Sevoflurane preconditioning in living liver donation is associated with better initial graft function after pediatric transplantation: a retrospective study.

INTRODUCTION: Initial allograft function determines the patient's immediate prognosis in pediatric liver transplantation. Ischemia-reperfusion injuries play a role in initial poor graft function (IPGF). In animal studies, preconditioning with inhaled anesthetic agents has demonstrated a protective effect on the liver. In humans, the few available studies are conflicting. This study assesses the association between the hypnotic agent used to maintain anesthesia during hepatectomy in living donors and the occurrence of IPGF after pediatric transplantation. METHODS: We conducted a single-center retrospective analysis of children who received a living donor liver transplant (LDLT) between 2010 and 2019. We analyzed the incidence of EAD according to the hypnotic agent used to maintain general anesthesia during donor hepatectomy. RESULTS: We included 183 pairs of patients (living donors-recipients). The anesthetics used in the donor were propofol (n = 85), sevoflurane (n = 69), or propofol with sevoflurane started 30 min before clamping (n = 29). Forty-two children (23%) developed IPGF. After multivariate logistic regression analysis, factors significantly associated with the occurrence of IPGF were the anesthesia maintenance agent used in the donor (p = 0.004), age of the donor (p = 0.03), duration of transplant surgery (p = 0.009), preoperative receiver neutrophil to lymphocyte ratio (p = 0.02), and albumin (p = 0.05). CONCLUSION: Significantly fewer children who received a graft from a donor in whom only sevoflurane was used to maintain anesthesia developed IPGF. Although additional research is needed, this preconditioning strategy may provide an option to prevent IPGF after living liver donation.

Implementing living-donor pediatric liver transplantation in Southern Vietnam: 15-year results and perspectives.

BACKGROUND: ND2 in Ho Chi Minh City is currently the only public center that performs PLT in Southern Vietnam. In 2005, the first PLT was successfully performed, with support from Belgian experts. This study reviews the implementation of PLT at our center and evaluates the results and challenges. METHODS: Implementation of PLT at ND2 required medico-surgical team building and extensive improvement of hospital facilities. Records of 13 transplant recipients from 2005 to 2020 were studied retrospectively. Short- and long-term complications, as well as the survival rates, were reported. RESULTS: The mean follow-up time was 8.3 ± 5.7 years. Surgical complications included one case of hepatic artery thrombosis that was successfully repaired, one case of colon perforation resulting in death from sepsis, and two cases of bile leak that were drained surgically. PTLD was observed in five patients, of whom three died. There were no cases of retransplantation. The 1-year, 5-year, and 10-year patient survival rates were 84.6%, 69.2%, and 69.2%, respectively. There were no cases of complication or death among the donors. CONCLUSION: Living-donor PLT was developed at ND2 for providing a life-saving treatment to children with end-stage liver disease. Early surgical complication rate was low, and the patient survival rate was satisfactory at 1 year. Long-term survival decreased considerably due to PTLD. Future challenges include surgical autonomy and improvement of long-term medical follow-up with a particular emphasis on prevention and management of Epstein-Barr virus-related disease.

Regional oxygen saturation measured by two different oximetry monitors in infants and children undergoing living donor liver transplantation with bilirubin measurements: A prospective observational study.

BACKGROUND: Tissue oximetry devices use wavelengths in the 680-870 nm range to separate between oxygenated/deoxygenated hemoglobin. Conjugated bilirubin has an absorption peak at 730 nm. AIMS: We hypothesized that ForeSight Elite using 5 wavelengths reduces interference from bilirubin and shows higher regional tissue oxygen saturation (rSO2 ) than INVOS 5100C incorporating 2 wavelengths. METHODS: Infants and children undergoing living donor liver transplantation were included between March 2019 and September 2020. Cerebral and somatic rSO2 were measured, and real-time simultaneous data were collected. Additionally, measurements were collected at (1) baseline, (2) beginning of dissection phase, (3) beginning of anhepatic phase, (4) reperfusion phase, and (5) skin closure. Bilirubin level was available at baseline and at reperfusion. Hyperbilirubinemia was defined as bilirubin level ≥1.0 mg/dl. RESULTS: Thirty-three patients with median age of 27 months and median weight of 12 kg were included. Baseline bilirubin levels were higher compared to values at reperfusion (p = .021). A linear mixed effects model considering bilirubin as fixed and patient as random effect showed that there was a statistically significant difference in cerebral rSO2 readings in function of time (p = .031), device (p < .001), and bilirubin concentrations (p = .007) but not for hemoglobin (p = .347), SpO2 (p = .882), and arterial partial pressure of CO2 (Pa CO2 ) (p = .146). The model showed that there was a statistically significant difference in somatic rSO2 readings in function of device (p < .001) and bilirubin concentrations (p = .023) but not for time (p = .074), hemoglobin (p = .954), SpO2 (p = .108), and Pa CO2 (p = .775). Bland-Altman plot analyzing cerebral and somatic rSO2 between both devices showed respectively a mean absolute bias and 95% limits of agreement of 21.73% (-10.21 to 53.67) and 19.52% (-29.51 to 68.54). CONCLUSIONS: Oximetry devices emitting light at >2 wavelengths may overcome interference from hyperbilirubinemia providing higher rSO2 readings.

Esophageal Trachea, a Unique Foregut Malformation Requiring Multistage Surgical Reconstruction: Case Report.

Abnormal connections between the esophagus and low respiratory tract can result from embryological defects in foregut development. Beyond well-known malformations, including tracheo-esophageal fistula and laryngo-tracheo-esophageal cleft, rarer anomalies have also been reported, including communicating bronchopulmonary foregut malformations and tracheal atresia. Herein, we describe a case of what we have called "esophageal trachea," which, to our knowledge, has yet to be reported. A full-term neonate was born in our institution presenting with a foregut malformation involving both the middle esophagus and the distal trachea, which were found to be longitudinally merged into a common segment, 3 cm in length, located just above the carina and consisted of esophageal tissue without cartilaginous rings. At birth, the esophagus and trachea were surgically separated via right thoracotomy, the common segment kept on the tracheal side only, creating a residual long-gap esophageal atresia. The resulting severe tracheomalacia was treated via simultaneous posterior splinting of such diseased segment using an autologous pericardium patch, as well as by anterior aortopexy. Terminal esophagostomy and gastrostomy were created at that stage due to the long distance between esophageal segments. Between ages 18 and 24 months, the patient underwent native esophageal reconstruction using a multistage traction-and-growth surgical strategy that combined Kimura extra-thoracic esophageal elongations at the upper esophagus and Foker external traction at the distal esophagus. Ten months after esophageal reconstruction, prolonged, refractory, and severe tracheomalacia was further treated via anterior external stenting using a semitubular ringed Gore-Tex® prosthesis, through simultaneous median sternotomy and tracheoscopy. Currently, 2 years after the last surgery, respiratory stabilization, and full oral feeding were stably achieved. Multidisciplinary management was crucial for assuring lifesaving procedures, correctly assessing anatomy, and planning for multiple sequential surgical approaches that aimed to restore long-term respiratory and digestive functions.

Novel insights into the assessment of risk of upper gastrointestinal bleeding in decompensated cirrhotic children.

OBJECTIVES: Cirrhotic children wait-listed for liver transplant are prone to bleeding from gastrointestinal varices. Grade 2-3 esophageal varices, red signs, and gastric varices are well-known risk factors. However, the involvement of hemostatic factors remains controversial because of the rebalanced state of coagulation during cirrhosis. METHODS: Children suffering from decompensated cirrhosis were prospectively included while being on waitlist. Portal hypertension was assessed by ultrasound and endoscopy. Coagulopathy was evaluated through conventional tests, thromboelastometry, and platelet function testing. The included children were followed up until liver transplantation, and all bleeding episodes were recorded. Children with or without bleeding were compared according to clinical, radiological, endoscopic, and biological parameters. In addition, validation of a predictive model for risk of variceal bleeding comprising of grade 2-3 esophageal varices, red spots, and fibrinogen level <150 mg/dL was applied on this cohort. RESULTS: Of 20 enrolled children, 6 had upper gastrointestinal bleeding. Significant differences were observed in fibrinogen level, adenosine diphosphate, and thrombin-dependent platelet aggregation. The model used to compute the upper gastrointestinal bleeding risk had an estimated predictive performance of 81.0%. Platelet aggregation analysis addition improved the estimated predictive performance up to 89.0%. CONCLUSIONS: We demonstrated an association between hemostatic factors and the upper gastrointestinal bleeding risk. A low fibrinogen level and platelet aggregation dysfunction may predict the risk of bleeding in children with decompensated cirrhosis. A predictive model is available to assess the upper gastrointestinal bleeding risk but needs further investigations. Clinicaltrials.gov number: NCT03244332.

Lung Middle Lobe Laceration Needing Lobectomy as Complication of Nuss Bar Removal.

Minimally invasive procedure for the treatment of pectus excavatum as described by Nuss has been used from 1987. The bar initially introduced blindly is now introduced under thoracoscopic control to increase safety of the procedure. It is usually removed two to three years after its insertion in a one-day procedure. Complications of the bar removal are rare but potentially serious. We report the case of a serious complication which occurred immediately after the Nuss bar removal. A 15-year-old boy underwent a Nuss procedure for a severe pectus excavatum without relevant complication. The bar has been removed two years after its insertion in a minimally invasive procedure. Unfortunately, he developed in the immediate postoperative period a hemopneumothorax due to a right middle lobe laceration which required a middle lobectomy by thoracotomy for hemostasis. Lesions of intrathoracic organs are a rare but potentially serious complication of the removal of the Nuss bar. We now propose to perform this procedure under thoracoscopic control to avoid it. In our experience, adhesions between the bar and the pleura are always present, and those with potential risk for bleeding or inducing intrathoracic organ lesions are suppressed prior to the bar removal.

Liver and systemic hemodynamics in children with cirrhosis: Impact on the surgical management in pediatric living donor liver transplantation.

Cirrhosis in adults is associated with modifications of systemic and liver hemodynamics, whereas little is known about the pediatric population. The aim of this work was to investigate whether alterations of hepatic and systemic hemodynamics were correlated with cirrhosis severity in children. The impact of hemodynamic findings on surgical management in pediatric living donor liver transplantation (LT) was evaluated. Liver and systemic hemodynamics were studied prospectively in 52 children (median age, 1 year; 33 with biliary atresia [BA]). The hemodynamics of native liver were studied preoperatively by Doppler ultrasound and intraoperatively using invasive flowmetry. Portosystemic gradient was invasively measured. Systemic hemodynamics were studied preoperatively by Doppler transthoracic echocardiography and intraoperatively by using transpulmonary thermodilution. Hemodynamic parameters were correlated with Pediatric End-Stage Liver Disease (PELD) score and the histological degree of fibrosis (collagen proportionate area [CPA]). Cirrhosis was associated with a 60% reduction of pretransplant total liver flow (n = 46; median, 36 mL/minute/100 g of liver) compared with noncirrhotic livers (n = 6; median, 86 mL/minute/100 g; P = 0.002). Total blood flow into the native liver was negatively correlated with PELD (P < 0.001) and liver CPA (P = 0.005). Median portosystemic gradient was 14.5 mm Hg in children with cirrhosis and positively correlated with PELD (P < 0.001). Portal vein (PV) hypoplasia was observed mainly in children with BA (P = 0.02). Systemic hemodynamics were not altered in our children with cirrhosis. Twenty-one children met the intraoperative criteria for PV reconstruction using a portoplasty technique during the LT procedure and had a smaller PV diameter at pretransplant Doppler ultrasound (median = 3.4 mm; P < 0.001). Cirrhosis in children appears also as a hemodynamic disease of the liver, correlated with cirrhosis severity. Surgical technique for PV reconstruction during LT was adapted accordingly. Liver Transplantation 23 1440-1450 2017 AASLD.

Evaluation of the Explorer Endoscopy Mask(©) for esogastroduodenoscopy in children: a retrospective study of 173 cases.

AIMS: The aim of this study was to evaluate the usability and safety of the Explorer Endoscopy Mask(®) (EM) as an alternative to endotracheal intubation in children undergoing elective esogastroduodenoscopy (EGD) under general anesthesia (GA). METHODS: This study was a retrospective observational study. The study was undertaken at the pediatric digestive endoscopy suite in the Cliniques universitaires Saint-Luc, Brussels, Belgium. We retrospectively analyzed the occurrence of minor and major airway-related adverse effects during pediatric EGD procedures performed under GA with the EM between June 2014 and March 2015. RESULTS: During the study period, 173 patients underwent EGD. Their mean age was 8.4 years (median: 9.1 years, range 4 months to 16 years). Mean duration of endoscopy (from insertion to removal of the endoscope) was 12.6 min (median: 12 min, range 3-47 min). The use of EM was uneventful in 159 (92%) cases. There were 24 airway-related adverse events in 14 children. Hypoxemia (SpO2 <90%) (13 events, 7.5%) was the most commonly encountered complication followed by laryngo- or bronchospasm (five events, 2.89%), cough (five events, 2.89%), and intubation (one event, 0.58%). No cases of regurgitation/aspiration were observed. CONCLUSIONS: Our data support the EM use in pediatric EGD. There were few transient respiratory adverse events which were easily solved with minor interventions.

Guidelines on the use of ultrasound guidance for vascular access.

Insertion of vascular access is a common procedure with potential for iatrogenic events, some of which can be serious. The spread of ultrasound scanners in operating rooms, intensive care units and emergency departments has made ultrasound-guided catheterisation possible. The first guidelines were published a decade ago but are not always followed in France. The French Society of Anaesthesia and Intensive Care has decided to adopt a position on this issue through its Guidelines Committee in order to propose a limited number of simple guidelines. The method used was the GRADE(®) method using the most recently published meta-analyses as the source of references. The level of evidence found ranged from low to high and all the positive aspects associated with ultrasound guidance, i.e. fewer traumatic complications at puncture, probably or definitely outweigh the potential adverse consequences regardless of whether an adult or child is involved and regardless of the site of insertion.

Living Donor Liver Transplantation in Children: Surgical and Immunological Results in 250 Recipients at Université Catholique de Louvain.

OBJECTIVES: To evaluate the outcome of pediatric living donor liver transplantation (LDLT) regarding portal vein (PV) reconstruction, ABO compatibility, and impact of maternal donation on graft acceptance. BACKGROUND: LDLT and ABO-mismatched transplantation constitute feasible options to alleviate organ shortage in children. Vascular complications of portal hypoplasia in biliary atresia (BA) and acute rejection (AR) are still major concerns in this field. METHODS: Data from 250 pediatric LDLT recipients, performed at Cliniques Universitaires Saint-Luc between July 1993 and June 2012, were collected retrospectively. Results were analyzed according to ABO matching and PV complications. Uni- and multivariate analyses were performed to study the impact of immunosuppression, sex matching, and maternal donation on AR rate. RESULTS: Overall, the 10-year patient survival rate was 93.2%. Neither patient or graft loss nor vascular rejection, nor hemolysis, was encountered in the ABO nonidentical patients (n = 58), provided pretransplant levels of relevant isoagglutinins were below 1/16. In BA recipients, the rate of PV complications was lower after portoplasty (4.6%) than after truncal PV anastomosis (9.8%) and to jump graft interposition (26.9%; P = 0.027). In parental donation, maternal grafts were associated with higher 1-year AR-free survival (55.2%) than paternal grafts (39.8%; P = 0.041), but only in BA patients. CONCLUSIONS: LDLT, including ABO-mismatched transplantation, constitutes a safe and efficient therapy for liver failure in children. In BA patients with PV hypoplasia, portoplasty seems to constitute the best technique for PV reconstruction. Maternal donation might be a protective factor for AR.

International evidence-based recommendations on ultrasound-guided vascular access.

PURPOSE: To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access. METHODS: An international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations. RESULTS: The recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter's tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications. CONCLUSIONS: These definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

Vascular access in the neonate.

Up to recently, inserting venous or arterial 'lines' in the neonate was essentially based on clinical skill and experience. The recent advent of portable ultrasound (US) machines with paediatric probes has resulted in the development of new approaches that, if correctly learned and used, should allow quicker and safer vascular access in this population. Both classic and new techniques are reviewed on the basis of literature and authors' experience.

Ultrasound-guided proximal and distal sciatic nerve blocks in children.

STUDY OBJECTIVE: To present the use of ultrasonography for the performance of proximal subgluteal and distal sciatic nerve blocks in children. DESIGN: Prospective descriptive study. SETTING: University hospital. PATIENTS: 45 ASA physical status I, II, and III patients, aged between 8 months and 16 years, scheduled for lower limb surgery. INTERVENTIONS: During general anesthesia, proximal, subgluteal, and distal sciatic nerve blocks using ultrasonography were performed. If severe postoperative pain was expected, a catheter technique was used. MEASUREMENTS: The injected amount of local anesthetic was noted. Based on the spread of local anesthetic, prediction for successful block was made. Complications, adverse effects, postoperative pain scores, and parent satisfaction scores were noted. MAIN RESULTS: 21 proximal sciatic nerve blocks (12 single-injection and 9 continuous blocks) and 35 distal sciatic nerve blocks (17 single-injection, 6 bilateral single-injection, 4 continuous, and one bilateral continuous block) were performed. A mean initial dose of 0.25 mL.kg(-1) of ropivacaine 0.375% was injected. A successful block was obtained in all children. Excellent postoperative pain relief was obtained. All parents were satisfied with the postoperative pain relief. No complications occurred. CONCLUSION: Ultrasonography is useful in the identification of the sciatic nerve and it facilitates needle and catheter placement for proximal and distal nerve blocks in children.

Nasal foreign bodies in children: a possible pitfall for the anesthesiologist.

Based on a recent surprising case in our institution, we analyze the possible dislodgment of an unknown foreign body in the nose during nasotracheal intubation in children. Nasal foreign bodies made of inert material can remain unnoticed for a long period of time. In addition to inserting a close-fitting suction catheter into the TT during its passage through the nasopharynx, we now suggest performing a pharyngoscopy when intubation is completed.