Robotic Surgery for Pediatric Choledochal Cysts: An American Case Series and Literature Review

INTRODUCTION

Choledochal cysts are rare congenital biliary cystic dilations. The US incidence rate varies between 5 and 15 cases per 1,000,000 people. In contrast, Asians, which are a large subset of the population of Hawaii, have an incidence of approximately one in every 1000 births. We report our experience with robot-assisted laparoscopic surgical management with biliary reconstruction of choledochal cysts which to date is the largest American case series to be reported.

MATERIALS AND METHODS

From 2006 to 2021, patients diagnosed with a choledochal cyst(s) at a tertiary children's hospital were retrospectively reviewed. Perioperative analysis was performed. Complications were defined as immediate, early, or late. The data underwent simple descriptive statistics.

RESULTS

Nineteen patients underwent choledochal cystectomy and hepaticoduodenostomy. Thirteen underwent a robotic approach while the rest were planned laparoscopic. Eighteen of 19 were female with 15/19 of Asian descent. The ages ranged from 5 mo to 21 y. Presenting diagnoses included jaundice, primary abdominal pain, pancreatitis, and cholangitis. Sixty eight percent had type 1 fusiform cysts while the rest were type 4a. Operative time and length of stay for robotic versus laparoscopic were 321 versus 267 min and 8.2 versus 17.3 d, respectively. For the robotic group, there was one immediate complication due to peritonitis. One-year follow-up revealed two patients requiring endoscopic retrograde cholangiopancreatography with dilation/stenting for an anastomotic stricture. There were no anastomotic leaks.

CONCLUSIONS

Robot-assisted laparoscopic choledochal cystectomy with hepaticoduodenostomy is associated with overall good outcomes with the most common long-term complication being anastomotic stenosis.

Association of Emergency Department Pediatric Readiness With Mortality to 1 Year Among Injured Children Treated at Trauma Centers

IMPORTANCE

There is substantial variability among emergency departments (EDs) in their readiness to care for acutely ill and injured children, including US trauma centers. While high ED pediatric readiness is associated with improved in-hospital survival among children treated at trauma centers, the association between high ED readiness and long-term outcomes is unknown.

OBJECTIVE

To evaluate the association between ED pediatric readiness and 1-year survival among injured children presenting to 146 trauma centers.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, injured children younger than 18 years who were residents of 8 states with admission, transfer to, or injury-related death at one of 146 participating trauma centers were included. Children cared for in and outside their state of residence were included. Subgroups included those with an Injury Severity Score (ISS) of 16 or more; any Abbreviated Injury Scale (AIS) score of 3 or more; head AIS score of 3 or more; and need for early critical resources. Data were collected from January 2012 to December 2017, with follow-up to December 2018. Data were analyzed from January to July 2021.

EXPOSURES

ED pediatric readiness for the initial ED, measured using the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment.

MAIN OUTCOMES AND MEASURES

Time to death within 365 days.

RESULTS

Of 88 071 included children, 30 654 (34.8%) were female; 2114 (2.4%) were Asian, 16 730 (10.0%) were Black, and 49 496 (56.2%) were White; and the median (IQR) age was 11 (5-15) years. A total of 1974 (2.2%) died within 1 year of the initial ED visit, including 1768 (2.0%) during hospitalization and 206 (0.2%) following discharge. Subgroups included 12 752 (14.5%) with an ISS of 16 or more, 28 402 (32.2%) with any AIS score of 3 or more, 13 348 (15.2%) with a head AIS of 3 or more, and 9048 (10.3%) requiring early critical resources. Compared with EDs in the lowest wPRS quartile (32-69), children cared for in the highest wPRS quartile (95-100) had lower hazard of death to 1 year (adjusted hazard ratio [aHR], 0.70; 95% CI, 0.56-0.88). Supplemental analyses removing early deaths had similar results (aHR, 0.75; 95% CI, 0.56-0.996). Findings were consistent across subgroups and multiple sensitivity analyses.

CONCLUSIONS AND RELEVANCE

Children treated in high-readiness trauma center EDs after injury had a lower risk of death that persisted to 1 year. High ED readiness is independently associated with long-term survival among injured children.

The Multi Split Ventilator System: Performance Testing of Respiratory Support Shared by Multiple Patients

Ventilator sharing has been proposed as a method of increasing ventilator capacity during instances of critical shortage. We sought to assess the ability of a regulated, shared ventilator system (Multi Split Ventilator System, MSVS) to individualize support to multiple simulated patients using one ventilator. We employed simulated patients of varying size, compliance, minute ventilation requirement, and PEEP requirement. Performance tests were performed to assess the ability of the QSVS, versus control, to achieve individualized respiratory goals to clinically disparate patients sharing a single ventilator following ARDSNet guidelines. Resilience tests measured the effects of simulated adverse events occurring to one patient on another patient sharing a single ventilator. The QSVS met individual oxygenation and ventilation requirements for multiple simulated patients with a tolerance similar to a single ventilator. Abrupt endotracheal tube occlusion or extubation occurring to one patient resulted in modest, clinically tolerable changes in ventilation parameters for the remaining patients. The QSVS is a regulated, shared ventilator system capable of individualizing ventilatory support to clinically dissimilar simulated patients. It is also resilient to common adverse events. The QSVS represents a feasible option to ventilate multiple patients during a severe ventilator shortage.

Cryoanalgesia in Patients Undergoing Nuss Repair of Pectus Excavatum: Technique Modification and Early Results

PURPOSE

The Nuss procedure for surgical correction of pectus excavatum often causes severe postoperative pain. Cryoanalgesia of intercostal nerves is an alternative modality for pain control. We describe our modification of the cryoICE™ probe that allows for nerve ablation through the ipsilateral chest along with early results utilizing this technique.

METHODS

To allow for ipsilateral nerve ablation, a 20-French chest tube was cut and secured to the cryoICE probe, thus providing insulation for the malleable end of the probe. A 3-year retrospective review of patients undergoing Nuss repair at our institution was performed. Patients who received cryoanalgesia (cryo, n = 6) were compared with a historical control cohort who did not receive cryoanalgesia (nocryo, n = 13) during Nuss repair. Hospital length of stay, postoperative narcotic requirement (PNR), and highest postoperative pain score were collected.

RESULTS

Both cohorts were similar regarding age, BMI, and pectus index. The cryo group had a significantly less PNR (6.4 versus 17.9 doses, P = .05) and was discharged on average >1 day earlier than nocryo patients (3.7 versus 2.2 days, P = .01). No complications occurred in either group.

CONCLUSIONS

Our technique modification simplifies previously described approaches to intercostal nerve cryoablation. Patients undergoing this adjunct benefit with less PNR and a faster discharge time.

Magnetic Compression Stricturoplasty For Treatment of Refractory Esophageal Strictures in Children: Technique and Lessons Learned

INTRODUCTION

Esophageal stricture is the most common complication following repair of esophageal atresia (EA). In general, these strictures are successfully managed using endoscopic techniques including bougie and balloon dilation, stenting, and chemotherapeutic agent application. If these techniques are unsuccessful, patients require segmental esophageal resection and reanastomosis or esophageal replacement. Magnetic compression anastomosis has been described in children. Herein we report our experience with magnetic compression stricturoplasty to treat refractory strictures after EA repair.

METHODS

We reviewed our experience using magnets to treat refractory strictures in 2 patients. Both patients failed multiple standard interventions. Because of near complete esophageal obstruction, both patients were candidates for esophageal replacement or segmental resection/anastamosis. In both patients, we applied neodymium-iron-boron magnets using fluoroscopic and endoscopic guidance.

RESULTS

The magnets were successfully positioned in both cases. Magnets were left in place for 7 and 10 days allowing for gradual compression stricturoplasty/anastamosis. Upon removal of the magnets, recanalization was visualized endoscopically and self-expanding stents were placed. There were no leaks or significant early complications. By 31 months post-magnetic stricturoplasty, both patients achieved durable esophageal patency without dysphagia.

CONCLUSION

Magnetic stricturoplasty was successful at establishing early patency of the esophagus in 2 patients with recalcitrant EA strictures. Fundamental knowledge of magnetism was critical in configuring magnet arrays for surgery. In both cases, early follow-up is promising. Further follow-up will define the long-term success of this technique.

Negative pressure dressing assisted healing in pediatric burn patients

BACKGROUND/PURPOSE

Pediatric burn patients traditionally require multiple dressing changes and significant amounts of narcotics. Negative pressure dressings (NPDs) have emerged as an effective wound therapy that may represent an alternative primary dressing for these patients.

METHODS

This is a single institution, retrospective study of pediatric burn patients treated with NPDs over a defined 2 year period. Twenty-two patients were identified and their charts reviewed for age, sex, mode of injury, location of injury, degree of burn, length of stay, length of dressing required, number of dressing changes, and narcotic use between dressing changes.

RESULTS

The average patient was 3.5 years old (range of 8 months to 10 years old) with partial thickness burns involving 8.5% (range 3-18%) body surface area. The average treatment regimen was 3.5 dressing changes more than 6.6 days, with a mean hospital stay of 9.6 days. The average child received 9.4 total doses of delivered narcotics during their inpatient care.

DISCUSSION

The use of NPD in pediatric burn patients does require sedation and narcotics which limits its usefulness in the general pediatric burn population. Yet, they adhere well and stay in place even on active children, they capture and quantify fluid losses, they only require changes every 2-4 days and promote the adherence of split thickness skin grafts making them useful in various clinical situations.

CONCLUSIONS

NPDs are a viable option for both partial and full thickness burns in pediatric patients that do not require transfer to a burn unit. NPDs may be advantageous in highly active children, those with extensive fluid losses, those that require sedation for dressing changes and those that will require grafting.

Thoracoscopic segmentectomy for treatment of congenital lung malformations

PURPOSE

Congenital lung malformations (CLM) predispose patients to recurrent respiratory tract infections and pose a rare risk of malignant transformation. Although pulmonary lobectomy is the most common treatment of a CLM, some advocate segmental resection as a lung preservation strategy. Our study evaluated lung-preserving thoracoscopic segmentectomy as an alternative to lobectomy for CLM resection.

METHODS

We conducted a retrospective review of patients who underwent thoracoscopic segmentectomy for CLM from 2007 to 2010.

RESULTS

Fifteen patients underwent thoracoscopic segmentectomy for CLM. There were five postoperative complications: three asymptomatic pneumothoraces and a small air leak that resolved without intervention. One patient developed a bronchopulmonary fistula requiring thoracoscopic repair. At follow-up, all patients are asymptomatic. One patient has a small amount of residual disease on postoperative computed tomography (CT), and re-resection has been recommended.

CONCLUSIONS

Thoracoscopic segmentectomy for CLM is a safe and effective means of lung parenchymal preservation. The approach spares larger airway anatomy and has a complication rate that is comparable with that of thoracoscopic lobectomy. Residual disease can often only be appreciated on postoperative CT scan and may require long-term follow-up or reoperation in rare cases. This lung preservation technique is best suited to smaller lesions.

Computed tomography findings of unanticipated prolonged ileocolic intussusception in children

BACKGROUND

Attempted nonsurgical reduction of ileocolic intussusceptions after 48 hours is controversial because of the low probability of reduction and an increased risk of perforation. We sought to retrospectively identify computed tomography (CT) criteria that may help to predict bowel viability and successful enema reduction in children with ileocolic intussusception.

METHODS

Unanticipated intussusception was diagnosed using CT in six children with mild, atypical symptoms of four to seven days' duration at a single institution during a one-year period. All patients underwent laparotomy without prior contrast enema. Surgical findings were compared with preoperative CT scan findings to identify any criteria that may predict successful nonsurgical management.

RESULTS

Contrast CT scan findings were diagnostic of ileocolic intussusception. At the time of laparotomy, three children had easily reducible ileocolic intussusception with nonischemic bowel. Two children had irreducible intussusception with ischemic bowel requiring resection, and one child had a difficult reduction of nonischemic but edematous bowel. Preoperative CT scan findings correlated well with intraoperative findings for all patients. Findings of bowel-wall edema of the intussuscipiens and partial small-bowel obstruction shown on CT were associated with intussusception that was nonreducible or difficult to reduce.

CONCLUSION

Patients with prolonged intussusception diagnosed using CT scan may safely undergo contrast enema reduction if no bowel-wall edema of the intussuscipiens or obstruction is demonstrated.

Routine interval appendectomy in children is not indicated

BACKGROUND

This study evaluates outcomes for children treated without interval appendectomy (IA) after successful nonoperative management of perforated appendicitis.

METHODS

A retrospective study of pediatric patients with appendicitis was performed from 12 regional acute-care hospitals from 1992 to 2004 with mean length of follow-up of 7.5 years. Main outcomes were recurrent appendicitis and cumulative length of hospital stay.

RESULTS

The study included 6439 patients, of which 6367 (99%) underwent initial appendectomy. Seventy-two (1%) patients were initially managed nonoperatively and 11 patients had IA. Of the remaining 61 patients without IA, 5 (8%) developed recurrent appendicitis. Age, sex, type of appendicitis, and abscess drainage had no influence on recurrent appendicitis. Cumulative length of hospital stay was 6.6 days in patients without IA, 8.5 days in patients with IA, and 9.6 days in patients with recurrent appendicitis.

CONCLUSION

Recurrent appendicitis is rare in pediatric patients after successful nonoperative management of perforated appendicitis. Routine IA is not necessarily indicated for these children.

Angiography and the pediatric trauma patient: a 10-year review

BACKGROUND/PURPOSE

Although interventional radiology has played an increasing role in the management of adult trauma patients, little has been written regarding its application in the care of the injured child. This study analyzed the indications, results, and complications for angiography in pediatric trauma patients.

METHODS

A retrospective review of pediatric patients (14 years or younger) admitted to Los Angeles County-University of Southern California Medical Center, Los Angeles, Calif (an urban level I trauma center), over a 10-year period (1993-2003) was performed. Patients who underwent angiography were identified using hospital angiography records, and further information was recorded from the trauma registry and medical records. Variables collected included age, sex, mechanism of injury, and injury severity score (ISS). Angiographic data analyzed included indications, results, therapeutic interventions, and procedure-related complications.

RESULTS

Twenty-five pediatric trauma patients who underwent angiography were identified (18 boys, 7 girls). The average age was 11 years (range, 1-14 years), with an ISS of 16 +/- 10. Indications for angiography included suspected limb ischemia (n = 9), suspected pelvic (n = 8) or solid organ bleeding (n = 8), suspected aortic injury (n = 6), and expanding hematoma (n = 1). Eleven patients (44%) had an abnormal finding, and 10 of 11 underwent a subsequent therapeutic intervention. There was 1 minor procedure-related complication and no procedure-related mortality.

CONCLUSIONS

Though used infrequently in pediatric trauma patients, the result of the angiography was abnormal in almost half of the children in this series. An abnormal finding prompted further therapeutic intervention in most cases. Angiography was associated with minimal morbidity and should be considered as a useful and safe adjunct when caring for injured children.

Splenic artery embolization in the management of an acute immune thrombocytopenic purpura-related intracranial hemorrhage

Although relatively rare, intracranial hemorrhage remains the most common cause of immune thrombocytopenic purpura-related mortality [Medeiros D. Current controversies in the management of idiopathic thrombocytopenic purpura during childhood. Pediatr Clin North Am . 1996;43:757-72]. The required decompressive treatment has the potential for substantial blood loss and must often be delayed because of resistant thrombocytopenia responsive only to splenectomy. Splenic embolization is a novel approach to this problem that can expedite definitive neurosurgical care and minimize permanent sequelae. This is the first reported case of splenic embolization in the management of a child with known immune thrombocytopenic purpura presenting with central nervous system bleeding.

Surgisis patch tracheoplasty in a rodent model for tracheal stenosis

BACKGROUND

Tracheal stenosis is a challenging surgical problem that can require reconstruction using autologous grafts or artificial stents. In this study, we evaluate the efficacy of Surgisis, a commercially available, biocompatible, acellular matrix, in the repair of a critical-size tracheal defect.

METHODS

A full-thickness defect (2 mm x 6 mm) was created in tracheal rings 4 through 6 in adult rats. A piece of 8-ply Surgisis (Cook; Bloomington, IN) was sutured to the edges of the defect with interrupted 8-0 polypropylene sutures. In control animals, the defect was closed primarily. The trachea was harvested at 4 weeks and prepared for histologic evaluation using conventional techniques. Cross-sectional area and perimeters were calculated using imaging software.

RESULTS

Tracheal defects without patch repair (n = 3) resulted in tracheal stenosis and immediate death. Animals that underwent Surgisis patch repair of tracheal defects (n = 10) tolerated the procedure well and had no audible stridor or evidence of respiratory distress. Eight of ten animals survived 4 weeks. The tracheal lumen was patent with no evidence of contracture or degradation of the Surgisis. Histologically, neovascularization of the Surgisis was noted with moderate inflammation. The surface of the Surgisis patch was covered ith a lining of ciliated epithelial cells.

CONCLUSION

In the rodent model, Surgisis appears to be an efficacious method for the patch repair of partial circumferential tracheal defects. Surgisis appears to be a safe and promising means of facilitating neovascularization and tissue regeneration. The long-term use of Surgisis warrants further investigation.

Ad libitum feeding: safely improving the cost-effectiveness of pyloromyotomy

BACKGROUND/PURPOSE

Patients undergoing pyloromyotomy traditionally have been placed on complex postoperative feeding regimens. The authors evaluated the substitution of an ad libitum feeding regimen to determine if it could decrease length of hospital stay and cost without increasing the morbidity rate.

METHODS

Fifty-six consecutive patients undergoing open pyloromyotomy were evaluated. The initial 31 patients were treated with a traditional protocol, whereas the next 25 patients received ad libitum feeding. Time to first full-strength feeding, amount and time of any emesis, and time to discharge were recorded. Hospital costs and number of readmissions were assessed.

RESULTS

Patients in the ad libitum group had a statistically significant shorter time to discharge (25.1 hours versus 38.8 hours), which translated into a savings of $1,290 per patient. Whereas more patients in the ad libitum group experienced postoperative emesis (32% v 26%), this was not statistically significant. There was no other morbidity and there were no readmissions in either group.

CONCLUSIONS

Postoperative ad libitum feedings resulted in significant decreases in hospital stay and associated costs without increasing morbidity. Ad libitum feeding is safe, simple, and cost effective, and may offer an avenue for short-stay pyloromyotomy in selected patients.