion with supplemental nutrition, prostacyclin, and bile salts. After a further 24-hour period of reperfusion of both groups on an extracorporeal circuit, the perfusate was assessed for both biochemical indices of synthetic and metabolic liver function as well as hepatocellular injury and blood gas analysis. RESULTS: Livers injured by cold ischemia during preservation displayed inferior synthetic and metabolic functions. Perfused livers, which displayed minimal ischemic injury, produced more bicarbonate than the cold-stored organs, suggesting autoregulation of pH homeostasis in perfused livers in contrast to progressively worsening acidosis in cold-stored organs. CONCLUSIONS: Given proper physiologic substrate the porcine liver has the ability to maintain acid-base homeostasis, provided there is not a significant ischemia-reperfusion injury.

Extended preservation of non-heart-beating donor livers with normothermic machine perfusion.

BACKGROUND: Non-heart-beating donor (NHBD) livers represent an important organ pool, but are seldom utilized clinically and require rapid retrieval and implantation. Experimental work with oxygenated perfusion during preservation has shown promising results by recovering function in these livers. This study compared sanguinous perfusion with cold storage for extended preservation of the NHBD liver in a porcine model. METHODS: Porcine livers were subjected to 60 min of in vivo total warm ischaemia before flushing, after which they were preserved by one of two methods: group 1 (n = 4), University of Wisconsin (UW) solution by standard cold storage for 24 h; group 2 (n = 4), oxygenated autologous blood perfusion on an extracorporeal circuit for 24 h. All livers were subsequently tested on the circuit during a 24-h reperfusion phase. RESULTS: Livers in group 1 showed no evidence of viability during the reperfusion phase with no bile production or glucose utilization; they also displayed massive necrosis. Livers in group 2 demonstrated recovery of function by synthetic function, substrate utilization and perfusion haemodynamics; these livers displayed less cellular injury by hepatocellular enzymes. All differences in parameters between the two groups were statistically significant (P < 0.05). These findings were supported by histological examination. CONCLUSION: Warm ischaemia for 1 h and simple cold storage (UW solution) for 24 h renders the liver non-viable. Oxygenated, sanguinous perfusion as a method of preservation recovers liver function to a viable level after 24 h of preservation.