Outcomes of laparoscopic and open ventriculoperitoneal shunt placement.

OBJECTIVE: Ventriculoperitoneal (VP) shunt placement requires a concurrent abdominal procedure. For peritoneal access laparoscopic or open approach may be utilized. Our aim was to compare patient/procedure characteristics and outcomes by peritoneal approach for VP shunts in children. METHODS: NSQIP-Pediatric procedure targeted cerebral spinal fluid shunt Participant Use Data Files from 2016 to 2020 were queried. Patients were grouped into laparoscopic vs open abdominal approach. Patient demographics, procedure characteristics and 30-day outcomes were compared. RESULTS: 7742 NSQIP-Pediatric patients underwent VP shunt placement. Patients undergoing laparoscopic approach were older and required less preoperative support. Mean operative time was longer with laparoscopy (mean(SD): 74.2(48.1) vs. 64.6(39) minutes, p â€‹< â€‹0.0001) but had shorter hospital LOS. There was no difference in SSI, readmissions, or reoperation rates. CONCLUSION: Patients undergoing laparoscopy for distal VP shunts are older with less support needs preoperatively. While laparoscopic approach had a shorter hospital LOS, there was no demonstratable difference in SSI, readmissions or reoperations between approaches. Further studies are needed to assess long-term outcomes.

The impact of abnormal BMI on surgical complications after pediatric colorectal surgery.

BACKGROUND/PURPOSE: While childhood obesity is a growing problem, the implications of BMI on elective pediatric surgery remains poorly described. This study evaluates the impact of obesity on surgical outcomes after elective colorectal procedures. METHODS: Children ages 2-18 years undergoing elective colorectal surgery for IBD were identified from the NSQIP-Pediatric database. Patients were classified as underweight (UW), normal weight (NW), overweight (OW) and obese (OB) based on their age- and sex-adjusted BMI. Postoperative complications were compared between cohorts. RESULTS: 858 patients (14.8% UW, 64.3% NW, 13.1% OW, 7.8% OB) were identified, with overall complications occurring in 15.3% and SSI in 10.1%. Obese/overweight patients had higher rates of deep incisional SSI (4.5%OB, 4.5%OW, 0%NW, p=0.002) and superficial wound disruption (5.4%OB, 5.8%OW, 1.6%NW, p=0.04). Incremental increase in BMI by 1.0kg/m2 was associated with 4.3% increased likelihood of developing deep incisional SSI and 2.3% increase of superficial wound disruption. Obese/overweight children also had increased incidence of septic shock and UTI, as well as longer operative times, days of mechanical ventilation and LOS. CONCLUSIONS: Increasing BMI was associated with increased wound complications in IBD patients undergoing elective intestinal surgery. Preoperative optimization and weight loss strategies may potentially reduce SSI and other infectious complications. LEVEL OF EVIDENCE: III.

Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial.

PURPOSE: To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis. METHODS: This was a randomized controlled trial of patients aged 4-17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I-contained perforation, II-localized contamination to right gutter/pelvis, and III-diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin-clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared. RESULTS: Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3 ± 3.6 versus 10.1 ± 3.6, p < 0.05) with higher BMI (20.9 ± 5.8 versus 17.9 ± 3.5, p < 0.05). There were no differences in gender, comorbidities, or perforation grade (I-20.4% vs. 26.3%, II-36.4% vs. 34.2%, III-43.2% vs. 39.5%, all p > 0.05). Comparing IV to oral, there was no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days, p > 0.05), postoperative abscess rate (11.6% vs. 8.1%, p > 0.05), or readmission rate (14.0% vs. 16.2%, p > 0.05). Hospital and outpatient charges were higher in the IV group (p < 0.0001). CONCLUSION: Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.

Thoracoscopic Versus Open Congenital Diaphragmatic Hernia Repair: Single Tertiary Center Review.

BACKGROUND: Congenital diaphragmatic hernia (CDH) can be repaired open or through thoracoscopy. Thoracoscopic CDH repair could improve cosmesis and avoid the complications of laparotomy, but may have higher recurrence rates. The purpose of this study was to examine the outcomes of thoracoscopic versus open CDH repair, with regard to recurrence, perioperative parameters, and postoperative complications. METHODS: We performed a retrospective review of open versus thoracoscopic CDH repairs over an 8.5-year period. The primary outcome was hernia recurrence. Secondary outcomes included intraoperative partial pressure of carbon dioxide (pCO2) levels, length of stay, and postoperative complications. All statistical analyses were performed using standard statistical methods. RESULTS: A total of 54 infants underwent CDH repair during the study period, of whom 25 underwent successful thoracoscopic repair. Two patients who had undergone open repair developed recurrent diaphragmatic hernias (recurrence rate 3.7%). Operative time and intraoperative pCO2 levels did not differ between groups. Length of stay was shorter in the thoracoscopic cohort. Four patients in the open cohort developed ventral hernias and five developed bowel obstructions during follow-up. No long-term complications were identified in the thoracoscopic cohort. The median follow-up was 27 months. CONCLUSIONS: In our experience, thoracoscopic CDH repair was performed safely and with similar outcomes compared to open repair. In addition to improved cosmesis, thoracoscopic repair may avoid some of the long-term complications of laparotomy. In our series, none of the thoracoscopic CDH repairs recurred. We conclude that thoracoscopic CDH repair is a safe and appropriate technique for select neonates.

National Trends in the Surgical Treatment of Ovarian Torsion in Children: An Analysis of 2041 Pediatric Patients Utilizing the Nationwide Inpatient Sample.

The aim of this study was to evaluate the national trends in surgical management of ovarian torsion (OT) in children. The Nationwide Inpatient Sample was queried from 1998 to 2011 for females less than 18 years of age with OT. Patients were stratified into three treatment groups: oophorectomy (OO), oophoropexy, or release of torsion (RT) alone. There were 2041 patients with OT, of which 1598 (78%) underwent OO, 126 (6%) oophoropexy, and 317 (15%) RT. RT significantly increased from 1998 to 2011 (9% vs 25%; P < 0.05). At nonteaching hospitals, there were higher rates of OO (89.3% vs 79.5%; P < 0.05) and lower rates of RT (10.7% vs 20.5%; P < 0.05) compared with teaching hospitals. RT was performed at a higher rate in Northeast United States compared with the South (22.7% vs 14.2%; P < 0.05). Girls presenting at nonteaching hospitals and the South had increased odds of undergoing OO compared with those presenting at teaching hospitals and the Northeast (P < 0.05). Although ovarian conservation for OT in children is more often performed in the Northeast United States and at teaching hospitals, this large population-based study demonstrates OO remains the most common surgical management for OT in the United States.

Adenosine A2A receptor agonist improves cardiac dysfunction from pulmonary ischemia-reperfusion injury.

BACKGROUND: Ischemia-reperfusion (IR) injury negatively impacts patient outcome in lung transplantation. Clinically, we observed that lung transplant patients with ischemia-reperfusion injury tend to have cardiac dysfunction. Previous studies have shown that ATL-146e (4-{3-[6-amino-9-(5-ethylcarbamoyl-3,4-dihydroxy-tetrahydro-furan-2-yl)-9H-purin-2-yl]-prop-2-ynyl}-cyclohexanecarboxylic acid methyl ester), a selective adenosine A2A receptor agonist, reduces lung inflammation after ischemia-reperfusion. We hypothesized that pulmonary ischemia-reperfusion causes secondary heart dysfunction and ATL-146e will improve this dysfunction. METHODS: We utilized an in vivo rabbit lung ischemia-reperfusion model. The Sham group underwent 120 minutes single lung ventilation. The IR and ATL groups underwent 90 minutes right lung ischemia with 30 minutes right lung reperfusion. The ATL-146e was given intravenously to the ATL group during reperfusion. Cardiac output and arterial blood gases were monitored, and neutrophil sequestration was measured by myeloperoxidase activity. RESULTS: Upon reperfusion, cardiac output (mL/min) significantly dropped in the IR and ATL groups. By 15 minutes reperfusion, cardiac output in the ATL group improved significantly over the IR group and remained significant thereafter. Lung myeloperoxidase activity was significantly reduced by ATL-146e. Although never hypoxemic, arterial oxygenation was lower in the IR and ATL groups while central venous pressures and mean arterial pressures were similar among groups. A separate experiment demonstrated that reperfusion with the antioxidant N-(2-mercaptopropionyl)glycine prevented cardiac dysfunction. CONCLUSIONS: Pulmonary ischemia-reperfusion causes cardiac dysfunction independent of preload, afterload, and oxygenation. The ATL-146e improves this dysfunction presumably by the antiinflammatory effects of adenosine A2A receptor activation on neutrophils. One likely mechanism involves the release of oxidants from the ischemic lung upon reperfusion, which has immediate negative effects on the heart.

Predictors of patients who will develop prolonged occult hypoperfusion following blunt trauma.

BACKGROUND: Prolonged occult hypoperfusion or POH (serum lactate >2.4 mmol/L persisting >12 hours from admission) represents a reversible risk factor for adverse outcomes following traumatic injury. We hypothesized that patients at increased risk for POH could be identified at the time of admission. METHODS: Prospective data from adult trauma admissions between January 1, 1998 and December 31, 2000 were analyzed. Potential risk factors for POH were determined by univariate analysis (p < or =0.10= significant). Significant factors were tested in a logistic regression model (LR) (p < or =0.05= significant). The predictive ability of the LR was tested by receiver operating curve (ROC) analysis (p < or =0.05= significant). RESULTS: Three hundred seventy-eight patients were analyzed, 129 with POH. Injury Severity Score (ISS), emergency department Glasgow Coma Scale score, hypotension, and the individual Abbreviated Injury Scale score (AIS) for Head (H), Abdominal/Pelvic Viscera (A) and Pelvis/Bony Extremity (P) were significantly associated with POH. LR demonstrated that ISS, A-AIS > or =3 and P-AIS > or =3 were independent predictors of POH (p <0.05). ROC analysis of the LR equation was statistically significant (Area=0.69, p <0.001). CONCLUSIONS: We identified factors at admission that placed patients at higher risk for developing POH. Select patients may benefit from rapid, aggressive monitoring and resuscitation, possibly preventing POH and its associated morbidity and mortality.

Differential local and systemic tumor necrosis factor-alpha responses to a second hit of lipopolysaccharide after hemorrhagic shock.

BACKGROUND: The immune response to subsequent stressors after traumatic hemorrhage and resuscitation (HR) may be dependent on timing and counterinflammatory cytokine expression. Our hypothesis was that the timing of the second hit would influence the immune response, and we investigated whether an early second stimulus after HR would result in worse acute lung injury. METHODS: One hour after HR or sham shock (Sham), mice were given intraperitoneal (IP) injections of lipopolysaccharide (LPS) or saline (Sal). Mortality, pulmonary function (PF), bronchoalveolar lavage neutrophil infiltration, and bronchoalveolar lavage (BAL), in addition to serum interleukin (IL)-10, IL-6, and tumor necrosis factor-alpha (TNF-alpha), were assessed. RESULTS: HR blunted serum TNF-alpha expression to LPS (HR+LPS, 424.8 pg/mL; Sham+LPS, 2,248.8 pg/mL; p < 0.05), but primed for increased bronchoalveolar lavage TNF-alpha (HR+LPS, 259.5 pg/mL; Sham+LPS, 23.5 pg/mL; p < 0.05). Elevated serum TNF-alpha corresponded with greater bronchoalveolar lavage neutrophil infiltration (HR+LPS, 0.93%; Sham+LPS, 17.5%; p < 0.05). IL-10 expression was similar in HR and Sham. There were no significant differences in mortality or PF between HR+LPS and Sham+LPS. CONCLUSION: Priming and blunting of the LPS-induced TNF-alpha response occurred concomitantly in two-hit mice, corresponding to an altered pattern of pulmonary inflammation, but no change in PF.

Young versus old: factors affecting mortality after blunt traumatic injury.

Advanced age predicts poor outcome after trauma. We have previously demonstrated that prolonged occult hypoperfusion (POH), defined as serum lactic acid >2.4 mmol/L persisting for >12 hours, is also associated with worse outcomes. We hypothesized that older patients--a group with potentially less physiologic reserve--would be at greater risk from POH. Prospective data from adult blunt trauma patients admitted to a surgical/trauma intensive care unit from January 1, 1998 through December 31, 1999 were analyzed. Mortality, POH, Injury Severity Score (ISS), chronic health designation (CH) from the Acute Physiology and Chronic Health Evaluation, emergency department Glasgow Coma Scale score (EDGCS), emergency department systolic blood pressure (EDSBP), and gender were compared between older (>55 years) and younger (<56 years) patients and then between nonsurvivors and survivors within age cohorts. Two hundred sixty-four patients were analyzed: 195 younger and 69 older. Mortality was 8.3 per cent (22/264). Older patients had higher mortality (20.3% vs 4.1%, P < 0.05), higher CH (42.9% +/- 1.3 vs 8.4% +/- 0.6), lower ISS (22.6 +/- 1.5 vs 25.6 +/- 0.8, P < 0.05), higher EDGCS (12.9 +/- 0.5 vs 10.7 +/- 0.4, P < 0.05), and higher EDSBP (141.5 +/- 4.1 vs 129.3 +/- 2.2). There were no differences in incidence of POH and gender. Within both age cohorts nonsurvivors had higher ISS, lower EDGCS, and higher CH. Older patients with POH had 34.6 per cent mortality as compared with 11.6 per cent for no POH (P < 0.05). Mortality in younger patients was no different in the presence of POH, and all non-survivors were male. Despite lower ISS and higher EDGCS and EDSBP older patients had five times the mortality of younger patients. Age-specific mortality was influenced by POH and gender. POH was associated with higher mortality only in older patients. With less physiologic reserve older patients may not have been able to adequately compensate for POH; this emphasizes the importance of rapidly correcting serum lactic acid as an endpoint in resuscitation in this population.

Improved resuscitation minimizes respiratory dysfunction and blunts interleukin-6 and nuclear factor-kappa B activation after traumatic hemorrhage.

OBJECTIVE: We hypothesized that modifying resuscitation would alter hemorrhagic shock-induced respiratory dysfunction and correlate with nuclear factor-kappa B and cytokine expression. DESIGN: Randomized, controlled, prospective study. SETTING: University hospital trauma research laboratory. SUBJECTS: Female, Swiss Webster mice, 8-12 wks old. INTERVENTIONS: Hemorrhagic shock was induced by removing 0.025 mL of blood/g of body weight via a carotid catheter. Animals were resuscitated 30 mins later. Mice were randomized into four groups: group I was cannulated but not bled (sham); group II received normal saline to three times their shed blood volume; group III received their shed blood; and group IV received shed blood + normal saline at two times shed blood volume. MEASUREMENTS AND MAIN RESULTS: We measured the following: serum lactates at the end of shock and after resuscitation, pulmonary function before any instrumentation and after 24 hrs, cytokine concentrations by enzyme-linked immunosorbent assay, and nuclear factor-kappa B activity by electrophoretic mobility shift assay. Groups that were hemorrhaged had significant hypotension and a significant increase in serum lactates over 30 mins. Resuscitation returned the blood pressure to baseline in all groups, and lactates improved in all groups except group II. Group II also demonstrated a significant decrease in pulmonary function characterized by increased airway resistance and decreases in minute volume, lung compliance, and alveolar function. Bronchoalveolar fluid and serum interleukin-6 and whole lung nuclear factor-kappa B activity also were elevated significantly in group II. CONCLUSIONS: Group II demonstrated the least improvement in serum lactate after resuscitation, the most significant acute lung injury, and the greatest interleukin-6 and nuclear factor-kappa B response. Group IV mice had the least acute lung injury, with no detectable interleukin-6 response. Improved resuscitation with crystalloid and shed blood minimized acute lung injury. The reduction in pulmonary dysfunction after improved resuscitation may be attributable to a blunting of the nuclear factor-kappa B and interleukin-6 responses to hemorrhage.

Blood transfusions correlate with infections in trauma patients in a dose-dependent manner.

Infections are a common and significant sequela of major traumatic injury. The objective of this study was to evaluate the relationship between infections in trauma patients and the transfusion of packed red blood cells (pRBCs) within the first 48 hours of admission. We hypothesized that transfusions of pRBCs were associated with an increased risk of infection in a dose-dependent manner. All adult patients admitted to the trauma service of a Level I trauma center from November 1996 to December 1999 were studied. Secondary analysis was performed on prospectively collected data. One thousand five hundred ninety-three consecutive patients were studied; of these 12.6 per cent developed at least one infection. The overall transfusion rate was 19.4 per cent. The infection rate in patients who received at least one transfusion was significantly higher (P < 0.0001) at 33.0 versus 7.6 per cent in patients receiving no pRBCs. Transfusions per patient ranged from 0 to 46 units. There was a clear exponential correlation in patients receiving between 0 and 15 transfusions (R2 = 0.757). Multivariate logistic regression, which was used to identify risk factors for the development of infection, demonstrated the odds ratio of receiving pRBCs to be 1.084, with a 95 per cent confidence interval of 1.028 to 1.142 (P = 0.0028). In summary there is a clear dose-dependent correlation between transfusions of pRBCs and the development of infection in trauma patients. Multivariate analysis further demonstrated that pRBCs were an independent risk factor for the development of infections. Although transfusions are frequently indicated, they should be administered appropriately and with no more pRBCs than absolutely necessary.