Vacuum-assisted closure: a novel method of managing surgical necrotizing enterocolitis.

PURPOSE: Necrotizing enterocolitis (NEC) requiring surgical intervention is associated with mortality rates approaching 50%. We evaluated outcomes of patients that underwent surgical treatment for NEC with vacuum-assisted closure (VAC) of the abdomen as compared with traditional laparotomy, bowel resection, and ostomy creation. METHODS: A retrospective review identified 26 patients from 2007 to 2012 with NEC. Overall, 17 patients were treated with laparotomy, and 9 were treated with laparotomy and VAC (LapVac). Age, weight, preoperative and postoperative mean airway pressure, length of bowel resected, duration on total peripheral nutrition, time until initiation of feeds, and length of stay were assessed. A Student's t-test was used for statistical analysis. RESULTS: Nine LapVac patients underwent a total of 1.2 ± 1.3 VAC changes and had open abdomens for 13.1 ± 19.1 days. LapVac and traditional laparotomy patients had similar outcomes with respect to amount of bowel resected, time on a ventilator, time to initiation of feeds, and length of hospital stay. Two of nine patients (22%) in the LapVac group were placed in continuity without the need for an ostomy. We identified a subset of patients in the LapVac group that demonstrated signs of abdominal compartment syndrome (ACS), exhibiting mean airway pressures greater than 15 cm H2O preoperatively. Patients with ACS treated with VAC therapy had shorter time to initiation of feeds (p=0.047) and shorter lengths of stay (p=0.0395) as compared with traditional laparotomy. CONCLUSION: Our data demonstrate that use of the wound VAC is a safe approach in the management of premature infants with NEC requiring surgical intervention with outcomes comparable to standard surgical management. Use of the wound VAC may allow the establishment of bowel continuity and abdominal closure without the need for an ostomy. VAC therapy may also hasten the recovery of NEC patients with concomitant ACS by eliminating the compartment syndrome. Larger studies are required to confirm this theory.

Vacuum-assisted closure in the treatment of extensive lymphangiomas in children.

BACKGROUND: The management of lymphangiomas in children is a complex problem with frequent recurrence and infection. Vacuum-assisted closure (VAC) devices have been shown to accelerate the healing of open wounds. We hypothesized that VAC therapy might decrease complications after resection of lymphangiomas. METHODS: A retrospective review was performed on 13 children (August 2005 to April 2010) who were patients undergoing lymphangioma resection with postoperative VAC therapy. Patient demographics, size and location of the lymphangioma, VAC duration and number of changes, hospital stay, complications, need for further surgery, and length of follow-up were recorded. RESULTS: Thirteen children (mean age, 8 years; mean weight, 34 kg) underwent 15 operations for lymphangiomas followed by postoperative VAC therapy. Locations included the head and neck, thorax and abdomen, and lower extremity. The mean VAC duration was 19 days, and they underwent a mean of 2.6 VAC changes. Six children had operative closure of the wound at a mean of 15 days postoperative. The remaining patients underwent closure by secondary intention. There were no recurrences. Complications included VAC device malfunctions requiring intervention and wound infections. Mean follow-up was 289 days. CONCLUSION: Postoperative VAC therapy for the treatment of lymphangiomas can be an effective adjunct to surgical treatment by decreasing risks of recurrence and infection.

Single-incision thoracoscopic surgery in children: equivalent results with fewer scars when compared with traditional multiple-incision thoracoscopy.

BACKGROUND: Single-incision pediatric endosurgery is gaining popularity, especially for abdominal operations. Several reports in the literature support the feasibility of the single-incision approach in pediatric laparoscopy. Here we compare our experience with single-incision thoracoscopic surgery (SITS) to traditional multiple-incision video-assisted thoracoscopic surgery (VATS) in children. METHODS: A chart review of all patients who underwent SITS at our institution was performed. The same number of demographically matched VATS case controls were selected from a pool of patients operated on during the same time period. Operative time, time until chest tube removal, length of stay, complications, and any need for further intervention were recorded. Statistical analysis was done by Student's t-test using Instat 3. RESULTS: Fourteen SITS procedures were performed during the study period. These patients were compared with 14 VATS case controls. Both groups were similar with regard to age, weight, sex, and procedures performed. The mean operative time in the SITS group was 84 ± 43 minutes versus 64 ± 30 in the VATS group (P=.18). Days until chest tube removal was 4 ± 2.2 in the SITS group and 2.8 ± 1.4 in the VATS group (P=.09). Length of hospital stay was 5.5 ± 4.4 days in the SITS group versus 7.2 ± 8.6 in the VATS group (P=.51). There were no intraoperative complications and no procedure conversions in either group. One SITS patient who underwent a wedge resection and mechanical pleurodesis for a spontaneous pneumothorax was readmitted for a recurrent pneumothorax and required a reoperation. CONCLUSIONS: Our experience demonstrates that there are no statistically significant differences in operative time, time until chest tube removal, and length of hospital stay when comparing SITS to VATS in children. We believe that SITS is an equivalent procedure that allows for fewer scars when compared with traditional multiple-incision VATS in children.

Prophylactic antibiotics do not decrease the incidence of wound infections after laparoscopic pyloromyotomy.

PURPOSE: Although laparoscopic pyloromyotomy is considered to be a clean case, many surgeons administer prophylactic preoperative antibiotics. The aim of this study was to evaluate the impact of prophylactic antibiotics on the wound infection rate after laparoscopic pyloromyotomy. METHODS: We conducted a retrospective review of all patients who underwent laparoscopic pyloromyotomy at our institution between August 2002 and December 2009. Data included patient age, sex, weight, serum HCO(3) at admission and at operation, and if the patient received prophylactic antibiotics. The rate of wound infection or other wound complications, including suture granuloma, umbilical granuloma, umbilical hernia, skin dehiscence, and omental evisceration, was determined. RESULTS: Two hundred ninety-nine patients underwent 301 consecutive laparoscopic pyloromyotomies. Sixty-four percent (n = 194) of patients returned for follow-up and were included in the study. Fifty-seven percent (group A, n = 111) received antibiotics, and 43% (group B, n = 84) did not. There were 3 wound infections in each of the equally matched groups (group A, 2.7%; group B, 3.5%; P = .73). Other wound complications occurred in 4.5% of patients (n = 5) in group A and 8.3% of patients (n = 7) in group B (P = .27). CONCLUSION: The use of prophylactic antibiotics does not significantly decrease the rate of wound infection or other wound complications after laparoscopic pyloromyotomy.

Early experience with single-incision thoracoscopic surgery in the pediatric population.

INTRODUCTION: Single-incision pediatric endosurgery is gaining popularity in children. We have recently applied the single-incision approach for thoracoscopic procedures. We report our initial experience with single-incision thoracoscopic surgery in the pediatric population. METHODS: A retrospective chart review of the first 10 single-incision thoracoscopic operations done at our institution was conducted. The patients' mean age and weight and the median operative time, postoperative length of stay, and time until discontinuation of chest tubes were determined. RESULTS: The 10 procedures were performed in eight patients (two patients each had bilateral procedures). The procedures performed included wedge resection and mechanical pleurodesis for spontaneous pneumothorax (n = 7), wedge biopsies for lymphoma (n = 1) and chronic granulomatous disease (n = 1), and resection of an apical extrapulmonary neuroblastoma (n = 1). All of the procedures were completed without intraoperative complication or significant blood loss. In each case, multiple trocars and/or unsheathed instruments were passed through a single small incision, which was subsequently used for the chest tube(s). The mean patient age was 13.5 years (range 3-18 years). The mean weight was 47 kilograms (range 16-63 kg). The median operative time was 64 minutes (range 50-201 minutes). The median postoperative length of stay was 7 days (range 3-19 days). The median time until chest tube removal was 3 days (range 2-15 days). The mean follow-up was 7 months (range 3-12 months). One patient developed a recurrent pneumothorax and persistent air leak after having undergone a wedge resection and pleurodesis for a spontaneous pneumothorax and required a reoperation. CONCLUSION: Single-incision thoracoscopic surgery is a feasible alternative to the traditional multiple-incision approach in the pediatric population. The in-line positioning of the camera and instruments often proves to be an advantage rather than a hindrance.

Hepatocyte growth factor increases glucagon immunoreactivity in jejunal cells during intestinal adaptation.

BACKGROUND: The administration of hepatocyte growth factor (HGF) during intestinal adaptation is known to enhance intestinal adaptation. Glucagon has also been implicated as a potential mediator of intestinal adaptation. Previous studies have shown that HGF and glucagon synergistically increase the proliferation of hepatocytes. HGF has also been shown to be preferentially expressed within the glucagon-positive cells of the pancreas, possibly indicating a paracrine or endocrine effect of HGF on glucagon. This study was designed to determine if HGF stimulation in the small intestine during intestinal adaptation influenced mucosal glucagon expression. METHODS: Adult male Sprague-Dawley rats were randomized to either a 70% massive small bowel resection group (MSBR) or an HGF-treated MSBR group (MSBR-HGF). Seven days after surgery, HGF was administered intravenously at 150 mug/kg per day for 14 days. At day 21, the ileal and jejunal mucosa was harvested. The RAE 230A GeneChip (Affymetrix, Santa Clara, Calif) and MAS5 software were used to determine alterations in gene expression in the small intestine mucosa. Immunofluorescent staining of the ileal and jejunal mucosa using an antiglucagon antibody was performed and evaluated qualitatively. RESULTS: The MSBR-HGF group had significantly greater protein and DNA content (P < .05) than the MSBR group. Glucagon gene expression in the MSBR-HGF group was decreased compared with the MSBR group, and immunohistostaining for glucagon in the ileum revealed no difference in intensity between the 2 groups. However, the jejunal MSBR-HGF group demonstrated significantly greater glucagon immunoreactivity than the jejunal MSBR group. CONCLUSION: Our data suggest that the HGF-induced increase in glucagon availability is disassociated from glucagon gene up-regulation. Thus, HGF may not only enhance intestinal adaptation directly, but also indirectly by increasing the "local" availability of other growth factors in the absence of their gene up-regulation.

Proteasome gene upregulation: a possible mechanism for intestinal adaptation.

BACKGROUND/PURPOSE: The mechanisms that control intestinal adaptation remain unknown. To better understand the adaptive process, microarray technology was used to analyze gene expression in a rat model of intestinal adaptation. METHODS: Adult male Sprague-Dawley rats underwent either a massive small bowel resection (70%) with anastomosis or a sham operation with small bowel transection and reanastomosis. After 21 days, ileal mucosa RNA was extracted. Individual RNA samples (n = 5 per group) were labeled and hybridized to 10 separate RAE 230A rat GeneChips. The signal values were calculated and the 2 groups were compared using a t test with the multiple testing correction of Benjamini and Hochberg (false discovery rate of 10%). Probe sets were analyzed for overrepresented physiologic pathways using Expression Analysis Systematic Explorer (EASE). RESULTS: Of the 15,866 probe sets on the RAE 230A GeneChip, 5437 probe sets were unexpressed and excluded. Of the remaining 10,429 probe sets, several overrepresented pathways (EASE score <0.01 after Bonferroni correction) were identified. Further analysis revealed that 13 probe sets related to proteasome degradation (an enzyme complex implicated in the regulation of cell proliferation) were significantly upregulated in the intestinal adaptation group compared to the sham group. CONCLUSIONS: Proteasomes may play a critical role in regulating the proliferation of intestinal mucosa during intestinal adaptation.