Preoperative Metal Allergy Testing for Pectus Excavatum Repair Does Not Effectively Identify Patients Who Develop Metal bar Allergy

BACKGROUND

Metal allergy following placement of a metal pectus bar for minimally invasive repair of pectus excavatum (MIRPE) is a rare complication with potentially significant morbidity. There is no consensus regarding preoperative metal allergy testing (MAT). This study aims to assess incidence of metal allergy and titanium bar use in tested and untested patients and trends in MAT with different approaches to MAT.

METHODS

A retrospective chart review was performed on patients who underwent MIRPE from July 2009 to June 2022 at a single institution. During this time, MAT was performed routinely (RT; routine testing) and selectively (ST; selective testing).

RESULTS

The cohort included 741 patients for analysis. Metal bar allergy was documented in 1.3 % of all patients; the incidence was 1.3 % in patients with MAT and 1.4 % without MAT. The incidence of bar allergy was 1.1 % in the RT group and 1.6 % in the ST group. In the RT group, bar allergy occurred in 1.4 % (3/216) of patients with a negative MAT. In the ST group, bar allergy occurred in 1.2 % (2/164) of patients with a negative MAT and in 1.9 % (3/162) of untested patients with a stainless-steel bar. Titanium bar use was not significantly different between the RT and ST groups (18.3 % vs 16.3 %, p > 0.05).

CONCLUSION

The incidence of metal bar allergy after MIRPE was less than 2 %, and titanium bar use was not significantly different in routine and selective testing groups. MAT was not associated with a reduction in bar allergy, and its use remains unsupported.

LEVEL OF EVIDENCE

III.

Recurrent Crohn's disease

Although surgical management of the ileocolic segment in pediatric Crohn's disease is not curative, the main goal of therapy is to allow for growth, adequate nutrition, and age-appropriate development. Recurrent disease at the site of anastomosis presents as a major morbidity. Several factors have been implicated in the development of surgical recurrence though data in the literature is scarce. This review explores the epidemiology of recurrent ileocolic disease following primary surgery, indications for surgical intervention, and techniques reported in the literature. Pediatric data is scarce, and therefore, much of it is extrapolated from adult literature.

Initial outcomes using cryoablation in surgical management of slipping rib syndrome

INTRODUCTION

Minimally invasive repair of pectus excavatum (MIRPE) and cartilaginous rib excision (CRE) for slipping rib syndrome (SRS) are painful procedures. Intercostal nerve cryoablation (Cryo) controls pain and decreases opioid use in MIRPE. Herein, we describe our experience with cryoablation in CRE.

METHODS

A retrospective chart review was performed of all patients undergoing CRE between 2018 and 2022. Data on demographics, clinical characteristics, operative details, and hospital course were collected.

RESULTS

A total of 98 patients underwent CRE: 68 CRE without cryo, 22 CRE + Cryo, and 8 combined MIRPE + CRE + Cryo. Ninety percent of patients underwent bioabsorbable rib plating. Patients were predominantly female (79%, 73%, 50% respectively) with median ages 17.6, 16.9, and 14.2 years respectively. CRE + Cryo patients used significantly less opioids in hospital (0.6 OME/kg [0.1,1.2]) compared to CRE without cryo (1.0 OME/kg [0.6,2.1]), p < 0.05. The median length of stay (LOS) in CRE + Cryo was 1 day [1,2] compared to 2 days in CRE without cryo [1,2], p = 0.09. MIRPE + CRE + Cryo patients used 0.6 OME/kg [0.2,8.0] with a 2 day [1,5.5] LOS. Ninety-one percent of Cryo patients had cryoablation of T9 and/or T10 intercostal nerves, with no documented abdominal wall laxity at median follow-up of 16 days. Cryo was applied extra-thoracically in CRE + cryo without thoracoscopy or lung isolation, while MIRPE + CRE + Cryo used a combination extra-/intra-thoracic cryoablation in with thoracoscopy.

CONCLUSION

Intercostal nerve cryoablation reduces opioid use and LOS in patients undergoing cartilaginous rib excision for slipping rib syndrome. Cryotherapy to as low as T10 did not result in abdominal wall laxity and can be applied extra-thoracically without the need for thoracoscopy. Ongoing prospective studies are required to assess the long-term outcomes.

LEVEL OF EVIDENCE

III.

Intercostal Nerve Cryoablation in Minimally Invasive Repair of Pectus Excavatum: Effect on Pulmonary Function

Introduction: Cryoablation of intercostal nerves is performed for pain control after minimally invasive repair of pectus excavatum (MIRPE). Cryoablation affects both sensory and motor neurons, resulting in temporary anesthesia to the chest wall and loss of intercostal motor function. The study objective is to determine the effect of cryoablation on incentive spirometry (IS) volumes, as a measure of pulmonary function, after MIRPE. Materials and Methods: A single-institution retrospective review of pediatric patients undergoing MIRPE was performed. All patients received a multimodal regimen (MMR) of analgesics postoperatively. Three groups were compared-cryoablation (CRYO), elastomeric pain pump (EPP), and MMR alone. The primary outcomes were postoperative IS volumes and IS volumes as a ratio of preoperative forced vital capacity (FVC). Secondary outcomes included pain scores, opioid use, length of stay (LOS), and infectious complications. Results: MIRPE was performed in 115 patients: 50 CRYO, 50 EPP, and 15 MMR alone. Groups were similar for demographics and pectus excavatum severity. Postoperative spirometry measurements were similar across groups: IS (CRYO 750 mL [500,961] versus EPP 750 mL [590,1019] versus MMR 696 mL [500,1037], P = .77); IS/FVC (CRYO 0.19 [0.14,0.26] versus EPP 0.20 [0.16,0.26] versus MMR 0.16 [0.15,0.24], P = .69). Although pain scores were also similar across groups, CRYO patients used less opioid (P < .05) and had shorter LOS (P < .05). Postoperative pneumonia was rare and similar across groups (P = 1.00). Conclusion: Intercostal nerve cryoablation during MIRPE does not adversely affect postoperative IS volumes or increase pneumonia rate, despite the temporary loss of motor innervation to intercostal muscles. Cryoablation provides effective pain control with less opioid use.

Cryoablation in 350 Nuss procedures: Evolution of hospital length of stay and opioid use

INTRODUCTION

Current studies show cryoablation decreases opioid requirements and lengths of stay (LOS) in patients undergoing the Nuss procedure for pectus excavatum. This study evaluated the relationship between cryoablation and clinical outcomes for the Nuss procedure.

METHODS

A retrospective single-center chart review was performed on patients undergoing the Nuss procedure with intercostal cryoablation from December 2017-August 2021. Demographics, hospital course, and postoperative complications were abstracted. To evaluate the evolution of outcomes over time, the earliest quarter (Q1) of cryoablation patients was compared to the last quarter (Q4).

RESULTS

Over 45 months, 350 Nuss procedures with cryoablation were performed. The mean age at operation was 15.7 ± 2.3 years with an average Haller Index of 5.4 ± 4.2. The mean operative time was 136 ± 40.5 minutes. On average, patients used 2.8 ± 2.5 OME/kg of opioid in hospital with a LOS of 2.7 ± 1.1 days. The Q4 patients were discharged 1.3 days earlier (p<0.05) than Q1 patients, with 80% of Q4 discharged by postoperative day #2 vs. 23% in Q1 (p<0.05). Q4 patients received 74% (p<0.05) less opioid in hospital and 21% (p<0.05) less on discharge. Within 90 days postoperatively, complication rates (chest tube placement, wound infection, readmission, neuropathic pain) were similar. Only two patients (0.6%) required reoperation for bar migration/slippage.

CONCLUSION

With increased experience, cryoablation for the Nuss procedure decreased opioid use by 74% and was associated with 80% of patients achieving early discharge. Major complication rates were not increased. Cryoablation can be successfully implemented as an effective method of postoperative analgesia.

LEVEL OF EVIDENCE

Level III.

Elastomeric Pain Pumps as an Adjunct for Postoperative Pain Control After Minimally Invasive Repair of Pectus Excavatum

Introduction: Pectus excavatum is a common congenital anomaly in the pediatric population. During the postoperative period, pain control is one of the top priorities. As a result, multiple techniques for pain control have been developed, including thoracic epidural analgesia, multimodal analgesia (MM), and elastomeric pain pump (EPP) placement. The purpose of this study was to evaluate the effectiveness of pain control using EPP as an adjunct to MM after the minimally invasive repair of pectus excavatum (MIRPE). Methods: We identified all pediatric patients undergoing MIRPE from June 2017 to July 2018. MM was employed in all patients; some patients additionally received subpleural EPP as adjuncts to postoperative analgesia. We reviewed pain scores, length of stay, opioid use, and complications. Results: During the study period, a total of 62 patients were included. The study cohort was divided into 15 patients undergoing MM alone versus 47 patients undergoing subpleural EPP placement plus MM (EPP + MM). Median pain scores were lower in the EPP + MM group (2.9 versus 4.2, P < .05). There was a significant reduction of total inpatient opioid use in the EPP + MM group (357.6 mg versus 466.9 mg, P = .03). There was no difference in median length of stay or complications. We found no significant difference between subpleural versus subcutaneous placement of the infusion catheters. Conclusion: The use of subpleural EPP as an adjunct to MM is an effective way to reduce pain and opioid use after MIRPE without increased risk of complications. Type of Study: Retrospective study with comparison group.

The impact of state laws on motor vehicle fatality rates, 1999-2015

BACKGROUND

Motor vehicle crash (MVC) fatalities have been declining while states passed various legislation targeting driver behaviors. This study assesses the impact of state laws on MVC fatality rates to determine which laws were effective.

METHODS

Publically available data were collected on driver-related motor vehicle laws, law strengths, enactment years, and numbers of verified-trauma centers. Prospective data on crash characteristics and MVC fatalities 16 years or older from Fatality Analysis Reporting System 1999 to 2015 (n = 850) were obtained. Generalize Linear Autoregressive Modeling was used to assess the relative contribution of state laws to the crude MVC fatality rate while controlling for other factors.

RESULTS

Lowering the minimum blood alcohol content (BAC) was associated with largest declines for all ages, especially the older cohorts: 16 years to 20 years (B = 0.23; p < 0.001), 21 years to 55 years (B = 1.7; p < 0.001); 56 years to 65 years (B = 3.2; p < 0.001); older than 65 years (B = 4.1; p < 0.001). Other driving under the influence laws were also significant. Per se BAC laws accompanying a reduced BAC further contributed to declines in crude fatality rates: 21 years to 55 years (B = -0.13; p < 0.001); older than 65 years (B = -0.17; p < 0.05). Driving under the influence laws enhancing the penalties, making revocation automatic, or targeting social hosts had mixed effects by age. Increased enforcement, mandatory education, vehicle impoundment, interlock devices, and underage alcohol laws showed no association with declining mortality rates. Red light camera and seatbelt laws were associated with declines in mortality rates for all ages except for older than 65 years cohort, but speed camera laws had no effect. Graduated Driver License laws were associated with declines for 16 years to 21 years (B = -0.06; p < 0.001) only. Laws targeting specific risks (elderly, motorcycles, marijuana) showed no effect on declining MVC mortality rates during the study period.

CONCLUSION

States have passed a wide variety of laws with varying effectiveness. A few key laws, specifically laws lowering allowable BAC, implementing red light cameras, and mandating seatbelt use significantly reduced MVC mortality rates from 1999 to 2015. Simply adding more laws/penalties may not equate directly to lives saved. Continued research on state laws will better inform policy makers to meet evolving public health needs in the management of MVC fatalities.

LEVEL OF EVIDENCE

Epidemiological, Level III.

Slipping Rib Syndrome: A review of evaluation, diagnosis and treatment

Slipping rib syndrome (SRS) is an under-diagnosed cause of intermittent, yet often debilitating lower rib and abdominal pain. SRS is caused by a hypermobility of the anterior false ribs that allows the 8^th-10^th ribs to slip or click as the cartilaginous rib tip abuts or slips under the rib above. Pain occurs from impingement of the intercostal nerve passing along the undersurface of the adjacent rib. Studies consistently find patients reporting months to years of typical pain symptoms, unnecessary tests and procedures prior to diagnosis. SRS is a clinical diagnosis, but dynamic ultrasound can be helpful for confirmation or diagnosis in difficult cases. Resection of the slipping rib cartilages is the mainstay of treatment, with good results for pain relief. Rib stabilization is an emerging option for recurrent symptoms.

Successful Singleton and Twin Pregnancies With the Nuss Bars in Place

Pectus excavatum (PE) occurs less commonly in women, and the implications on a pregnancy after repair during the period when support bars are in place are unknown. We present 2 cases: 1 with a successful twin gestation and another with a successful singleton gestation. These women carried the pregnancies to term and delivered their infants with the Nuss bars in place.

Pediatric trauma patient alcohol screening: a 3 year review of screening at a Level I pediatric trauma center using the CRAFFT tool

INTRODUCTION

Alcohol use is a risk factor for adult trauma. Alcohol may significantly influence pediatric trauma risk, but literature is sparse. The aim of this study was to examine the impact of alcohol use screening in pediatric trauma patients.

METHODS

A retrospective review was performed of all trauma patients to identify those undergoing CRAFFT alcohol screening assessment between July 1, 2009, and January 31, 2011. Inclusion criteria involved screening of level 1 or 2 trauma activations for patients greater than 12 years.

RESULTS

During the study period, 232 patients were eligible for screening, of which 51% (n=118) were screened. Among the patients screened, 21 (18%) had a positive screen (mean age 14.6 years, range 13-16). Twenty patients were referred for further counseling. Sixteen males and 5 females screened positive during the study. The most common mechanism of injury in the positive screen patients was motor vehicle or ATV accident (n=9), followed by assault (n=6), and motor versus pedestrian collision (n=2). Of the 21 patients who screened positive, 10 had positive blood alcohol content (BAC) or urine drug screen (UDS) at the time of injury. No patients with a positive screen returned during the study as a trauma patient.

CONCLUSION

Alcohol and drug screening for injured pediatric trauma patients is frequently omitted despite policy-required screening. Of those patients screened, 18% admitted to risky alcohol or drug-related behaviors or had positive BAL or UDS at presentation. Pediatric trauma screening for risky alcohol use identifies a significant number of children. Alcohol and drug screening in pediatric trauma appears over age 13 years to have a yield which justifies continued screening. Alcohol related trauma recidivism, however, does not seem common.

Return of the surgeon in the diagnosis of pyloric stenosis

BACKGROUND

The diagnosis of pyloric stenosis (PS) by physical examination is a lost art that has been replaced by radiology-performed ultrasound (US). The purpose of this study is to demonstrate that the diagnosis of PS can be made solely upon the surgeons US evaluation.

METHODS

Surgical ultrasonographers included 2 senior general surgery residents and 2 pediatric surgery residents without prior formal US experience. These surgeons underwent proctored training in the use of US for PS. Measurements including channel length and muscle thickness were recorded at bedside. A positive examination included muscle thickness more than 4 mm and channel length more than 16 mm. Patients with positive results underwent pyloromyotomy. Negative results were confirmed with a repeat US through the radiology department, and infants without PS were subsequently referred for appropriate medical management.

RESULTS

Thirty-two consecutive patients with suspected PS were evaluated using surgeon-performed ultrasonography. All examinations were diagnostically accurate. There were no false-positive or false-negative result. Seven patients (22%) were correctly determined to be negative for PS. The remaining 25 infants underwent successful pyloromyotomy with resolution of symptoms.

CONCLUSION

Surgeons who have undergone focused training to perform US for PS can diagnose the condition without confirmatory testing by a radiologist.

Surgeon-performed ultrasound for diagnosis of pyloric stenosis is accurate, reproducible, and clinically valuable

PURPOSE

We will demonstrate that a surgical resident with proven accuracy in the diagnosis of hypertrophic pyloric stenosis (HPS) can teach other surgeons to diagnose HPS with reproducible accuracy.

METHODS

A surgical resident with proven sonographic accuracy in diagnosing HPS instructed 5 other surgical residents in the technique. Consecutive patients referred to pediatric surgery with a presumed clinical diagnosis of HPS were examined, and measurements of residents were compared with formal radiology studies. Each surgeon was proctored for 5 examinations before independent evaluation and was blinded to results from both radiologists and other residents. Results were evaluated using Student's t test; P less than .05 was considered significant.

RESULTS

Seventy-one patients were evaluated by 5 surgical residents. Residents were diagnostically accurate in all cases. There was no statistically significant difference between pyloric muscle thickness or channel length measurements obtained by radiology and any of the residents.

CONCLUSION

Surgeon-performed ultrasound examination for the diagnosis of HPS is accurate and reproducible through surgeon-to-surgeon instruction on appropriate technique. This skill is a valuable asset in the initial surgical evaluation of any patient with suspected HPS, expediting appropriate management.

Small-Bowel Diaphragm Disease

HYPOTHESIS

Small-bowel diaphragm disease is an important source of gastrointestinal tract bleeding and subacute intestinal obstruction that may require surgical intervention.

DESIGN

Case series.

SETTING

Tertiary-care academic medical center.

PATIENTS

Seven consecutive patients with histologically confirmed enteropathy induced by use of nonsteroidal anti-inflammatory drugs received treatment at our institution from February 2001 to February 2004.

INTERVENTIONS

Laparotomy with small-bowel resection.

MAIN OUTCOME MEASURES

Initial symptoms and signs, findings at diagnostic workup, type of medication and duration of use, operation performed, and intraoperative findings were evaluated.

RESULTS

Patients were identified who had symptoms of subacute intestinal obstruction or signs of gastrointestinal tract bleeding and were determined to have used nonsteroidal anti-inflammatory drugs for differing periods. All 7 patients underwent extensive nondiagnostic radiologic and endoscopic examinations. The diagnosis of diaphragm disease was ultimately made at either video capsule endoscopy or laparotomy. Randomly distributed diaphragms throughout the jejunum and ileum necessitated resection in all cases. No patient has had a documented recurrence, although follow-up is short (range, 0-20 months).

CONCLUSIONS

Nonsteroidal anti-inflammatory drugs are clearly linked to pathologic findings of diaphragm disease in both the upper and lower gastrointestinal tracts. Although rarely reported in the surgical literature, small-bowel diaphragm disease may be more common than thought and can manifest as gastrointestinal tract bleeding or obstruction. Diagnosis is difficult and may require laparotomy and small-bowel resection.

Is breast cancer sentinel lymph node mapping valuable for patients in their seventies and beyond?

BACKGROUND

Axillary lymph node dissection (ALND) is performed less commonly for the axillary staging of elderly patients because it is felt to uncommonly alter therapy. Sentinel lymph node (SLN) dissection can accomplish axillary staging with less morbidity, but it is unclear if it alters subsequent therapy.

METHODS

Review of a prospectively collected breast cancer SLN mapping database. Medical records were reviewed to supplement the database.

RESULTS

Among 730 breast cancer SLN mapping patients, 261 (35.8%) were >or=70 years of age (range 70 to 95). The overall SLN identification rate was 98.8% among those <70 and 97.1% for those >or=70 (P=.11) and 100% and 99.4%, respectively (P=.25), among the most recent 500 patients. SLN metastases were detected by hematoxalin and eosin staining (H&E) in 24.2% of those <70 and 13.4% of those >/=70 (P<.01) and by immunohistochemistry staining (IHC) only in 4.6% and 5.0% of patients, respectively. No elderly patients with histologically negative SLNs underwent ALND, but 88.9% of patients with H&E metastases and 84.6% with IHC metastases underwent ALND. Of the H&E-positive women, 88% underwent adjuvant systemic therapy versus 55% of H&E-negative women (P<.01). Hormonal therapy was administered to 86.9% of SLN-positive women and 54.3% of SLN-negative women (P<.01) and cytotoxic chemotherapy was administered to 24% of SLN-positive patients versus 2.8% of SLN-negative patients (P<.01). SLN status was associated with significantly different rates of systemic therapy for patients with tumors <1 cm and 1 to 2 cm, but not with tumors >2 cm. Mean follow-up was 15.4 months. No patient experienced local or regional recurrence. Distant metastases occurred in 8.2% of patients with SLN metastases and in no patients with negative SLNs (P<.01).

CONCLUSIONS

The results of SLN mapping and biopsy in elderly patients significantly influences subsequent therapy decisions, including ALND, hormonal therapy, and cytotoxic chemotherapy. SLN biopsy should be recommended to elderly breast cancer patients.

Lymphoma creating colojejunal fistula: report of a case and review of the literature

Malignant fistula of the colon to the small bowel is rare and is most often due to adenocarcinoma. Colonic lymphoma is unusual, representing only 0.5 percent of all colonic malignancies. We report a case of intestinal lymphoma presenting with diarrhea and malnutrition. A colojejunal fistula was discovered during colonoscopy by biopsy of small bowel through a fistula in the sigmoid colon. Celiotomy revealed a 12 cm mass in the sigmoid colon with a fistula to the jejunum. Pathology was consistent with T-cell lymphoma. This is a rare entity in a nonimmunocompromised host and has not been described in the English literature.

Characterization of dihydrates prepared from carbamazepine polymorphs

To clarify earlier literature suggesting its existence in more than one solid form, carbamazepine dihydrate was prepared from individual anhydrous carbamazepine polymorphs I and III. The resultant materials were characterized by thermal and spectroscopic techniques, including variable-temperature Fourier transform (FT) Raman spectroscopy. On thermal dehydration, the carbamazepine dihydrates formed different anhydrous polymorphs depending on both starting material and dehydration conditions. Under conditions where liberated hydrate water cannot readily escape from around the sample, the dihydrate originating from polymorph III reverted to polymorph III, but under conditions of lower humidity/moisture, this dihydrate reverted to polymorph I. The dihydrate originating from polymorph I reverted to polymorph I irrespective of dehydration conditions. These observations could be due to a trace amount of nonhydrated original polymorph existing in the dihydrate phase that acts as a seed to regenerate the original polymorph under conditions where liberated hydrate water cannot readily escape from around the sample during dehydration. No evidence was generated that supported the existence of true polymorphs of carbamazepine dihydrate.