Cecal perforation secondary to fungal necrotizing enterocolitis in a premature neonate.

INTRODUCTION: Necrotizing enterocolitis (NEC) remains one of the most critical gastrointestinal comorbidities associated with neonatal prematurity and low birth weight. Despite extensive research and innovations for successful management, NEC remains the leading cause of morbidity and mortality in premature infants. NEC is commonly appreciated at the level of the small bowel, but in rare instances, it is experienced at the colon. While colonic perforation is rare, cecal perforation, specifically, is seldom reported. CASE REPORT: We report the successful surgical intervention of a preterm African-American infant born at 24-weeks' gestation found to have a cecal perforation due to fungal necrotizing enterocolitis. DISCUSSION: Perforation is a major cause of morbidity in necrotizing enterocolitis, and even with extensive research in the management of necrotizing enterocolitis, mortality rates have remained unchanged; the treatment option with the most advantageous outcomes is still uncertain. CONCLUSION: To our knowledge, there are few reported cases of cecal perforation due to NEC. The pathologic report of our colonic specimen demonstrated mucosal invasion with Candida Albicans. This case report is noteworthy due to the unusual location of bowel perforation, fungal sepsis, and successful surgical outcome that is not commonly seen in neonates with intestinal candidiasis. Cecal perforation is rare in necrotizing enterocolitis but should not rule out the pathology.

Education of pediatric surgery residents over time: Examining 15 years of case logs.

BACKGROUND/PURPOSE: Surgical indications and techniques have changed over the last 15 years. The number of Pediatric Surgery training programs has also increased. We sought to examine the effect of these changes on resident education by examining case log data. METHODS: Accreditation Council for Graduate Medical Education (ACGME) case logs for graduating Pediatric Surgery residents were examined from 2004 to 2018. Using the summary statistics provided, linear regression analysis was conducted on each case log code and category. RESULTS: In 2004, there were 24 Pediatric Surgery training programs and 24 Pediatric Surgery residents graduating with an average of 979.8 total cases logged. In 2018, there were 36 programs with 38 residents graduating with an average of 1260.2 total cases logged. Total case volume of graduating residents significantly increased over the last 15 years (p < 0.001). Significant increases were demonstrated in skin/soft tissue/musculoskeletal (p < 0.01), abdominal (p < 0.001), hernia repair (p < 0.001), genitourinary (p < 0.01), and endoscopy (p < 0.001). No significant changes were seen in the head and neck, thoracic, cardiovascular, liver/biliary, and non-operative trauma categories. No categories significantly decreased over the time period. No significant changes were seen in the number of multiple index congenital cases, including tracheoesophageal fistula/esophageal atresia repair, omphalocele, gastroschisis, choledochal cyst excision, perineal procedure for imperforate anus, and major hepatic resections for tumors. Pertinent increases in specific procedures include diaphragmatic hernia repair (p < 0.01), ECMO cannulation/decannulation(p < 0.05), thyroidectomy (p < 0.001), parathyroidectomy (p < 0.001), biliary atresia (p < 0.001), and circumcision (p < 0.001) as well as most laparoscopic abdominal procedures. Specific procedure codes with significant decreases include tracheostomy (p < 0.05), minimally invasive decortication/pleurectomy/blebectomy (p < 0.001), laparoscopic splenectomy (p < 0.001), as well as most open abdominal procedures. CONCLUSION: Despite increasing numbers of Pediatric Surgery residents and training programs, the number of cases performed by each graduating resident has increased. This increase is primarily fueled by increase in abdominal, skin/soft tissue/musculoskeletal, hernia repair, genitourinary, and endoscopic cases. LEVEL OF EVIDENCE: Level II.

Surgical Jeopardy: Play to Learn.

BACKGROUND: General Surgery residencies use protected education time in various fashions in order to optimize content quality and yield for their learners. This knowledge is tested annually with the American Board for Surgery In-Training Examination (ABSITE) exam and is used to evaluate several aspects of a resident. We hypothesized that using a jeopardy game in educational conference would encourage residents to engage in self-learning and improve ABSITE scores at a single institution. MATERIALS AND METHODS: At a single institution, during protected education conference, residents played an hour-long surgical jeopardy game every 7 wk to summarize high yield topics discussed during the previous 6 wk of didactic learning. A 5-point Likert survey was completed by general surgery residents to discern the utility of the game format for learning. The ABSITE category scores were also evaluated from the year before and the year after the game was implemented. RESULTS: Twenty-four general surgery residents took the survey with >80% agreeing that the jeopardy format was either a fun or an effective way to learn general surgery topics. Additionally, over 80% of residents thought the game format helped with retention of knowledge. ABSITE categories that had a jeopardy session improved from 65.9% to 70.4% correct (P = 0.0003). ABSITE categories that did not have dedicated jeopardy had a non-significant increase in scores (67.7%-69.9%, P = 0.1). CONCLUSIONS: Implementing surgical jeopardy as a component of educational conferences in general surgery resident training is correlated with improvement of ABSITE scores. Surgical jeopardy may be easily adopted and implemented to stimulate self-directed learning for residents.

Complete gastroesophageal junction avulsion after near drowning: A case report and review of literature.

INTRODUCTION: Gastroesophageal (GE) junction injuries are rare in the pediatric population. A complete GE junction separation in a child secondary to trauma has not reported in the literature yet. PRESENTATION OF CASE: A 14-year-old boy presented with a complete GE junction avulsion after a near-drowning experience. He underwent immediate damage control surgery and delayed gastric pull-up esophageal reconstruction in 3-months. At the most recent clinic visit 5 months from the reconstruction, he can tolerate a regular diet without difficulty and is gaining weight and recovering well. CONCLUSION: Complete GE junction injuries and avulsions are rare with limited data to guide management. These injuries are associated with mortality rates from 25% to 33%, therefore, high index of suspicion, prompt recognition and careful surgical planning is needed for favorable outcomes.

Impact of an untrained CPR Coach in simulated pediatric cardiopulmonary arrest: A pilot study.

AIM: To determine if an untrained cardiopulmonary resuscitation (CPR) Coach, with no access to real-time CPR feedback technology, improves CPR quality. METHODS: This was a prospective randomized pilot study at a tertiary care children's hospital that aimed to integrate an untrained CPR Coach into resuscitation teams during simulated pediatric cardiac arrest. Simulation events were randomized to two arms: control (no CPR Coach) or intervention (CPR Coach). Simulations were run by pediatric intensive care unit (PICU) providers and video recorded. Scenarios focused on full cardiopulmonary arrest; neither team had access to real-time CPR feedback technology. The primary outcome was CPR quality. Secondary outcomes included workload assessments of the team leader and CPR Coach using the NASA Task Load Index and perceptions of CPR quality. RESULTS: Thirteen simulations were performed; 5 were randomized to include a CPR Coach. There was a significantly shorter duration to backboard placement in the intervention group (median 20 s [IQR 0-27 s] vs. 52 s [IQR 38-65 s], p = 0.02). There was no self-reported change in the team leader's workload between scenarios using a CPR Coach compared to those without a CPR Coach. There were no significant changes in subjective CPR quality measures. CONCLUSIONS: In this pilot study, inclusion of an untrained CPR Coach during simulated CPR shortened time to backboard placement but did not improve most metrics of CPR quality or significantly affect team leader workload. More research is needed to better assess the value of a CPR Coach and its potential impact in real-world resuscitation.

Pediatric arterial catheters: Complications and associated risk factors.

BACKGROUND/PURPOSE: Arterial catheter complications are a common problem in a pediatric critical care setting, but reported complication rates and risk factors associated with peripheral arterial catheter complications vary. We conducted a retrospective cohort study to identify risk factors in a pediatric patient population. METHODS: We performed a detailed abstraction of provider notes in the electronic medical records of inpatients ≤18years of age who underwent arterial line placement between January 1, 2008 and January 1, 2013 at a university-affiliated standalone pediatric hospital. Inpatient records were assessed for complications associated with arterial catheterization and risk factors inherent to arterial catheter insertion. RESULTS: Two hundred twenty-eight children were identified, of whom 75 (33%) had a total of 106 arterial catheter complications. Complications included line malfunctions (59%, n=63), bleeding (16%, n=17), multiple complications (11%, n=12), infiltration (8%, n=9), and hematoma (4%, n=4). Line malfunction was reported in all patients with multiple complications. Independent predictors of complications associated with arterial catheterization were the presence of more than one provider during the insertion (p=0.007) and insertion attempts at multiple sites (p=0.036). CONCLUSIONS: Our analysis suggests the need for a prospective study to comprehensively assess provider-related risk factors associated with arterial catheter complications in children. LEVEL OF EVIDENCE: IV.

Incidental GIST after appendectomy in a pediatric patient: a first instance and review of pediatric patients with CD117 confirmed GISTs.

A 7-year-old boy underwent uncomplicated laparoscopic appendectomy for acute appendicitis. Incidentally, he was found to have a spindle cell tumor with CD117 immunopositivity, consistent with gastrointestinal stromal tumor (GIST) in the appendix. Although commonly reported in adults, pediatric GISTs are rare gastrointestinal malignancies that occur in only 1.4-2.7% of children and adolescents. Due to the paucity of reports, data are insufficient to adequately characterize tumor behavior, recurrence, and survival. We present the first case of pediatric GIST in the appendix. In addition, a review of the literature for CD117 confirmed pediatric GISTs was conducted to summarize its clinical features and current treatment options.

Hepatobiliary cystadenoma: a rare pediatric tumor.

Hepatobiliary cystadenoma is a rare hepatic neoplasm that has been reported only 10 times in the pediatric population. Although considered a benign cystic tumor of the liver, hepatobiliary cystadenoma has a high risk of recurrence with incomplete excision and a potential risk for malignant degeneration. Complete tumor excision with negative margins is the mainstay in treatment. Unfortunately, due to the paucity of cases and its vague presentation, hepatobiliary cystadenoma is rarely diagnosed preoperatively. Therefore, in patients with hepatic cystic masses without a clear diagnosis, total resection of the lesion with negative margins is indicated to adequately evaluate for malignant potential and limit the risk of recurrence. We describe a 2-year-old girl with an asymptomatic abdominal mass that was found to be hepatobiliary cystadenoma. In addition, the pathogenic, histopathologic and clinical features of hepatobiliary cystadenoma are reviewed.

Prune belly syndrome, splenic torsion, and malrotation: a case report.

An 18 year old male with a history of prune belly syndrome (PBS) presented with acute abdominal pain and palpable left upper quadrant mass. Computed tomography (CT) of the abdomen revealed a medialized spleen with a "whirl sign" in the splenic vessels, consistent with splenic torsion. Coincidentally, the small bowel was also noted to be on the right side of the abdomen, while the colon was located on the left, indicative of malrotation. Emergent diagnostic laparoscopy confirmed splenic torsion and intestinal malrotation. Successful laparoscopic reduction of the splenic torsion was achieved, however, conversion to an open procedure by a vertical midline incision was necessary owing to the patient's unique anatomy. Open splenopexy with a mesh sling and Ladd's procedure were subsequently performed. Malrotation and wandering spleen are known, rare associated anomalies in PBS; however, both have not been reported concurrently in a patient with PBS in the literature. In patients with PBS, acute abdominal pain, and an abdominal mass, high clinical suspicion for gastrointestinal malformations and prompt attention can result in spleen preservation and appropriate malrotation management. We present a case of a teenager who presented with a history of PBS, acute abdominal pain, and a palpable abdominal mass. The patient was found to have splenic torsion and intestinal malrotation. The clinical findings, diagnostic imaging, and surgical treatment options of splenic torsion are reviewed.

Severe menorrhagia, unilateral ovarian mass, elevated inhibin levels, and severe hypothyroidism: an unusual presentation of Van Wyk and Grumbach syndrome.

A 10 year old female presented with a 3 week history of persistent vaginal bleeding, lower abdominal pain, and generalized fatigue. Further work-up determined that she had severe autoimmune hypothyroidism, precocious puberty, and a large left cystic ovarian mass, consistent with Van Wyk and Grumbach syndrome. In addition, the patient had elevated inhibin A and B levels, which may be elevated in granulosa cell tumor. The patient was managed with thyroid hormone replacement therapy and careful observation. Complete resolution of the ovarian mass and interval normalization of the inhibin levels were achieved. In females with severe primary hypothyroidism, ovarian masses, and elevated tumor markers, operative resection may be avoided with appropriate thyroid replacement therapy and close observation.

Heterotopic gastric mucosa of the upper esophagus following repair of esophageal atresia with tracheoesophageal fistula.

A term female newborn underwent uncomplicated repair of esophageal atresia with tracheoesophageal fistula (type C) then coarctation of the aorta. Subsequently, she developed symptomatic esophageal strictures, which required serial dilations. In addition, she suffered feeding intolerance from esophageal dysmotility and gastroesophageal reflux disease, necessitating Nissen fundoplication with gastrostomy. At 6 years of age, surveillance esophagogastroduodenoscopy revealed mild stenosis and heterotopic gastric mucosa of the upper esophagus at the level of the anastomosis. This is the second report of heterotopic gastric mucosa of the upper esophagus at the level of the anastomosis following repair of esophageal atresia with tracheoesophageal fistula.