Esophageal Atresia and Tracheoesophageal Fistula: Overview and Considerations for the General Surgeon.

Esophageal atresia (EA) with tracheoesophageal fistula (TEF) is among the most common congenital anomalies requiring surgical intervention in infancy. General surgeons practicing in rural or austere environments may encounter emergency situations requiring their involvement. Respiratory emergencies can arise in the neonatal period; the recommended approaches are the ligation of the fistula through the chest or occlusion of the distal esophagus through the abdomen. As survivors of the condition reach late adulthood, general surgeons can anticipate encountering these patients. An understanding of risk factors, common symptoms, associated anomalies, and the appropriate diagnostic evaluation will facilitate care.

Non-Radiographic Severity Measurement of Pectus Excavatum.

BACKGROUND: To avoid the radiation exposure of CT imaging and the expense of CT or MRI studies, we sought to develop a non-radiographic severity measurement of pectus excavatum based on 3D photogrammetric imaging. METHODS: Over 28 mo, ten consecutive patient volunteers with pectus excavatum underwent 3D stereophotogrammetric imaging. The surface width to surface depth ratio (Surface Lengths Pectus Index), the chest deformity's surface area to total chest surface area (Pectus Surface Area Ratio), and the chest deformity's volume to total chest volume (Pectus Volume Ratio) were calculated. Simple linear regression analysis compared the Surface Lengths Pectus Index, Pectus Surface Area Ratio, and Pectus Volume Ratio calculations each to the corresponding known CT pectus index. RESULTS: The correlation between CT pectus index versus Surface Lengths Pectus Index yielded an R-squared value of 0.7637 and a P value of 0.0013. A CT pectus index of 3.4 or greater (eight patients) corresponded to a Surface Lengths Pectus Index of 1.86 or greater (six patients). The CT pectus index versus Pectus Surface Area Ratio (R-squared = 0.4627, P = 0.0305) and the CT pectus index versus the Pectus Volume Ratio (R-squared = 0.3048, P = 0.0990) demonstrated less correlation. CONCLUSION: Surface Lengths Pectus Index corresponds to the CT pectus index and may be adequate to determine severity of pectus excavatum in some patients.

Cold atmospheric plasma for the ablative treatment of neuroblastoma.

BACKGROUND: Recent breakthroughs have allowed for production of plasma at room temperature. Cold atmospheric plasma (CAP) may offer the capability of delivering reactive oxygen species directly into tissues, representing a novel modality for targeted cancer therapy. We studied helium-based CAP's effect on neuroblastoma, both in-vitro and in an in-vivo murine model. METHODS: Mouse neuroblastoma cultures were treated with CAP for 0, 30, 60, and 120 s and assayed for apoptotic and metabolic activity immediately and at 24 and 48 h post-treatment. Five-millimeter tumors were ablated with a single transdermal CAP treatment, and tumor volume and mouse survival were measured. RESULTS: CAP decreased metabolic activity, induced apoptosis, and reduced viability of cancer cells in proportion to both duration of exposure and time post-treatment. In-vivo, a single treatment ablated tumors and eventual tumor growth was decelerated. Furthermore, survival nearly doubled, with median survival of 15 vs. 28 days (p<0.001). CONCLUSIONS: Our findings demonstrate the sensitivity of neuroblastoma to CAP treatment, both in-vitro and in an in-vivo mouse model of established tumor. While further investigation is necessary to establish the mechanism and optimize the treatment protocol, these initial observations establish cold atmospheric plasma as a potentially useful ablative therapy in neuroblastoma.

Haitian earthquake relief: disaster response aboard the USNS comfort.

OBJECTIVE: The Haitian earthquake of January 12, 2010, was a disaster essentially unprecedented in the Western Hemisphere's recorded history. The USNS Comfort departed from Baltimore, Maryland, within 72 hours of the earthquake and arrived in Port-au-Prince harbor on January 19. During the subsequent 40 days, the ship provided one of the largest relief efforts in the US Navy's history. METHODS: The data analyzed included all patients evaluated and treated by the USNS Comfort between January 19 and February 27, 2010. A medical chart with a unique identifier was created for each patient on admission. A patient database was created from these records and used for this analysis. RESULTS: A total of 872 patients and 185 patient escorts were processed aboard the ship. Ages ranged from younger than 1 day to 89 years: 635 were adults and 237 were children. Of those admitted, 817 of the patients were admitted for longer than 24 hours; the average length of stay was 8.0 days. The need for surgery was substantial: 454 patients went to the operating room (OR) 843 times for 927 cumulative procedures. A total of 58 patients underwent amputations. CONCLUSIONS: Haiti was almost completely reliant on foreign medical teams for trauma care. Analysis of the data illustrates the challenges of triage and treatment in a humanitarian mass-casualty response. The remarkable coordination and cooperation among the Haitian Ministry of Health, nongovernmental humanitarian aid organizations, and the US military highlighted the responders' respective capabilities and demonstrated the importance of collaboration in future disaster response efforts.

Continuing promise 2009--assessment of a recent pediatric surgical humanitarian mission.

PURPOSE: Surgical organizations have begun to focus their efforts on providing humanitarian assistance in international communities. Most surgeons do not have previous international experience and lack an understanding of what is expected and what care they can provide. The unknown factors include case types, patient volume, postoperative care, and equipment. This abstract presents humanitarian assistance mission and highlights the importance of preparation, host nation involvement, and understanding the local politics of each country. METHODS: In April to July 2009, the USNS (United States Naval Ship) Comfort deployed to provide humanitarian assistance to 7 countries through Central and South America. Data collected included numbers and types of procedures, rate of rejection of patients for operation, patient age, American Society of Anesthesiology (ASA) score, and length of procedure. RESULTS: These data represent the total mission of Continuing Promise 2009 including a total of 1137 surgical procedures of which 340 were pediatric (<18 years old). The average number of pediatric cases for each country in 7 days was 48.3 ± 21.4, with a range of 24 to 84. The average age was 7.5 years (range, 1 month to 18 years). In partnership with host physicians, preoperative screening occurred over 2 to 3 days for every 7 operative days. We maintained a low threshold for rejection (rate of 43%; range, 21%-62%) and average ASA score of 1.3. Including all pediatric subspecialties, the most frequent procedures were inguinal (23%) and umbilical (14%) hernias. Although these were the most frequent procedure, the range and variety of cases varied widely. We had a very low early complication rate (1.2%), including 3 wound infections and 1 early hernia recurrence. CONCLUSIONS: Our data represent the largest collection to date on the pediatric surgical care of children in a humanitarian effort. Our experience can be used to identify the most likely types of cases in South and Central America and as a model for the safe and efficient treatment of children in a developing country.

T-cell activation is enhanced by targeting IL-10 cytokine production in toll-like receptor-stimulated macrophages.

Toll-like receptor (TLR) agonists represent potentially useful cancer vaccine adjuvants in their ability to stimulate antigen-presenting cells (APCs) and subsequently amplify the cytotoxic T-cell response. The purpose of this study was to characterize APC responses to TLR activation and to determine the subsequent effect on lymphocyte activation. We exposed murine primary bone marrow-derived macrophages to increasing concentrations of agonists to TLRs 2, 3, 4, and 9. This resulted in a dose-dependent increase in production of not only tumor necrosis factor-alpha (TNF-α), a surrogate marker of the proinflammatory response, but also interleukin 10 (IL-10), a well-described inhibitory cytokine. Importantly, IL-10 secretion was not induced by low concentrations of TLR agonists that readily produced TNF-α. We subsequently stimulated lymphocytes with anti-CD3 antibody in the presence of media from macrophages activated with higher doses of TLR agonists and observed suppression of interferon gamma release. Use of both IL-10 knockout macrophages and IL-10 small-interfering RNA (siRNA) ablated this suppressive effect. Finally, IL-10 siRNA was successfully used to suppress CpG-induced IL-10 production in vivo. We conclude that TLR-mediated APC stimulation can induce a paradoxical inhibitory effect on T-cell activation mediated by IL-10.

Three phases of disaster relief in Haiti--pediatric surgical care on board the United States Naval Ship Comfort.

BACKGROUND: On January 12, 2010, Haiti experienced the western hemisphere's worst-ever natural disaster. Within 24 hours, the United States Naval Ship Comfort received orders to respond, and a group of more than 500 physicians, nurses, and staff undertook the largest and most rapid triage and treatment since the inception of hospital ships. METHODS: These data represent pediatric surgical patients treated aboard the United States Naval Ship Comfort between January 19 and February 27, 2010. Prospective databases managed by patient administration, radiology, blood bank, laboratory services, and surgical services were combined to create an overall patient care database that was retrospectively reviewed for this analysis. RESULTS: Two hundred thirty-seven pediatric surgical patients were treated, representing 27% of the total patient population. These patients underwent a total of 213 operations composed of 243 unique procedures. Orthopedic procedures represented 71% of the total caseload. Patients returned to the operating room up to 11 times and required up to 28 days for completion of surgical management. CONCLUSIONS: This represents the largest cohort of pediatric surgical patients in an earthquake response. Our analysis provides a model for anticipating surgical caseload, injury patterns, and duration of surgical course in preparing for future disaster response missions. Moreover, we propose a 3-phased response to disaster medicine that has not been previously described.