Contrast Challenge Algorithms for Adhesive Small Bowel Obstructions Are Safe in Children: A Multi-Institutional Study

OBJECTIVE

The purpose of this study was to evaluate the safety of a water-soluble contrast challenge as part of a nonoperative management algorithm in children with an adhesive small bowel obstruction (ASBO).

BACKGROUND

Predicting which children will successfully resolve their ASBO with non-operative management at the time of admission remains difficult. Additionally, the safety of a water-soluble contrast challenge for children with ASBO has not been established in the literature.

METHODS

A retrospective review was performed of patients who underwent non-operative management for an ASBO and received a contrast challenge across 5 children's hospitals between 2012 and 2020. Safety was assessed by comparing the complication rate associated with a contrast challenge against a pre-specified maximum acceptable level of 5%. Sensitivity, specificity, negative (NPV) and positive (PPV) predictive values of a contrast challenge to identify successful nonoperative management were calculated.

RESULTS

Of 82 children who received a contrast challenge, 65% were successfully managed nonoperatively. The most common surgical indications were failure of the contrast challenge or failure to progress after initially passing the contrast challenge. There were no complications related to contrast administration (0%; 95% confidence interval: 0-3.6%, P = 0.03). The contrast challenge was highly reliable in determining which patients would require surgery and which could be successfully managed non-operatively (sensitivity 100%, specificity 86%, NPV 100%, PPV 93%).

CONCLUSION

A contrast challenge is safe in children with ASBO and has a high predictive value to assist in clinical decision-making.

Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium

BACKGROUND/PURPOSE

Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias.

METHODS

Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair.

RESULTS

Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy.

CONCLUSION

Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair.

LEVEL OF EVIDENCE

Level III.

Acid suppression duration does not alter anastomotic stricture rates after esophageal atresia with distal tracheoesophageal fistula repair: A prospective multi-institutional cohort study

INTRODUCTION

Anastomotic stricture is the most common complication after esophageal atresia (EA) repair. We sought to determine if postoperative acid suppression is associated with reduced stricture formation.

METHODS

A prospective, multi-institutional cohort study of infants undergoing primary EA repair from 2016 to 2020 was performed. Landmark analysis and multivariate Cox regression were used to explore if initial duration of acid suppression was associated with stricture formation at hospital discharge (DC), 3-, 6-, and 9-months postoperatively.

RESULTS

Of 156 patients, 79 (51%) developed strictures and 60 (76%) strictures occurred within three months following repair. Acid suppression was used in 141 patients (90%). Landmark analysis showed acid suppression was not associated with reduction in initial stricture formation at DC, 3-, 6- and 9-months, respectively (p = 0.19-0.95). Multivariate regression demonstrated use of a transanastomotic tube was significantly associated with stricture formation at DC (Hazard Ratio (HR) = 2.21 (95% CI 1.24-3.95, p<0.01) and 3-months (HR 5.31, 95% CI 1.65-17.16, p<0.01). There was no association between acid suppression duration and stricture formation.

CONCLUSION

No association between the duration of postoperative acid suppression and anastomotic stricture was observed. Transanastomotic tube use increased the risk of anastomotic strictures at hospital discharge and 3 months after repair.

Norwood With Obstructed Total Anomalous Pulmonary Venous Connection and Tracheoesophageal Fistula Repair: Operating Room Delivery

A baby boy with prenatally diagnosed hypoplastic left heart syndrome variant with obstructed veins was born in the operating room (OR) and underwent emergent Norwood operation and repair of obstructed infra-diaphragmatic total anomalous pulmonary venous connection. Post-operatively, esophageal atresia with tracheoesophageal fistula was identified and repaired on day of life 11. The patient is thriving at 22 months of age. (Level of Difficulty: Advanced.)

Long-term complications after staging laparotomy for Hodgkin lymphoma

e20007

Background: There are over 164,000 long-term survivors of Hodgkin lymphoma in the US. Awareness of the potential for preventable high risk late complications is critical for avoiding early mortality and insuring quality of life. We sought to identify key late complications in patients who had undergone staging laparotomy Methods: Retrospective review of hospital records and database of cancer survivors at our institution. Results: 95 patients with HL were identified; of these 24 patients with HL underwent staging laparotomy from 1971-1994. 18 patients had complete data available with median age at diagnosis of 13.7 years and median follow-up of 27.9 years. 16 patients underwent splenectomy, 12 patients received chemotherapy and 17 received XRT. Six patients (33%) had findings of intra-abdominal disease on laparotomy. Three patients (17%) required four repeat laparotomies for bowel obstruction more than 10 years after staging laparotomy. Of the 3 patients requiring repeat laparotomy for bowel obstruction, one had radiation to the inguinal region, one had mantle radiation (patient with 2 bowel obstructions requiring laparotomy and lysis of adhesions), and one had unknown radiation therapy history. In contrast, there were no cases of bowel obstruction in the other 71 patients who did not receive initial staging laparotomy. There were no documented cases of post-splenectomy sepsis and all post splenectomy patients received some prophylactic antibiotics. Conclusions: This is the first study to examine long term complications after staging laparotomy in a longitudinal cohort of survivors of HL. In long term follow-up, patients who underwent staging laparotomy for HL appear to have an increased incidence of repeat laparotomy, 3-4 fold higher than the expected rate of post laparotomy bowel obstruction incidence in the literature. Otherwise, the long term outcome of splenectomy in these patients appears to be very good with no episodes of post splenectomy sepsis, These findings underscore the importance of a high index of suspicion for bowel obstruction and related complications in HL survivors who had previous abdominal operative procedures. This work also underscores the importance of long term follow-up and screening in this population.

Selection of live-related liver transplantation candidates

PURPOSE

Living donor liver transplantation (LR) is an important alternative for children. We compared our outcomes of LR and cadaveric (CAD) graft recipients, with attention to the pediatric end-stage liver disease (PELD) score and perioperative morbidity and mortality to identify appropriate candidates for LR.

METHODS

Our transplant database and electronic medical records were searched for demographics and outcome measures.

RESULTS

From 2000 to 2008, 81 children underwent liver transplantation from 37 LR and 44 CAD donors. There were no significant differences in graft or overall survival at 3 months or 1 year. The LR group was significantly younger (4.46 +/- 5.2 years vs 7.41 +/- 6.6 years; P = .03) and had a significantly lower PELD score (12.7 +/- 13 vs 22 +/- 12; P = .001) at the time of transplantation. Ten patients were transplanted for unresectable tumor in the LR group vs 4 CAD (P = .03). Significantly fewer LR recipients required return to the operating room in the first 30 days posttransplant (13.9% vs 34.1%; P = .03). The LR recipients had a higher rate of biliary stricture requiring reoperation (22.2% vs 2.3%; P = .005).

CONCLUSIONS

The LR liver transplantation is highly selected for patients with a parent donor who will need transplant but do not yet have a high PELD score. A lower PELD score at operation may have contributed to the lower incidence of postoperative complications requiring reoperation.

Approach to a social stranger is associated with low central nervous system serotonergic responsivity in female cynomolgus monkeys (Macaca fascicularis)

It is widely hypothesized that individual differences in central nervous system (CNS) serotonergic activity underlie dimensional variation in "impulsive" vs. "inhibited" social behavior in both humans and nonhuman primates. To assess relative impulsivity in a social context, a behavioral challenge involving animals' exposure to a social stranger (termed the "Intruder Challenge") was recently validated in adolescent and adult male vervet monkeys (Cercopithecus aethiops sabaeus). Among these animals, monkeys that quickly approached the intruder were found to have lower cerebrospinal fluid (CSF) concentrations of the serotonin (5-HT) metabolite, 5-hydroxyindoleacetic acid, than less impulsive animals. In the present study we extended these observations to determine whether approach to a social stranger, as operationalized by the Intruder Challenge, is similarly associated with diminished CNS serotonergic function in female cynomolgus monkeys (Macaca fascicularis). Study animals were 25 adult monkeys that had been housed for 2 years in stable social groups. In each animal, the rise in plasma prolactin concentration induced by acute administration of the 5-HT agonist, fenfluramine, was used to assess "net" central serotonergic responsivity. When exposed later to an unfamiliar female of the same species in a catch-cage placed for 20 min within the subjects' home enclosure, monkeys that approached to within 1 m of the intruder (median latency to approach=3 min) were found to have significantly smaller prolactin responses to fenfluramine (diminished serotonergic responsivity) compared to "inhibited" animals that failed to approach the intruder (t=2.9, df=23, P<0.009; rpb=-0.51). Neither approach behavior nor the animals' fenfluramine-induced prolactin responses covaried significantly with nondirected expressions of arousal (or anxiety) or with aggressive behaviors exhibited during testing. We conclude that in female cynomolgus monkeys, social impulsivity (vs. inhibition) correlates inversely with individual differences in CNS serotonergic activity, as assessed by neuroendocrine challenge.