Large Bowel Internal Hernia Secondary to Reimplanted Ureter.

Internal hernias are difficult to diagnose clinically, and normal cross-sectional imaging has been documented in many patients. Transmesenteric hernias from congenital defects or prior abdominal surgery are most common. A 46-year-old previously healthy female presented to the emergency department with acute onset nausea and vomiting eight years after a right ureteral transection during a laparoscopic hysterectomy, with a delayed ureterolysis and reimplantation into the bladder. Rectal contrast CT scan demonstrated a partial large bowel obstruction that was unclear if it was due to an underlying mass, stricture, or internal herniation. The patient was taken for exploratory laparotomy which demonstrated redundant transverse colon herniated under the mobile right ureter; an extended right hemicolectomy was performed. This report describes alteration of retroperitoneal anatomy creating a potential space for colonic herniation and emphasizes that clinical suspicion must remain high for patients presenting with obstructive or partially obstructive symptoms.

Neonatal Carotid Artery and Internal Jugular Vein Management Practices at Extracorporeal Membrane Oxygenation Decannulation: No Standard Approach.

BACKGROUND: There are currently no commonly accepted standardized guidelines for management of cervical vessels at neonatal extracorporeal membrane oxygenation (ECMO) decannulation. This study investigates neonatal ECMO decannulation practices regarding management of the carotid artery and internal jugular vein, use of post-repair anticoagulation, and follow-up imaging. METHODS: A survey was distributed to the 37 institutions in the Children's Hospitals Neonatal Consortium. Respondents reported their standard approach to carotid artery and internal jugular vein management (ligation or repair) at ECMO decannulation by their pediatric surgery and cardiothoracic (CT) surgery teams as well as post-repair anticoagulation practices and follow-up imaging protocols. RESULTS: The response rate was 95%. Pediatric surgeons performed most neonatal respiratory ECMO cannulations (88%) and decannulations (85%), while all neonatal cardiac ECMO cannulations and decannulations were performed by CT surgeons. Pediatric surgeons overwhelmingly ligate both vessels (90%) while CT surgeons typically repair both vessels at decannulation (83%). Of the responding centers that repair, 28% (7) have a standard anticoagulation protocol after neck vessel repair. While 52% (13) of centers routinely image cervical vessel patency at least once post repair, most do not subsequently repeat neck vessel imaging. CONCLUSIONS: Significant practice differences exist between pediatric and CT surgeons regarding the approach to cervical vessels at neonatal ECMO decannulation. For those centers that do repair the vessels there is little uniformity in post-repair anticoagulation or imaging protocols. There is a need to develop standardized cervical vessel management guidelines for neonatal ECMO patients and to study their impact on both short- and long-term outcomes. LEVEL OF EVIDENCE: IV.

The Use of the Perioperative Nutrition Score in Postoperative Pediatric Inflammatory Bowel Disease Patients.

BACKGROUND AND OBJECTIVES: Preoperative malnutrition is associated with increased postoperative morbidity. The perioperative nutrition score (PONS) was developed to identify patients at risk of malnutrition. We sought to assess the correlation between preoperative PONS and postoperative outcomes in pediatric inflammatory bowel disease (IBD) patients. METHODS: We performed a retrospective cohort study of IBD patients, less than 21 years of age, who underwent elective bowel resection between June 2018 and November 2021. Patients were divided based upon whether they met PONS criteria. The primary outcome was postoperative surgical site infections. RESULTS: 96 patients were included. Sixty-one patients (64%) met at least one PONS criteria, while 35 patients (36%) met none. PONS positive patients more frequently received preoperative TPN supplementation (p < .001). There was no difference in preoperative oral nutritional supplementation between groups. Patients that screened positive for PONS had a longer hospital stay (p = .002), more readmissions (p = .029), and more surgical site infections (p = .002). CONCLUSIONS: Our data highlight the prevalence of malnutrition in the pediatric IBD population. Patients who screened positive had worse postoperative outcomes. Further, very few of these patients received preoperative optimization with oral nutritional supplementation. There is a need for standardization of nutritional evaluation to improve preoperative nutritional status and postoperative outcomes. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Retrospective Cohort.

Enteral tube feeding selection at NICU discharge and resource utilization.

OBJECTIVE: To evaluate resource utilization in infants discharged with different forms of feeding access. STUDY DESIGN: Retrospective chart review of neonates discharged from 2012 to 2018. Data were collected from the medical record and relevant outcomes were compared. RESULTS: 300 patients were sampled. 196 (65%) were discharged on NG feeds, 95 (32%) via GT, and 9 gastrojejunal (GJ 3%). NG-fed infants discharged sooner (mean DOL: NG = 85.4 vs GT = 122.8, p < 0.001). More GT/GJ patients required emergency department (ED) visits for tube complications (GT = 61 vs GJ = 7 vs NG = 42, p < 0.001) and more frequently (mean visits: GT = 1.63 ± 2.33 vs GJ = 4.22 ± 4.44 vs NG = 0.48 ± 1.40, p < 0.001). However, 44 (24%) of the patients discharged on NG later had a GT placed. CONCLUSIONS: Many patients discharged from the NICU can be supported with NG feeds. This may shorten hospital stays and decrease ED visits but select patients will later merit surgical tube placement.

Impedance planimetry (EndoFLIP) assisted laparoscopic esophagomyotomy in pediatric population.

INTRODUCTION: Functional lumen imaging probe (EndoFLIP) is a diagnostic technology that assesses esophageal cross-sectional area via impedance planimetry during controlled volumetric distention. The purpose of this study is to evaluate the utility of EndoFLIP intraoperatively during laparoscopic esophagomyotomy. METHODS: We performed a retrospective cohort study reviewing all patients undergoing EndoFLIP assisted laparoscopic esophagomyotomy for achalasia between January and December 2021 (n = 10). Twenty-two patients with achalasia that underwent traditional laparoscopic esophagomyotomy between July 2014 and September 2019 served as a comparison. Primary outcome evaluated was resolution of symptoms at discharge. Secondary outcomes included change in distensibility index (DI), operative time, length of stay, time to regular diet, and reinterventions. RESULTS: All patients managed with EndoFLIP assistance had resolution of dysphagia and postprandial vomiting following intervention. Mean change in DI was 5.32 mm2/mmHg with a myotomy length of 3.6 cm. Operative time was shorter in the EndoFLIP cohort (97 min versus 185 min, p = <0.001). Study patients did not undergo an antireflux operation. There was no difference in length of stay or time to soft diet between groups. All patients were discharged on postoperative day 1 tolerating a mechanical soft diet. No acid suppressive medications were prescribed during the observation period. One patient required dilation for recurrent symptoms and one required reoperation for mucosal leak. CONCLUSION: EndoFLIP assisted laparoscopic esophagomyotomy results in similar short-term outcomes to traditional surgical technique. EndoFLIP allows for focused myotomy length and a shorter operative time. LEVEL OF EVIDENCE: III.

Pain after Arteriovenous Access Creation.

OBJECTIVES: Dialysis access creation is a common outpatient procedure that can be completed using general, regional, or local anesthetic techniques. There are few endorsed guidelines regarding opioid-based pain control following fistula creation. The purpose of this study was to determine whether utilization of regional anesthesia (RA) is associated with the decreased use of narcotics postoperatively. METHODS: We performed a prospective cohort study including all patients undergoing arteriovenous fistula creation with one vascular surgeon from August 2019 to February 2020. Patients were selected for regional versus general anesthesia. Selection for anesthesia type was determined by the primary anesthesiologist. Patients selected for RA underwent supraclavicular brachial plexus block with 30 cm3 of 0.5% ropivacaine. Patients were seen in clinic follow-up and completed a questionnaire regarding their postoperative opiate use and pain control. RESULTS: In the study period, 52 patients underwent arteriovenous fistula creation and completed the follow-up questionnaire. Forty patients received RA. Seventy-five percent of patients sent home with a narcotic prescription filled the prescription. There was a significant difference in postoperative opioid use between the two study groups. Patients who received regional block took on average 3.3 pills totaling 16.5 morphine milligram equivalents, whereas patients who received general anesthesia took on average 6.64 pills totaling 33.2 morphine milligram equivalents (P = 0.04). CONCLUSIONS: Morbidity and mortality related to opiate use continues to be a public health issue in the United States. This study demonstrates that regional anesthetic techniques in comparison to general anesthesia can result in a significant decrease in postoperative opiate consumption.

Impact of coronavirus disease 2019 (COVID-19) on trauma surgical education at a level I trauma center.

BACKGROUND: During the coronavirus disease 2019 pandemic, trauma presentations to the emergency room decreased across the country. The goal of this study is to analyze the educational impact of coronavirus disease 2019 on trauma education and training at a level I trauma center. METHODS: Trauma patient presentations were analyzed 6 months before a Tennessee executive stay-at-home order and 6 months after the state executive order. To control for the seasonal trauma volumes, an additional 6 months before the executive order was then analyzed comparing month to month. Total number of presentations, demographics, procedures, airway management, and coronavirus disease 2019 status of patients and residents were analyzed. RESULTS: The number of trauma presentations were sustained after executive orders at our level I trauma center. There was no significant difference in intubations, central line placements, and chest tube placements before and during the pandemic. Blunt trauma decreased after stay-at-home orders. Of the 36 residents, no residents tested positive during the study period. CONCLUSION: Trauma-focused surgical education was not affected at an academic level I trauma center. Understanding that it is region, city, and hospital specific, this study shows that quality trauma education can continue throughout the coronavirus disease 2019 pandemic while keeping trainees safe. Proper airway management, personal protective equipment, social distancing, and coronavirus disease 2019-preventative protocols seem to protect residents from potential harm while allowing them to participate and continue in quality trauma education and training.