Association of Intercostal Nerve Cryoablation During Nuss Procedure With Complications and Costs.

BACKGROUND: Intercostal nerve cryoablation with the Nuss procedure has been shown to decrease opioid requirements and hospital length of stay; however, few studies have evaluated the impact on complications and hospital costs. METHODS: A retrospective cohort study was performed for all Nuss procedures at our institution from 2016 through 2020. Outcomes were compared across 4 pain modalities: cryoablation with standardized pain regimen (n = 98), patient-controlled analgesia (PCA; n = 96), epidural (n = 36), and PCA with peripheral nerve block (PNB; n = 35). Outcomes collected included length of stay, opioid use, variable direct costs, and postoperative complications. Univariate and multivariate hierarchical regression analysis was used to compare outcomes between the pain modalities. RESULTS: Cryoablation was associated with increased total hospital cost compared with PCA (cryoablation, $11 145; PCA, $8975; P < .01), but not when compared with epidural ($9678) or PCA with PNB ($10 303). The primary driver for increased costs was operating room supplies (PCA, $2741; epidural, $2767; PCA with PNB, $3157; and cryoablation, $5938; P < .01). With multivariate analysis, cryoablation was associated with decreased length of stay (-1.94; 95% CI, -2.30 to -1.57), opioid use during hospitalization (-3.54; 95% CI, -4.81 to -2.28), and urinary retention (0.13; 95% CI, 0.05-0.35). CONCLUSIONS: Cryoablation significantly reduces opioid requirements and length of stay relative to alternative modalities, but it was associated with an increase in total hospital costs relative to PCA, but not epidural or PCA with PNB. Cryoablation was not associated with allodynia or slipped bars requiring reoperation.

Variations in Nuss Procedure Operative Techniques and Complications: A Retrospective Review.

INTRODUCTION: The Nuss procedure is the most common and preferred operative correction of pectus excavatum. Surgeon preference and patient factors can result in variations in Nuss procedure technique. We hypothesize that certain techniques are associated with increased risk of complications. MATERIALS AND METHODS: We performed a single-center retrospective review of Nuss operations from 2016 to 2020. Variations in intraoperative techniques included sternal elevator (SE) use, number of bars placed, and usage of bilateral stabilizing sutures. Patient demographics, intraoperative data, and postoperative outcomes were reported as median with interquartile ranges or percentages. Statistical significance (p < 0.05) was determined with Wilcoxon's rank-sum and chi-square tests. Multivariate analysis was performed to control for introduction of intercostal nerve cryoablation and surgeon volume, and reported as odds ratio with 95% confidence interval. RESULTS: Two hundred and sixty-five patients were identified. Patients repaired with two bars were older with a larger Haller index (HI). Patient demographics were not significantly different for SE or stabilizing suture use. Placement of two bars was associated with significantly increased risk of readmission. Similarly, SE use was associated with increased risk of pleural effusion and readmission. Finally, the use of bilateral stabilizing sutures resulted in less frequent slipped bars without statistical significance. CONCLUSION: Older patients with a larger HI were more likely to need two bars placed to repair pectus excavatum. Placement of multiple bars and SE use are associated with significantly higher odds of certain complications.

The strong correlation between neonatal early-onset Group B Streptococcal disease and necrotizing enterocolitis.

BACKGROUND: Necrotizing enterocolitis (NEC) is a leading cause of newborn gastrointestinal emergencies, affecting 1-3 per 1000 live births. Although NEC has been linked to a microbial etiology, associations with maternal intrapartum and resultant newborn early-onset invasive Group B streptococcus (EO-GBS) have been weakly defined. OBJECTIVE: The study aim was to determine the relationship between EO-GBS and NEC. STUDY DESIGN: Data from 2008 to 2015 were collected from pediatric records with ICD diagnosis codes consistent with all stages of NEC, with the exception of neonatal EO-GBS data (only available 2011-2015). RESULTS: For the 131 newborns meeting inclusion criteria, the mean gestational age (GA) and birthweight at delivery was 30.2 weeks and 1449 g. Maternal comorbidities were not associated with a more advanced stage of NEC, however male gender (OR 3.2, p < .001), lower mean 1 (OR = 0.89, p = .045) and 5 min Apgar scores (OR = 0.84, p = .009) were significantly associated with higher NEC stage, after controlling for GA. Infectious morbidities including chorioamnionitis (OR = 1.5, p = .553) and intrapartum antibiotic administration (OR = 1.3, p = .524) were not significantly associated with higher NEC stage. Neither neonatal sepsis workup (OR = 0.27, p = .060) nor positive blood culture (OR = 0.97, p = .942) prior to NEC diagnosis were statistically significant. Type of feed prior to diagnosis (p = .530) was not significantly associated with NEC stage, however, expressed breast milk tended to be protective against higher stage of NEC (OR = 0.49, p = .055). Type of feed included total parenteral nutrition, mother's or donor expressed breast milk, trophic, full and high calorie feeds. Of the 579 newborns admitted from 2011 to 2015, 13 (2%) were diagnosed with EO-GBS and 64 met diagnostic criteria for NEC. GBS positive newborns had significantly higher odds of NEC (OR = 5.37, p = .009). NEC stage was not significantly different for patients with GBS positive vs. GBS negative mothers (p = .732), nor was there a significant difference in GA (p = .161). CONCLUSION: Our study is the first to describe a strong correlation between neonatal EO- GBS disease and NEC, with more than a five-fold increase in the odds of developing NEC in newborns of GBS positive mothers. PURPOSE: To investigate a possible relationship between EO-GBS disease and the neonatal diagnosis of NEC. Secondary analysis will determine if maternal antepartum and intrapartum factors along with neonatal variables contribute to a more advanced stage of NEC by retrospective chart review of patient data collected at Children's Hospital: New Orleans.

An extended phase II trial of iodine-125 methylene blue for sentinel lymph node identification in women with breast cancer.

BACKGROUND: The aim of this study was to determine if an intraoperative injection of iodine-125-labeled methylene blue ((125)I-MB) is a sensitive and effective method for detecting SLNs in women with breast cancer. STUDY DESIGN: Sixty-two women were enrolled in an extended phase II trial using (125)I-MB to guide SLNB. All patients were anesthetized and then injected subcutaneously with 1 mCi (125)I-MB in the outer quadrant of the areola. RESULTS: Radioactivity was detected in the axilla within 3 to 5 minutes. Fifty-eight of 62 (94%) patients had SLNs detected during their procedure. Mean (±SD) number of SLNs per patient was 1.8 ± 1.3 (range 0 to 6). A total of 112 nodes were dissected from 58 women; 110 of these nodes were considered sentinel. One hundred and eight (98%) nodes were hot, 98 (89%) nodes were blue, and 96 (87%) nodes were both hot and blue. Two women had complications; 1 had superficial skin staining and 1 had a superficial skin slough. Both healed uneventfully. No allergic reactions were observed. No radioactive uptake in the thyroid was seen. CONCLUSIONS: Iodine-125-labeled methylene blue can be mixed and administered in the operating room, improving hospital efficiency. Patient satisfaction is higher with (125)I-MB than with the technetium 99m sulfur colloid procedure because (125)I-MB does not produce localized burning and other adverse reactions associated with the traditional method, and 125I-MB is administered with the patient under anesthesia. Iodine-125 emits a lower-energy gamma ray than technetium 99m, lowering the surgeon's radiation exposure. Iodine-125-labeled methylene blue SLN identification is safe, cost effective, and produces equivalent outcomes compared with the traditional technique, making it an attractive alternative.

Femororenal arteriovenous graft: a viable option for hemodialysis access.

There has been a significant increase in the number of patients with end-stage renal disease. The limited number of kidney transplants necessitates that most patients become dependent upon chronic dialysis. Due to the numerous complications associated with temporary access catheters, permanent arteriovenous access is more beneficial for long-term vascular access. However, with the restricted availability of sites for permanent vascular access, it is important to have a variety of possibilities. In this case report, we present an alternative choice for an arteriovenous graft, left common femoral artery to left renal vein, in a patient with limited vascular access options.

Development of 125I-methylene blue for sentinel lymph node biopsy.

BACKGROUND: Sentinel lymph node biopsy is an established alternative to complete lymph node dissection in some patients. We have developed a novel, radiolabeled methylene blue dye that may be a useful alternative to the traditional two-step procedure involving 99mTc-labeled colloid and unlabeled blue dye. We hypothesize that 125I-labeled methylene blue will be rapidly absorbed into the lymphatics and transported to the drainage basin containing the sentinel nodes. MATERIALS AND METHODS: Rabbits footpads were injected with 1 mCi of 125I-labeled methylene blue admixed with unlabeled dye. A hand-held gamma detection device allowed tracking of radiolabeled dye to nodes in the popliteal and inguinal regions. At pre-established time points animals were sacrificed, and the nodal basin dissected. Nodal radioactivity as well as uptake of blue dye was recorded. RESULTS: The spread of the radiolabeled methylene blue compound from the footpad to the popliteal lymph nodes occurred in 5-10 min. CONCLUSION: The radiolabeled dye rapidly progresses through lymphatics to the draining nodes. Use of radiolabeled methylene blue may be an attractive alternative to current two-step sentinel node techniques, as it may be less painful, and may reduce the cost associated with the time-delay between the injection of the radioactive compound and surgery.