Transcystic Laparoscopic Common Bile Duct Exploration for Pediatric Patients with Choledocholithiasis: A Multi-Center Study

BACKGROUND

Patients with choledocholithiasis are often treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Upfront LC, intraoperative cholangiogram (IOC), and possible transcystic laparoscopic common bile duct exploration (LCBDE) could potentially avoid the need for ERCP. We hypothesized that upfront LC + IOC ± LCBDE will decrease length of stay (LOS) and the total number of interventions for children with suspected choledocholithiasis.

METHODS

A multicenter, retrospective cohort study was performed on pediatric patients (<18 years) between 2018 and 2022 with suspected choledocholithiasis. Demographic and clinical data were compared for upfront LC + IOC ± LCBDE and possible postoperative ERCP (OR1st) versus preoperative ERCP prior to LC (OR2nd). Complications were defined as postoperative pancreatitis, recurrent choledocholithiasis, bleeding, or abscess.

RESULTS

Across four centers, 252 children with suspected choledocholithiasis were treated with OR1st (n = 156) or OR2nd (n = 96). There were no differences in age, gender, or body mass index. Of the LCBDE patients (72/156), 86% had definitive intraoperative management with the remaining 14% requiring postoperative ERCP. Complications were fewer and LOS was shorter with OR1st (3/156 vs. 15/96; 2.39 vs 3.84 days, p < 0.05).

CONCLUSION

Upfront LC + IOC ± LCBDE for children with choledocholithiasis is associated with fewer ERCPs, lower LOS, and decreased complications. Postoperative ERCP remains an essential adjunct for patients who fail LCBDE. Further educational efforts are needed to increase the skill level for IOC and LCBDE in pediatric patients with suspected choledocholithiasis.

LEVEL OF EVIDENCE

Level III.

Lessons Learned From the First-In-Human Compassionate Use of Connect-EA™ in Ten Patients With Esophageal Atresia

INTRODUCTION

Delayed primary repair of esophageal atresia in patients with high-risk physiologic and anatomic comorbidities remains a daunting challenge with an increased risk for peri-operative morbidity and mortality via conventional repair. The Connect-EA device facilitates the endoscopic creation of a secure esophageal anastomosis. This follow-up study reports our long-term outcomes with the novel esophageal magnetic compression anastomosis (EMCA) Connect-EA device for EA repair, as well as lessons learned from the ten first-in-human cases. We propose an algorithm to maximize the advantages of the device for EA repair.

METHODS

Under compassionate use approval, from June 2019 to December 2022, ten patients with prohibitive surgical or medical risk factors underwent attempted EMCA with this device. All patients underwent prior gastrostomy, tracheoesophageal fistula ligation (if necessary), and demonstrated pouch apposition prior to EMCA.

RESULTS

Successful device deployment and EMCA formation were achieved in nine patients (90%). Mean time to anastomosis formation was 8 days (range 5-14) and the device was retrieved endoscopically in five (56%) cases. At median follow-up of 22 months (range 4-45), seven patients (78%) are tolerating oral nutrition. Balloon dilations (median 4, range 1-11) were performed either prophylactically for radiographic asymptomatic anastomotic narrowing (n = 7, 78%) or to treat clinically-significant anastomotic narrowing (n = 2, 22%) with no ongoing dilations at 3-month follow up post-repair.

CONCLUSION

EMCA with the Connect-EA device is a safe and feasible minimally-invasive alterative for EA repair in high-risk surgical patients. Promising post-operative outcomes warrant further Phase I investigation.

LEVEL OF EVIDENCE

IV, Case series of novel operative technique without comparison group.

Indocyanine green (ICG) fluorescence-enhanced applications in pediatric surgery

The breadth of pediatric surgical practice and variety of anatomic anomalies that characterize surgical disease in children and neonates require a unique level of operative mastery and versatility. Intraoperative navigation of small, complex, and often abnormal anatomy presents a particular challenge for pediatric surgeons. Clinical experience with fluorescent tissue dye, specifically indocyanine green (ICG), is quickly gaining widespread incorporation into adult surgical practice as a safe, non-toxic means of accurately visualizing tissue perfusion, lymphatic flow, and biliary anatomy to enhance operative speed, safety, and patient outcomes. Experience in pediatric surgery, however, remains limited. ICG-fluorescence guided surgery is poised to address the challenges of pediatric and neonatal operations for a growing breadth of surgical pathology. Fluorescent angiography has permitted intraoperative visualization of colorectal flap perfusion for complex pelvic reconstruction and anastomotic perfusion after esophageal atresia repair, while its hepatic absorption and biliary excretion has made it an excellent agent for delineating the dissection plane in the Kasai portoenterostomy and identifying both primary and metastatic hepatoblastoma lesions. Subcutaneous and intra-lymphatic ICG injection can identify iatrogenic chylous leaks and improved yields in sentinel lymph node biopsies. ICG-guided surgery holds promise for more widespread use in pediatric surgical conditions, and continued evaluation of efficacy will be necessary to better inform clinical practice and identify where to focus and develop this technical resource.

Framework for pediatric robotic surgery program development

Pediatric robotic surgery has seen increasing implementation for its many benefits over the past two decades. As more pediatric surgeons gain exposure to robotic surgery, the interest in utilizing this technology is growing. However, there are no guidelines or existing framework for developing pediatric general surgery robotic programs. Programmatic development can be challenging, requiring institutional support, a minimum 12-month multistep process in partnership with the robot manufacturer, and organization of a local dedicated team. A cornerstone to all program building is collaboration and communication with key stakeholders who are committed to establishing a robotic surgery program. In this manuscript, we detail numerous best practices for implementation, followed by three variations of programmatic development, each drawing lessons from one of three practice settings: (i) A children's hospital in a large medical center associated with an adult hospital, (ii) a free-standing children's hospital, and (iii) a community-based practice. We aim for this article to provide a framework that can serve as a guide for those beginning this process, consolidating the key resources and strategies used to develop a robust pediatric robotic surgery program.

Thoracoscopic Resection of a Rare Congenital Lung Lesion With a Tracheal Bronchus

A tracheal bronchus is a rare anatomic variant characterized by a bronchus originating from the trachea rather than the carina. These are most commonly asymptomatic and found incidentally but can cause recurrent pneumonias in children. Here, we present a case of a thoracoscopic resection of an azygous lobe with a tracheal bronchus in a 9-year-old female.

Multicenter Assessment of Cryoanalgesia Use in Minimally Invasive Repair of Pectus Excavatum: A 20-center Retrospective Cohort Study

OBJECTIVE

To assess the clinical implications of cryoanalgesia for pain management in children undergoing minimally invasive repair of pectus excavatum (MIRPE).

BACKGROUND

MIRPE entails significant pain management challenges, often requiring high postoperative opioid use. Cryoanalgesia, which blocks pain signals by temporarily ablating intercostal nerves, has been recently utilized as an analgesic adjunct. We hypothesized that the use of cryoanalgesia during MIRPE would decrease postoperative opioid use and length of stay (LOS).

MATERIALS AND METHODS

A multicenter retrospective cohort study of 20 US children's hospitals was conducted of children (age below 18 years) undergoing MIRPE from January 1, 2014, to August 1, 2019. Differences in total postoperative, inpatient, oral morphine equivalents per kilogram, and 30-day LOS between patients who received cryoanalgesia versus those who did not were assessed using bivariate and multivariable analysis. P value <0.05 is considered significant.

RESULTS

Of 898 patients, 136 (15%) received cryoanalgesia. Groups were similar by age, sex, body mass index, comorbidities, and Haller index. Receipt of cryoanalgesia was associated with lower oral morphine equivalents per kilogram (risk ratio=0.43, 95% confidence interval: 0.33-0.57) and a shorter LOS (risk ratio=0.66, 95% confidence interval: 0.50-0.87). Complications were similar between groups (29.8% vs 22.1, P =0.07), including a similar rate of emergency department visit, readmission, and/or reoperation.

CONCLUSIONS

Use of cryoanalgesia during MIRPE appears to be effective in lowering postoperative opioid requirements and LOS without increasing complication rates. With the exception of preoperative gabapentin, other adjuncts appear to increase and/or be ineffective at reducing opioid utilization. Cryoanalgesia should be considered for patients undergoing this surgery.

Infectious Complications and Antibiotic Use in Gastroschisis

Background: Gastroschisis is a challenging neonatal condition often with prolonged hospitalizations, need for parenteral nutrition, infectious complications, and can even result in death. Infection is reported to occur in up to two-thirds of patients with gastroschisis and is a strong risk factor for increased morbidity and mortality. Increased days with a central venous catheter, complex gastroschisis, and delayed abdominal wall closure have been consistently found to be associated with increased risk of infection, whereas sutureless gastroschisis closure has been associated with fewer infections. Although one of the most common complications of gastroschisis is infection, the use of antibiotic agents varies widely with variability in the literature to guide management. Antibiotic usage should be selective and short-term, especially in neonates with simple gastroschisis regardless of method for abdominal wall closure. Conclusions: Future initiatives should focus on development of evidence-based guidelines on the care of these patients with the goal of reducing variability and improve outcomes within and across institutions.

Esophageal Surveillance Practices in Esophageal Atresia Patients: A Survey by the Eastern Pediatric Surgery Network

INTRODUCTION

Endoscopic surveillance guidelines for patients with repaired esophageal atresia (EA) rely primarily on expert opinion. Prior to embarking on a prospective EA surveillance registry, we sought to understand EA surveillance practices within the Eastern Pediatric Surgery Network (EPSN).

METHODS

An anonymous, 23-question Qualtrics survey was emailed to 181 physicians (surgeons and gastroenterologists) at 19 member institutions. Likert scale questions gauged agreement with international EA surveillance guideline-derived statements. Multiple-choice questions assessed individual and institutional practices.

RESULTS

The response rate was 77%. Most respondents (80%) strongly agree or agree that EA surveillance endoscopy should follow a set schedule, while only 36% claimed to perform routine upper GI endoscopy regardless of symptoms. Many institutions (77%) have an aerodigestive clinic, even if some lack a multi-disciplinary EA team. Most physicians (72%) expressed strong interest in helping develop evidence-based guidelines.

CONCLUSIONS

Our survey reveals physician agreement with current guidelines but weak adherence. Surveillance methods vary greatly, underscoring the lack of evidence-based data to guide EA care. Aerodigestive clinics may help implement surveillance schedules. Respondents support evidence-based protocols, which bodes well for care standardization. Results will inform the first multi-institutional EA databases in the United States (US), which will be essential for evidence-based care.

LEVEL OF EVIDENCE

This is a prognosis study with level 4 evidence.

The novel application of an emerging device for salvage of primary repair in high-risk complex esophageal atresia

INTRODUCTION

Preservation of native esophagus is a tenet of esophageal atresia (EA) repair. However, techniques for delayed primary anastomosis are severely limited for surgically and medically complex patients at high-risk for operative repair. We report our initial experience with the novel application of the Connect-EA, an esophageal magnetic compression anastomosis device, for salvage of primary repair in 2 high-risk complex EA patients. Compassionate use was approved by the FDA and treating institutions.

OPERATIVE TECHNIQUE

Two approaches using the Connect-EA are described - a totally endoscopic approach and a novel hybrid operative approach. To our knowledge, this is the first successful use of a hybrid operative approach with an esophageal magnetic compression device.

OUTCOMES

Salvage of delayed primary anastomosis was successful in both patients. The totally endoscopic approach significantly reduced operative time and avoided repeat high-risk operation. The hybrid operative approach salvaged delayed primary anastomosis and avoided cervical esophagostomy.

CONCLUSION

The Connect-EA is a novel intervention to achieve delayed primary esophageal repair in complex EA patients with high-risk tissue characteristics and multi-system comorbidities that limit operative repair. We propose a clinical algorithm for use of the totally endoscopic approach and hybrid operative approach for use of the Connect-EA in high-risk complex EA patients.

Elective choledochal cyst excision is associated with improved postoperative outcomes in children

PURPOSE

The majority of pediatric patients with choledochal cysts (CDC) are symptomatic prior to undergoing CDC excision. This study investigated the impact of surgical timing of CDC excision on postoperative outcomes among children.

METHODS

We performed a retrospective review of 59 patients undergoing open CDC excision with Roux-Y hepaticojejunostomy between 2000 and 2020. Patients were grouped based on whether they underwent an electively scheduled or urgent CDC excision, as defined as CDC excision within the same admission due to CDC-related symptoms. Patient characteristics and perioperative data were compared between the two groups.

RESULTS

Patients who underwent an elective surgery were older, had more Todani-type 1 CDC, and had decreased postoperative hospital length of stay and opioid use compared to patients who underwent CDC excision within the same admission due to CDC-related symptoms. No significant differences emerged regarding postoperative complications. Multivariable analysis showed that elective cyst excision (HR = 0.55, p = 0.04; HR = 0.59, p = 0.008) and type 1 CDC (HR = 0.32, p = 0.03; HR = 0.12, p < 0.001) were independently associated with decreased opioid use and postoperative hospital length of stay.

CONCLUSIONS

Elective CDC excision is associated with shortened hospital stay and decreased opioid use among children compared to patients who undergo a CDC excision during the same admission for CDC-related symptoms.

Intraoperative Ultrasound Guided Laparoscopic Spleen-Preserving Distal Pancreatectomy for Primitive Neuroendocrine Tumors in a Pediatric Patient with MEN-1

This case details the presentation and surgical management of a 15-year-old male patient with multiple endocrine neoplasia syndrome type 1 (MEN1) who required distal pancreatectomy for multiple nonfunctional pancreatic tumors. An intraoperative ultrasound was utilized to allow for proper location of the distal pancreatectomy, as well as visualization of the splenic vessel relationships and to ensure all lesions were contained within the specimen. Pathology demonstrated 5 well-differentiated neuroendocrine tumors with no evidence of malignancy. This case utilized innovative technology and a multidisciplinary approach in a challenging case to achieve a safe minimally invasive resection. The use of ultrasound intraoperatively provided confidence that all lesions had been identified, as well as demonstration of safe planes separate from the nearby vasculature.

Endoluminal Silicone-Covered Stenting in Children: Novel Applications and Lessons Learned

BACKGROUND

Silicone-covered endoluminal stents have been applied to various hollow visceral disorders in adult patients with varying success. Efficacy of retrievable endoluminal stenting in children is less well-established.

PURPOSE

The purpose of this study was to evaluate our experience with evolving applications of endoluminal silicone-covered stenting in children.

RESEARCH DESIGN

Eight children 19 years and younger having silicone-covered stent placement for various indications at a single institution (2014-2021) were reviewed retrospectively.

RESULTS

Eight patients received a total of 26 silicone-covered stents. Four stent placements (15.4%) were associated with a direct adverse event. To resolve the endoluminal disorder, four patients received multiple stents or further intervention. When evaluating novel applications, clinical benefit was noted for one patient with vaginal atresia, and another after ileal pouch anal anastomosis disruption.

CONCLUSION

This experience highlights the broad and innovative applications for endoluminal silicone-covered natural orifice stenting in children. Acute processes respond well and rapidly to stenting, although chronic, established fistula may require additional manipulations or surgery.

Laparoscopic Resection of Pediatric Solid Pseudopapillary Tumors of the Pancreas

BACKGROUND

Solid pseudopapillary tumors (SPTs) of the pancreas arise rarely in children, are often large, and can associate intimately with splenic vessels. Splenic preservation is a fundamental consideration when resecting distal SPT. Occasionally, the main splenic vessels must be divided to resect the SPT with negative margins, but the spleen can be preserved if the short gastric vessels remain intact (ie, Warshaw procedure). The purpose of this study was to evaluate outcomes of distal pancreatectomy (DP) for SPT in children and to highlight 2 cases of splenic preservation using the Warshaw procedure.

METHODS

Patients 19 years and younger who were treated at a single children's hospital between July 2004 and January 2021 were examined. Patient characteristics were collected from the electronic medical record. A pediatric radiologist calculated SPT and pre- and post-operative (ie, non-infarcted) splenic volumes.

RESULTS

Eleven patients received DP for SPT. Six DPs were performed open and 5 laparoscopically. The spleen was preserved in 3 open and 4 laparoscopic DPs. A laparoscopic Warshaw procedure was performed in 2 patients. Laparoscopic resection associated with less frequent epidural use (P = .015), shorter time to full diet (P = .030), and post-operative length of stay (P = .009), compared to open resection. Average residual splenic volume after the laparoscopic Warshaw procedure was 70% of preoperative volume.

DISCUSSION

Laparoscopic DP for pediatric SPT achieved similar oncologic goals to open resection. Splenic preservation was feasible with laparoscopy in most cases and was successfully supplemented with the Warshaw procedure, which has not been previously reported for SPT resection in children.

Choledocholithiasis-a new clinical pathway

The incidence of cholecystectomy in children has increased considerably since the early 1990s. Management of gallbladder disease in children must include an awareness of choledocholithiasis treatment strategies. Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis. Laparoscopic cholecystectomy with preoperative or postoperative ERCP is at least a two-procedure process while cholecystectomy with laparoscopic common bile duct exploration (LCBDE) can provide definitive treatment in a single procedure under one anesthetic. Despite this, the trend over the last decade continues towards less LCBDE utilization in favor of ERCP. This trend has resulted in decreased familiarity with LCBDE by adult and pediatric surgeons and their trainees. Access to the necessary tools and education on the technical aspects can allow for successful single-stage treatment of choledocholithiasis by surgeons during laparoscopic cholecystectomy. This may include a pre-defined stepwise algorithm and understanding of all the equipment and resources necessary to perform a LCBDE. Ultimately, increased understanding of the equipment and procedural steps necessary for LCBDE will result in widened adoption of the technique and thus confer advantages to the patient such as decreased length of stay and fewer required anesthetics.

How Long Does it Take to Diagnose Appendicitis? Time Point Process Mapping in the Emergency Department

OBJECTIVES

Appendicitis is the most common surgical emergency encountered in the pediatric emergency department (ED). We analyzed the time course of children evaluated for suspected appendicitis in relation to implementation of a risk-stratified ultrasound scoring system and structured reporting template (Appy-Score).

METHODS

In July 2013, a 6-level ultrasound (US)-based appendicitis scoring system was developed and implemented. The records of children (age ≤18 years) who underwent limited abdominal US exams for suspected appendicitis at a large academic pediatric ED were reviewed retrospectively. Time periods evaluated were from January 1 to April 1, 2013 (before implementation of the US scoring system, "PRE") and July 1 to October 1, 2013 (after implementation of the US scoring system, "POST"). Times are presented as medians with interquartile range.

RESULTS

A total of 926 children were included (median age, 9.5 years [range, 0.1-18 years]; 49% female). Four hundred eighty-one patients were evaluated PRE and 445 POST. When comparing the 2 groups, there were no differences in the PRE and POST periods with regard to time from US ordered to first read (102 vs 112 minutes, P = 0.30), US ordered to disposition (215 vs 208 minutes, P = 0.40) and operating room posting (121 vs 122 minutes, P = 0.59), and overall ED stay (329 vs 333 minutes, P = 0.39).

CONCLUSIONS

The development of a radiographic appendicitis score, although allowing for a standardized reporting method, did not significantly alter the ED process flow for evaluation of appendicitis. This reflects the complexities in ED throughput and reveals the need for additional factors to change to improve patient flow.

In-utero radiofrequency ablation in fetal piglets: Lessons learned

INTRODUCTION

Radiofrequency ablation (RFA) is increasingly utilized in minimally invasive fetal intervention. However, the response of different fetal tissues to RFA is poorly characterized. We sought to determine the extent of RFA damage in a fetal environment.

METHODS

90Day gestation Yorkshire piglets (term 115days) were subjected to RFA of the chest and abdominal viscera under various temperatures and wattages. The extent of tissue damage was determined by NADPH diaphorase histochemistry.

RESULTS

Tyne temperature was widely variable and displayed varying responses between lung and liver tissue. Tyne exposure to amniotic fluid resulted in an increase in amniotic fluid temperature. Collateral damage, even across the diaphragm, was readily seen, and ultrasonography did not always reflect this injury.

CONCLUSIONS

Utilization of extracorporeal tynes heats fluid at a greater rate than solid tissue and reliance on temperature sensitive probes may result in overheating. The extent of injury may extend beyond damage observed by ultrasound examination and varies for different tissues. Additional studies on the use of devices that regulate tyne temperature are needed to define optimal conditions and better define the extent of adjacent tissue injury.

Repeated isoflurane exposure and neuroapoptosis in the midgestation fetal sheep brain

BACKGROUND

Advances in surgery and technology have resulted in increased in-utero procedures. However, the effect of anesthesia on the fetal brain is not fully known. The inhalational anesthetic agent, isoflurane, other gamma amino butyric acid agonists (benzodiazepines, barbiturates, propofol, other inhalation anesthetics), and N-methyl D aspartate antagonists, eg, ketamine, have been shown to induce neuroapoptosis. The ovine model has been used extensively to study maternal-fetal physiologic interactions and to investigate different surgical interventions on the fetus.

OBJECTIVE

The purpose of this study was to determine effects of different doses and duration of isoflurane on neuroapoptosis in midgestation fetal sheep. We hypothesized that repeated anesthetic exposure and high concentrations of isoflurane would result in increased neuroapoptosis.

STUDY DESIGN

Time-dated, pregnant sheep at 70 days gestation (term 145 days) received either isoflurane 2% × 1 hour, 4% × 3 hours, or 2% × 1 hour every other day for 3 exposures (repeated exposure group). Euthanasia occurred following anesthetic exposure and fetal brains were processed. Neuroapoptosis was detected by immunohistochemistry using anticaspase-3 antibodies. Fetuses unexposed to anesthesia served as controls. Another midgestation group with repeated 2% isoflurane exposure was examined at day 130 (long-term group) and neuronal cell density compared to age-matched controls. Representative sections of the brain were analyzed using Aperio Digital imaging (Leica Microsystems Inc, Buffalo Grove, IL). Data, reported by number of neurons per cubic millimeter of brain tissue are presented as means and SEM. Data were analyzed using the Mann-Whitney U and Kruskal-Wallis tests as appropriate.

RESULTS

A total of 34 fetuses were studied. There was no significant difference in neuroapoptosis observed in fetuses exposed to 2% isoflurane for 1 hour or 4% isoflurane for 3 hours. Increased neuroapoptosis was observed in the frontal cortex following repeated 2% isoflurane exposure compared to controls (1.57 ± 0.22 × 10(6)/mm(3) vs 1.01 ± 0.44 × 10(6)/mm(3), P = .02). Fetuses at 70 days gestation with repeated exposure demonstrated decreased frontal cortex neurons at day 130 when compared to age-matched controls (2.42 ± 0.3 × 10(5)/mm(3) vs 7.32 ± 0.4 × 10(5)/mm(3), P = .02). No significant difference in neuroapoptosis was observed between the repeated exposure group and controls in the hippocampus, cerebellum, or basal ganglia.

CONCLUSION

Repeated isoflurane exposure in midgestation sheep resulted in increased frontal cortex neuroapoptosis. This persisted into late gestation as decreased neuronal cell density. While animal studies should be extrapolated to human beings with caution, our findings suggest that the number of anesthetic/sedative exposures should be considered when contemplating the risks and benefits of fetal intervention as certain fetal therapies may need to be repeated.

Assessment of quality of life outcomes using the pediatric quality of life inventory survey in prenatally diagnosed congenital diaphragmatic hernia patients

INTRODUCTION

Congenital diaphragmatic hernia patients can have significant postnatal morbidity. To date, there has been no quality of life (QOL) study in a prenatally diagnosed CDH patient population, assessing prenatal disease severity and QOL. The purpose of this pilot study was to assess the QOL in a single institution fetal center CDH experience.

METHODS

The study was a retrospective cohort study of CDH patients diagnosed by fetal ultrasound and MRI at a fetal center between March 2002-March 2014. Parents of children ≥2years were contacted by telephone to participate in the validated Pediatric Quality of Life Inventory (PedsQL™, Version 4.0).

RESULTS

Of 95 CDH survivors, 68 met inclusion criteria, of which 28 (42%) completed the survey (mean age, range: 5.5, 2.3-11.7years). Based on prenatal markers of disease severity, there were no differences in performance between those with mild or severe forms of CDH. Overall, patients had minimal QOL limitations, but those with limitations had a higher risk for oxygen dependence at 30days of life (71%v. 29%, OR 0.16, CI, 0.031-0.82, p=0.02). ECMO was not associated with significantly worse QOL in physical or psychosocial functioning. Cronbach's alpha reliability coefficient yielded a correlation of 0.951 for the overall survey, 0.911 for physical functioning, and 0.901 for psychosocial functioning questions.

CONCLUSIONS

Patients that are prenatally diagnosed with severe forms of CDH have similar QOL outcomes across all categories of physical and psychosocial functioning. This pilot study is encouraging and may allow improved counseling for expectant parents of CDH patients.

Feeding gastrostomy in children with complex heart disease: when is a fundoplication indicated?

PURPOSE

Malnutrition is common among children with complex heart disease (CHD). Feeding gastrostomies are often used to improve the nutritional status of such patients. Our purpose was to evaluate a cohort of children with CHD following open Stamm gastrostomy without fundoplication.

METHODS

We reviewed all CHD patients who underwent feeding gastrostomy placement from 1/1/2004 to 4/7/2015. Demographic data, cardiac diagnoses, operative details, post-operative complications, and the need for GJ feeding and fundoplication were examined.

RESULTS

Open Stamm gastrostomy was performed in 111 patients. Median age at surgery was 37 weeks (3 weeks-13.7 years); average weight was 5.3 ± 4.9 kg. Thirty-four patients (30 %) experienced a total of 37 minor complications, including tube dislodgement after stoma maturation (20), superficial surgical site infection (13), mechanical failure (3), and bleeding (1). Three patients experienced a major complication (need for return to the OR or peri-operative death <30 days). Three patients required a subsequent fundoplication. Fifty-six surviving patients (62 %) continue gastrostomy feeds, of which 7 (13 %) patients require GJ feeds.

CONCLUSION

Children with CHD tolerate an open Stamm gastrostomy well with minimal major complications. These results support very selective use of fundoplication in infants and children with CHD who require a feeding gastrostomy.

Quantification of liver herniation in fetuses with isolated congenital diaphragmatic hernia using two-dimensional ultrasonography

OBJECTIVES

To describe a method of quantifying the amount of liver herniation in fetuses with isolated congenital diaphragmatic hernia (CDH) using two-dimensional ultrasonography and to correlate this finding with neonatal outcome.

METHODS

Ultrasound images obtained from 77 consecutive fetuses that presented with isolated CDH between January 2004 and July 2012 were reviewed. Liver herniation and thoracic area were measured in a cross-sectional plane of the fetal chest at the level of the four-chamber view of the heart (the same section as is used to measure the lung area-to-head circumference ratio) and the ultrasound-derived liver-to-thoracic area ratio (US-LiTR) was calculated by dividing the liver herniation area by the thoracic area. Receiver-operating characteristics (ROC) curve analysis was used to evaluate the performance of US-LiTR in predicting neonatal outcome (survival to 6 months after delivery and need for extracorporeal membrane oxygenation (ECMO)). In addition, the US-LiTR was compared with the magnetic resonance imaging (MRI)-derived volume ratio (MRI-LiTR) and percentage of liver herniation (MRI-%LH).

RESULTS

The overall neonatal mortality in the 77 cases with isolated CDH was 20.8% (16/77). ECMO was needed in 35.5% (27/76) of the newborns, with a survival rate of 52%. The US-LiTR was associated statistically with mortality (P < 0.01) and with the need for ECMO (P < 0.01). Good correlations were observed between US-LiTR and MRI-LiTR (r = 0.87; P < 0.001) and between US-LiTR and MRI-%LH (r = 0.90; P < 0.001). Based on ROC curve analysis, all three parameters had similar accuracy in predicting mortality (US-LiTR: area under the ROC curve (AUC), 0.78 (95% CI, 0.65-0.92), P < 0.01; MRI-LiTR: AUC, 0.77 (95% CI, 0.63-0.90), P < 0.01; MRI-%LH: AUC, 0.79 (95% CI, 0.65-0.92), P < 0.01, respectively) as well as the need for ECMO (US-LiTR: AUC, 0.72 (95% CI, 0.60-0.84), P < 0.01; MRI-LiTR: AUC, 0.73 (95% CI, 0.60-0.88), P < 0.01; MRI-%LH: AUC, 0.77 (95% CI, 0.64-0.89), P < 0.01, respectively).

CONCLUSIONS

Two-dimensional ultrasound measurement of the amount of liver herniation in fetuses with isolated CDH is feasible and demonstrates a predictive accuracy for neonatal outcome similar to that of MRI.

Low Abdominal NIRS Values and Elevated Plasma Intestinal Fatty Acid-Binding Protein in a Premature Piglet Model of Necrotizing Enterocolitis

To identify early markers of necrotizing enterocolitis (NEC), we hypothesized that continuous abdominal near-infrared spectroscopy (A-NIRS) measurement of splanchnic tissue oxygen saturation and intermittent plasma intestinal fatty-acid binding protein (pI-FABP) measured every 6 hours can detect NEC prior to onset of clinical symptoms. Premature piglets received parenteral nutrition for 48-hours after delivery, followed by enteral feeds every three hours until death or euthanasia at 96-hours. Continuous A-NIRS, systemic oxygen saturation (SpO₂), and heart rate were measured while monitoring for clinical signs of NEC. Blood samples obtained at 6-hour intervals were used to determine pI-FABP levels by ELISA. Piglets were classified as fulminant-NEC (f-NEC), non-fulminant-NEC (nf-NEC) and No-NEC according to severity of clinical and histologic features. Of 38 piglets, 37% (n=14) developed nf-NEC, 18% (n=7) developed f-NEC and 45% (n=17) had No-NEC. There were significant differences in baseline heart rate (p=0.008), SpO₂ (p<0.001) and A-NIRS (p<0.001) among the three groups. A-NIRS values of NEC piglets remained lower throughout the study with mean for f-NEC of 69±3.8%, 71.9±4.04% for nf-NEC, and 78.4±1.8% for No-NEC piglets (p<0.001). A-NIRS <75% predicted NEC with 97% sensitivity and 97% specificity. NEC piglets demonstrated greater variability from baseline in A-NIRS than healthy piglets (10.1% vs. 6.3%; p=0.04). Mean pI-FABP levels were higher in animals that developed NEC compared to No-NEC piglets (0.66 vs. 0.09 ng/mL;p<0.001). In f-NEC piglets, pI-FABP increased precipitously after feeds (0.04 to 1.87 ng/mL;p<0.001). pI-FABP levels increased in parallel with disease progression and a value >0.25ng/mL identified animals with NEC (68% sensitivity and 90% specificity). NIRS is a real-time, non-invasive tool that can serve as a diagnostic modality for NEC. In premature piglets, low A-NIRS in the early neonatal period and increased variability during initial feeds are highly predictive of NEC, which is then confirmed by rising plasma I-FABP levels. These modalities may help identify neonates with NEC prior to clinical manifestations of disease.

Congenital heart anomaly in newborns with congenital diaphragmatic hernia: a single-center experience

OBJECTIVE

To evaluate the impact of the presence of a congenital heart anomaly (CHA) and its potential contribution to morbidity and mortality in infants with congenital diaphragmatic hernia (CDH).

METHODS

In this retrospective cohort study, prenatal and postnatal data of all newborns diagnosed with CDH between January 2004 and December 2012 in a single center were reviewed. Cases were classified into two groups: those with 'isolated' CDH and those with both CDH and CHA. Patients with CHA were further subclassified into those with a major or minor CHA based on the Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1), and the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery (STS-EACTS) scoring systems. Patients with associated non-cardiac anomalies, including 'syndromic cases', were excluded from the analysis. Primary and secondary outcomes were survival up to 1 year of age and a need for extracorporeal membrane oxygenation (ECMO), respectively.

RESULTS

Of the 180 infants with CDH, 41 were excluded because of the presence of non-cardiac associated anomalies, 118 had isolated CDH and 21 had CDH with CHA (16 with minor and five with major CHA). Receiver-operating characteristics curve analysis demonstrated that the best cut-off for survival was when the score for CHA was ≤ 2 for both RACHS-1 (area under the curve (AUC), 0.74 (P = 0.04); sensitivity, 80.0%; specificity, 87.5%) and STS-EACTS (AUC, 0.83 (P = 0.03); sensitivity, 100%; specificity, 87.5%). Survival rate at 1 year was significantly lower in those with CHD and a major CHA (40.0%; P = 0.04) than in those with isolated CDH (77.1%) and those with CDH and a minor CHA (81.3%). We found no significant differences among the groups with regard to the need for ECMO.

CONCLUSIONS

In general, a milder form of CHA does not appear to have a negative impact on the survival of infants with CDH. However, mortality appears to be significantly higher in infants with CDH and a major form of CHA. The scoring systems appear to be useful as predictors for classifying the effects of CHA in this population of patients.

Persistent hypercarbia after resuscitation is associated with increased mortality in congenital diaphragmatic hernia patients

BACKGROUND

Within congenital diaphragmatic hernia (CDH) care, there have been attempts to identify clinical parameters associated with patient survival, including markers of postnatal pulmonary gas exchange. This study aimed to identify whether postnatal pulmonary gas exchange parameters correlated with CDH patient survival.

METHODS

A retrospective review was performed of isolated CDH neonates treated at a single institution from 1/2007 to 12/2013. Patient demographics, prenatal imaging, and postnatal clinical parameters, including arterial blood gas values within the first 24hours of life, were collected.

RESULTS

Seventy-four patients with isolated CDH were identified. Fifty-seven had fetal MRI. Overall, 30-day patient survival was 85%. Sixteen infants (22%) required ECMO within 24hours. Mean initial PaCO2 in nonsurvivors was higher, and infants who remained hypercarbic postresuscitation (72±19mmHg) had a worse prognosis than those who resuscitated to a normal PaCO2 (39±1.6mmHg) (p<0.001). Prenatal fetal lung volumes measured by MRI were not strongly correlated with PaCO2 levels.

CONCLUSION

CDH nonsurvivors are unable to maintain sufficient pulmonary gas exchange during the first 24hours of resuscitation. Furthermore, prenatal fetal lung volumes are weakly correlated with actual pulmonary gas exchange. These data may be useful for patient counseling during the resuscitative phase of CDH care.

Vitamin E in New-Generation Lipid Emulsions Protects Against Parenteral Nutrition-Associated Liver Disease in Parenteral Nutrition-Fed Preterm Pigs

INTRODUCTION

Parenteral nutrition (PN) in preterm infants leads to PN-associated liver disease (PNALD). PNALD has been linked to serum accumulation of phytosterols that are abundant in plant oil but absent in fish oil emulsions.

HYPOTHESIS

Whether modifying the phytosterol and vitamin E composition of soy and fish oil lipid emulsions affects development of PNALD in preterm pigs.

METHODS

We measured markers of PNALD in preterm pigs that received 14 days of PN that included 1 of the following: (1) Intralipid (IL, 100% soybean oil), (2) Intralipid + vitamin E (ILE, d-α-tocopherol), (3) Omegaven (OV, 100% fish oil), or (4) Omegaven + phytosterols (PS, β-sitosterol, campesterol, and stigmasterol).

RESULTS

Serum levels of direct bilirubin, gamma glutamyl transferase, serum triglyceride, low-density lipoprotein, and hepatic triglyceride content were significantly lower (P < .05) in the ILE, OV, and PS compared to IL. Hepatic cholesterol 7-hydroxylase and organic solute transporter-α expression was lower (P < .05) and portal plasma FGF19 higher in the ILE, OV, and PS vs IL. Hepatic expression of mitochondrial carnitine palmitoyltransferase 1A and microsomal cytochrome P450 2E1 fatty acid oxidation genes was higher in ILE, OV, and PS vs IL. In vivo (13)C-CDCA clearance and expression of pregnane X receptor target genes, cytochrome P450 3A29 and multidrug resistance-associated protein 2, were higher in ILE, OV, and PS vs IL.

CONCLUSIONS

α-tocopherol in Omegaven and added to Intralipid prevented serum and liver increases in biliary and lipidemic markers of PNALD in preterm piglets. The addition of phytosterols to Omegaven did not produce evidence of PNALD.

Are all pulmonary hypoplasias the same? A comparison of pulmonary outcomes in neonates with congenital diaphragmatic hernia, omphalocele and congenital lung malformation

INTRODUCTION

Patients with congenital diaphragmatic hernias (CDH), omphaloceles, and congenital lung malformations (CLM) may have pulmonary hypoplasia and experience respiratory insufficiency. We hypothesize that given equivalent lung volumes, the degree of respiratory insufficiency will be comparable regardless of the etiology.

METHODS

Records of all fetuses with CDH, omphalocele, and CLM between January 2000 and June 2013 were reviewed. MRI-based observed-to-expected total fetal lung volumes (O/E-TFLV) were calculated. An analysis of outcomes in patients with O/E-TFLV between 40% and 60%, the most inclusive range, was performed.

RESULTS

285 patients were evaluated (161, CDH; 24, omphalocele; 100, CLM). Fetuses with CDH had the smallest mean O/E-TFLV. CDH patients were intubated for longer and had a higher incidence of pulmonary hypertension. Fifty-six patients with the three diagnoses had an O/E-TFLV of 40%-60%. The need for ECMO, supplemental oxygen at 30days of life, and 6-month mortality were similar among groups. CDH patients had a significantly longer duration of intubation and higher incidence of pulmonary hypertension than the other two diagnoses.

CONCLUSION

Given equivalent lung volumes (40%-60% of expected), CDH patients require more pulmonary support initially than omphalocele and CLM patients. In addition to lung volumes, disease-specific factors, such as pulmonary hypertension in CDH, also contribute to pulmonary morbidity and overall outcome.

Outcomes comparing dual-lumen to multisite venovenous ECMO in the pediatric population: the Extracorporeal Life Support Registry experience

PURPOSE

The purpose of this study is to evaluate outcomes associated with single site dual-lumen venovenous cannulas (VVDL) and to compare them to those associated with multisite VV ECMO (VVMS) cannulation.

METHODS

The Extracorporeal Life Support (ELSO) Registry was reviewed to identify all children 31days to 18years treated with venovenous ECMO from 1998 to 2011 using either VVDL or VVMS techniques. Patient demographics, cannula type, ECMO variables, complications, and patient survival were analyzed.

RESULTS

From 1998 to 2011, 1323 children underwent venovenous ECMO. The annual utilization of VVDL cannulas has increased and recently surpassed VVMS. Fifty-four percent (n=717) of patients had VVDL cannulation. This group was significantly younger and weighed less than the VVMS group. VVDL cannulas demonstrated improved weight-adjusted flow performance than traditional cannulation. Overall survival was comparable, 64.4% and 68.6%, for VVMS and VVDL respectively. VVDL cannulas experienced higher mechanical (26.2% vs. 22.5%; p=0.004) and cardiovascular complications rates (24.4% vs. 21.7%; p=0.03) than VVMS cannulas, but when stratified by VVDL cannula type, there were no differences between wire-reinforced and non-wire reinforced cannulas.

CONCLUSIONS

VVDL cannulation has become the preferred modality for ECMO therapy in children with respiratory failure and it is mainly utilized in younger patients. The use of newer VVDL cannulas may provide improved pump flow performance without substantial additional risk.

Fetal lung volume and quantification of liver herniation by magnetic resonance imaging in isolated congenital diaphragmatic hernia

OBJECTIVE

To determine associations between fetal lung and liver herniation volumes measured by magnetic resonance imaging (MRI) and mortality/need for extracorporeal membrane oxygenation (ECMO) in cases of isolated congenital diaphragmatic hernia (CDH). A secondary objective was to compare prenatal MRI parameters with two-dimensional ultrasound lung measurements.

METHODS

A retrospective review of medical records of all fetuses with isolated CDH evaluated between January 2004 and July 2012 was performed. The following MRI parameters were measured at 20-32 weeks: observed/expected total fetal lung volume (o/e-TLV), predicted pulmonary volume (PPV), percentage of liver herniated into the fetal thorax (%LH) and the liver/thoracic volume ratio (LiTR). These were compared with the ultrasound-determined lung-to-head ratio (LHR) and the observed/expected LHR (o/e-LHR) in the same cohort. The predictive value of MRI and ultrasound parameters for mortality and the need for ECMO was evaluated by univariate, multivariate and factor analysis and by receiver-operating characteristics curves.

RESULTS

Eighty fetuses with isolated CDH were evaluated. Overall mortality was 18/80 (22.5%). Two newborns died a few hours after birth. ECMO was performed in 29/78 (37.2%) newborns, with a survival rate of 48.3% (14/29). The side of the diaphragmatic defect was not associated with mortality (P = 0.99) or the need for ECMO (P = 0.48). Good correlation was observed among o/e-TLV, PPV, LHR and o/e-LHR as well as between %LH and LiTR (r = 0.89; P < 0.01); however, fetal lung measurements and measures of liver herniation were not correlated (all P > 0.05). All parameters were statistically associated with mortality or the need for ECMO. The best combination of measurements to predict mortality was o/e-TLV and %LH, with 83% accuracy.

CONCLUSION

Mortality and the need for ECMO in neonates with isolated CDH can be best predicted using a combination of MRI o/e-TLV and %LH.

Fetal MRI lung volumes are predictive of perinatal outcomes in fetuses with congenital lung masses

PURPOSE

The purpose of this study was to evaluate fetal magnetic resonance imaging (MRI) as a modality for predicting perinatal outcomes and lung-related morbidity in fetuses with congenital lung masses (CLM).

METHODS

The records of all patients treated for CLM from 2002 to 2012 were reviewed retrospectively. Fetal MRI-derived lung mass volume ratio (LMVR), observed/expected normal fetal lung volume (O/E-NFLV), and lesion-to-lung volume ratio (LLV) were calculated. Multivariate regression and receiver operating characteristic analyses were applied to determine the predictive accuracy of prenatal imaging.

RESULTS

Of 128 fetuses with CLM, 93% (n=118) survived. MRI data were available for 113 fetuses. In early gestation (<26weeks), MRI measurements of LMVR and LLV correlated with risk of fetal hydrops, mortality, and/or need for fetal intervention. In later gestation (>26weeks), LMVR, LLV, and O/E-NFLV correlated with neonatal respiratory distress, intubation, NICU admission and need for neonatal surgery. On multivariate regression, LMVR was the strongest predictor for development of fetal hydrops (OR: 6.97, 1.58-30.84; p=0.01) and neonatal respiratory distress (OR: 12.38, 3.52-43.61; p≤0.001). An LMVR >2.0 predicted worse perinatal outcome with 83% sensitivity and 99% specificity (AUC=0.94; p<0.001).

CONCLUSION

Fetal MRI volumetric measurements of lung masses and residual normal lung are predictive of perinatal outcomes in fetuses with CLM. These data may assist in perinatal risk stratification, counseling, and resource utilization.

Fetal MRI improves diagnostic accuracy in patients referred to a fetal center for suspected esophageal atresia

PURPOSE

The purpose of this study was to describe prenatal imaging characteristics and outcomes of fetuses with suspected esophageal atresia (EA) in order to improve prenatal diagnosis, counseling, and management.

METHODS

The medical records of all patients referred to our multidisciplinary fetal center for suspected EA from January 2003 to April 2013 were reviewed retrospectively.

RESULTS

Thirty-three patients were referred with a prenatal diagnosis of possible EA. Following fetal center evaluation with MRI, EA was deemed unlikely in 6 (18%) fetuses. Of 27 fetuses in whom EA could not be excluded, EA was confirmed postnatally in 15 (56%), excluded in 7 (26%), and unconfirmed in 5 (3 fetal losses; 2 lost to follow-up). Imaging characteristics on fetal MRI associated with the highest positive predictive values (PPV) were an esophageal pouch (100%) and a small stomach (75%). The finding of polyhydramnios had high sensitivity (93%) but low specificity (31%) and PPV (61%) for a diagnosis of EA.

CONCLUSION

Prenatal imaging and fetal center evaluation correctly identify the presence or absence of esophageal atresia in 78% of patients referred on suspicion of this condition. The presence of an esophageal pouch on fetal MRI has significant predictive value for EA. These data may assist with evidence-based prenatal family counseling.

Prenatal MRI fetal lung volumes and percent liver herniation predict pulmonary morbidity in congenital diaphragmatic hernia (CDH)

PURPOSE

The purpose of this study was to determine whether prenatal imaging parameters are predictive of postnatal CDH-associated pulmonary morbidity.

METHODS

The records of all neonates with CDH treated from 2004 to 2012 were reviewed. Patients requiring supplemental oxygen at 30 days of life (DOL) were classified as having chronic lung disease (CLD). Fetal MRI-measured observed/expected total fetal lung volume (O/E-TFLV) and percent liver herniation (%LH) were recorded. Receiver operating characteristic (ROC) curves and multivariate regression were applied to assess the prognostic value of O/E-TFLV and %LH for development of CLD.

RESULTS

Of 172 neonates with CDH, 108 had fetal MRIs, and survival was 76%. 82% (89/108) were alive at DOL 30, 46 (52%) of whom had CLD. Neonates with CLD had lower mean O/E-TFLV (30 vs.42%; p=0.001) and higher %LH (21.3±2.8 vs.7.1±1.8%; p<0.001) compared to neonates without CLD. Using ROC analysis, the best cutoffs in predicting CLD were an O/E-TFLV<35% (AUC=0.74; p<0.001) and %LH>20% (AUC=0.78; p<0.001). On logistic regression, O/E-TFLV<35% and a %LH>20% were highly associated with indicators of long-term pulmonary sequelae. On multivariate analysis, %LH was the strongest predictor of CLD in patients with CDH (OR: 10.96, 95%CI: 2.5-48.9, p=0.002).

CONCLUSION

Prenatal measurement of O/E-TFLV and %LH is predictive of CDH pulmonary morbidity and can aid in establishing parental expectations of postnatal outcomes.

Mainstem bronchial atresia: a lethal anomaly amenable to fetal surgical treatment

PURPOSE

The purpose of this study was to review the unique imaging characteristics, prenatal course, and outcomes for fetuses with mainstem bronchial atresia (MBA).

METHODS

The records of all patients referred for a fetal lung malformation from 2001 to 2012 and the medical literature were reviewed to identify cases of MBA.

RESULTS

Of 129 fetuses evaluated, 3 were diagnosed prenatally with right-sided MBA. The first had a CCAM-volume ratio (CVR) of 9, hydrops, mirror syndrome, and preterm delivery of a nonviable fetus. The second (CVR 2.6) had ascites, preterm delivery at 34-weeks, and neonatal demise. The third fetus (CVR 5.7) presented with hydrops at 21-weeks, prompting fetal pneumonectomy. Postoperatively, hydrops resolved, and the contralateral lung grew dramatically, but preterm delivery occurred 3 weeks later. Ventilation could not be sustained, and the infant died. Four similar cases of MBA were in the literature, all right-sided. Two fetuses with hydrops delivered at 25-weeks and died immediately. One pregnancy was terminated. One fetus underwent pneumonectomy at 24-weeks but died intraoperatively.

CONCLUSION

MBA is a rare and lethal lesion that must be distinguished from other right-sided lung masses. Fetal pneumonectomy can be performed with resolution of hydrops and compensatory contralateral lung growth, but remains limited by complications of preterm birth.

Non-operative management of a rare diagnosis of splenic torsion in a child with a history of giant omphalocele: a case report and literature review

BACKGROUND

Splenic torsion is rare and as a result the appropriate management is unclear. While there has been a shift towards splenectomy and laparoscopic splenopexy, we present a successful case of non-operative management of splenic torsion in a patient with a history of a giant omphalocele.

CASE PRESENTATION

A 3 year-old female presented with a three-day history of abdominal pain, fever and non-bloody emesis three and a half years after repair of her giant omphalocele. Abdominal radiographs and ultrasound demonstrated migration of the spleen and a subsequent computerized tomography scan confirmed splenic torsion and an infarcted spleen. Given her late presentation, she was successfully managed with observation, analgesia, immunization against capsulated organisms and daily penicillin prophylaxis with excellent outcome at 19 months follow-up. A review of the literature revealed that splenic torsion is rarely managed non-operatively. Rarer still is the occurrence of splenic torsion following a history of omphalocele.

CONCLUSION

Although rare, splenic torsion should be considered in a child with a history of omphalocele presenting with abdominal pain. Non-operative management of an infarcted spleen can be a safe treatment option to avoid surgery in complex patients.

Repair of congenital diaphragmatic hernias on Extracorporeal Membrane Oxygenation (ECMO): does early repair improve patient survival?

INTRODUCTION

The optimal timing of repair for congenital diaphragmatic hernia (CDH) patients that require ECMO is controversial. Early repair on ECMO theoretically allows for restoration of normal thoracic anatomy but entails significant bleeding risks. The purpose of this study was to examine the institutional outcomes of early CDH repair on ECMO.

METHODS

The records of infants with CDH placed on ECMO from 2001 to 2011 were reviewed. Since 2009, a protocol was instituted for early repair while on ECMO. For this study, three cohorts were analyzed: early repair (<72 h), late repair (>72 h), and post-decannulation. These groups were compared for outcomes regarding morbidity and survival.

RESULTS

Forty-six CDH patients received ECMO support with an overall survival of 53%. Twenty-nine patients (11 early/18 late) were repaired on ECMO, while 17 patients had repair post-decannulation. Survival was 73%, 50%, and 64% for those repaired early, late, or post-decannulation, respectively. Despite significantly worse prenatal factors, patients repaired early on ECMO had a similar survival. When comparing patients repaired on ECMO, the early group patients were decannulated 6 days earlier (p-value=0.009) and had significantly lower circuit complications (p=0.03).

CONCLUSION

In conclusion, early repair on ECMO was associated with decreased ECMO duration, decreased circuit complications, and a trend towards improved survival.

The presence of a hernia sac in congenital diaphragmatic hernia is associated with better fetal lung growth and outcomes

PURPOSE

The purpose of this study was to evaluate the relationship between the presence of a hernia sac and fetal lung growth and outcomes in infants with Congenital, Diaphragmatic Hernia (CDH).

METHODS

The medical records of all neonates with CDH treated in our institution between 2004 and 2011 were reviewed. The presence of a hernia sac was confirmed at the time of surgical repair or at autopsy. Data were analyzed using parametric and non-parametric tests where appropriate. Multivariable regression and survival analyses were applied.

RESULTS

Of 148 neonates treated for CDH, 107 (72%) had isolated CDH and 30 (20%) had a hernia sac. Infants with a hernia sac had significantly lower need for ECMO, patch repair, supplemental oxygen at 30 days of life, and shorter duration of mechanical ventilation and hospital stay. Ninety-three patients had prenatal imaging. The mean observed-to-expected total fetal lung volume in the sac group was higher throughout gestation. Although a greater percentage of sac patients had liver herniation as a dichotomous variable, the amount of herniated liver (%LH and LiTR) was significantly lower in the presence of a hernia sac.

CONCLUSION

The presence of a hernia sac in Congenital Diaphragmatic Hernia is associated with less visceral herniation, greater fetal lung growth, and better post-natal outcomes.

Maternal morbidity and reproductive outcomes related to fetal surgery

PURPOSE

The purpose of this manuscript was to examine the maternal morbidity and reproductive outcomes following maternal-fetal surgery with an emphasis on the EXIT procedure.

METHODS

The medical records of all women who underwent an ex-utero intrapartum treatment (EXIT) procedure or mid-gestation open maternal fetal surgery (OMFS) at our center from December 2001 to December 2011 were reviewed retrospectively. Future reproductive outcomes were obtained via telephone questionnaire.

RESULTS

Thirty-three women underwent maternal-fetal surgery. Twenty-six had EXIT, and seven had OMFS. The questionnaire response was 82% (27/33). Eighty-one percent (17/21) of the EXIT cohort desired future pregnancy. All who attempted (13/13) were successful. The majority (85%) conceived spontaneously and within 2.5 years on average. In the OMFS group, 40% experienced complications. One had uterine dehiscence, and another had uterine rupture requiring urgent delivery at 36 weeks. In subsequent pregnancies, 20% of OMFS cases were complicated by uterine rupture, and 8% of EXIT patients had uterine dehiscence. All had good maternal-fetal outcome.

CONCLUSION

Future reproductive capacity and complication rates in subsequent pregnancies following EXIT procedure are similar to those seen in the general population. In contrast, mid-gestation OMFS remains associated with relatively morbid complications. This evidence can help guide in counseling expectant mothers who are faced with the challenge of considering fetal surgery.

Outcomes of fetuses with lower urinary tract obstruction treated with vesicoamniotic shunt: a single-institution experience

PURPOSE

The purpose of this manuscript was to examine the outcomes of patients with lower urinary tract obstruction (LUTO) treated with vesicoamniotic shunt (VAS) to improve the quality of prenatal consultation and therapy.

METHODS

The medical records of all patients diagnosed with LUTO at our center between January 2004 and March 2012 were reviewed retrospectively.

RESULTS

Of 14 male fetuses with LUTO, all with characteristic ultrasound findings, 11 underwent intervention. One patient received vesicocentesis alone, while 10 had VAS. Two fetuses additionally underwent cystoscopy (one with attempted valve ablation), and two had peritoneoamniotic shunts. Of 16 total VAS, 13 were placed successfully, 8 dislodged (median 7 days), and 1 obstructed (84 days). Two fetuses suffered in utero demise, and two have unknown outcomes. LUTO was confirmed in six of eight live-born fetuses. One patient died in the neonatal period, while seven survived. All six available at follow-up (median 3.7 years), had significant genitourinary morbidity. Five patients had chronic kidney disease, but only one has required dialysis and transplant. Three had respiratory insufficiency, and one required a tracheostomy.

CONCLUSION

Despite significant perinatal and long-term morbidity, VAS offers patients faced with a poor prognosis an improved chance of survival. Our results underscore the need for further research into the diagnosis and treatment of LUTO.

EXIT-to-resection for fetuses with large lung masses and persistent mediastinal compression near birth

PURPOSE

To identify prenatal diagnostic features that will help select fetuses with lung masses (LM) who may benefit from ex-utero intrapartum treatment (EXIT procedure) as the preferred mode of delivery.

METHODS

The CCAM-volume ratio (CVR), fetal treatment, and outcomes of all fetuses with LM evaluated between 2001 and 2011 were reviewed retrospectively. Fetuses with hydrops or CVR>1.6 were classified as high risk. Indications for fetal interventions included hydrops and heart failure, and indication for EXIT-to-resection was the finding of persistent mediastinal compression (PMC) near birth.

RESULTS

Of 110 fetuses evaluated for LM, 78 were classified as low-risk. No fetus in this group had PMC near birth and none required perinatal treatment. Of 32 high-risk fetuses, 8 developed heart failure of which 4 survived (3 following fetal surgery). Nine high-risk fetuses with no PMC near birth were asymptomatic postnatally and treated electively. Sixteen high-risk fetuses had PMC near birth. All 9 babies with PMC treated with EXIT-to-resection did well with discharge at a median of 10 days post-operatively. All 7 fetuses treated without an EXIT developed respiratory distress following birth requiring an urgent operation; 2 died.

CONCLUSION

The EXIT-to-resection procedure is a favorable delivery approach for those fetuses with large LM and PMC near birth.

Water-absorbing balls: a "growing" problem

Foreign body ingestion is a potentially serious clinical problem in children. We report a case of an 8-month-old infant who developed complete bowel obstruction requiring laparotomy due to ingestion of a superabsorbent polymer ball with advertised growth up to 400 times its original size. Most ingested foreign bodies that pass through the pylorus will make it safely through the gastrointestinal tract. This is not true for water-absorbing balls that progressively increase in size and cause intestinal obstruction. Other household products and toys on the market use a similar polymer-based water-absorbing technology, thus increasing the risk for accidental ingestion by young children. These rapidly expanding objects can cause significant morbidity, and timely diagnosis and treatment are prudent to improve patient outcomes.

Increased in vitro differentiation of fibrocytes from keloid patients is inhibited by serum amyloid P

Keloid scarring is a form of fibroproliferative dermal wound healing characterized by growth beyond the confines of the original wound. Fibrocytes, derived from peripheral blood mononuclear cells and inhibited by serum amyloid P (SAP), have been linked to other fibroproliferative diseases. We hypothesized that peripheral blood mononuclear cells of keloid formers have a higher propensity to differentiate into fibrocytes and are more resistant to the effects of SAP. To test this hypothesis, plasma was isolated from peripheral blood samples of keloid (n = 10) and age/sex/race-matched control (n = 10) subjects, and SAP levels were measured by enzyme-linked immunosorbent assay. Equal numbers of peripheral blood mononuclear cells were also isolated from these samples and fibrocytes cultured in serum-free media with increasing concentrations of SAP. No difference in plasma SAP levels was found between keloid and control subjects. In the absence of SAP, keloid patients (n = 7) had almost 20 times more fibrocytes than controls (n = 7) in culture (median: 1,087 cells vs. 60 cells; p < 0.01). SAP inhibited the differentiation of keloid fibrocytes in vitro, although a higher concentration of SAP was needed when compared with controls (20 μg/mL keloid vs. 5 μg/mL control). Fibrocytes may contribute to the pathogenesis of keloids, and SAP has potential as a therapeutic agent in the prevention of these lesions.

The relation between identity status and romantic attachment style in middle and late adolescence

This study examined the linkages between identity formation and romantic attachment in an ethnically diverse sample of high school (n=189) and college students (n=324). Individuals in the foreclosed identity status group had significantly lower relationship avoidance scores than the diffused identity status group, and the foreclosed group had significantly lower relationship anxiety scores than both the achieved identity and moratorium groups. Identity status and romantic attachment style were significantly related among the college sample, but not among the high school sample. Some ethnic differences in attachment style were noted. Developmental implications are discussed.