Risk and safety requirements for diagnostic and therapeutic procedures in allergology : World Allergy Organization Statement

Peer reviewe

Hybrid notes: Incisionless intragastric stapled cystgastrostomy of a pancreatic pseudocyst

PURPOSE: We present a case report of a novel hybrid natural orifice transluminal endoscopic surgery (NOTES). The operation performed was a transgastric cystgastrostomy with endoscopic guidance for a pancreatic pseudocyst. This operation was completed entirely through an existing gastrostomy site with no incisions, thus avoiding the peritoneal cavity. METHODS: This is a case of a 7-year-old boy with neurologic impairment from congenital herpes simplex virus encephalitis who is tube fed. He had acute pancreatitis and developed a 9 cm pancreatic pseudocyst. The pseudocyst failed to resolve after 6 weeks and developed a mature wall. Due to a history of multiple abdominal surgeries and known abdominal adhesions, a minimally invasive approach that would avoid entering the peritoneal cavity was the desired approach. The technique involved a trans-oral endoscope for visualization and the use of the gastrostomy as access to the gastric lumen and pseudocyst. The pancreatic pseudocyst was stabilized with two T-fasteners and confirmed with needle aspiration under endoscopic visualization. The pseudocyst was then opened with the LigaSure (Valleylab, Boulder, CO). The cystgastrostomy anastomosis was completed with an Endopath ETS-Flex Articulating Linear Stapler/Cutter (Ethicon Endo-Surgery, Inc, Cincinnati, OH). The operation took less than 2 hours and was completed without an incision. Under the policies of the Human Research Protection Program, review of a single case is outside the scope of the definition of human subjects research and does not require institutional review board review and approval. RESULTS: The patient did well postoperatively and had a dramatic reduction in size of the pancreatic pseudocyst to 3.5 cm by 2 weeks. CONCLUSIONS: Hybrid NOTES cystgastrostomy performed through an existing gastrocutaneous fistula is an excellent approach for minimally invasive drainage of pancreatic pseudocysts. Copyright 2010 Elsevier Inc. All rights reserved

Association of Hyperchloremia and Acute Kidney Injury in Pediatric Moderate and Severe Traumatic Brain Injury

PURPOSE: Acute kidney injury (AKI) is an established complication of adult traumatic brain injury (TBI) and known risk factor for mortality. Evidence demonstrates an association between hyperchloremia and AKI in critically ill adults but studies in children are scarce. Given frequent use of hypertonic saline in the management of pediatric TBI, we believe the incidence of hyperchloremia will be high and hypothesize that it will be associated with development of AKI. METHODS: Single-center retrospective cohort study was completed at an urban, level 1 pediatric trauma center. Children \u3e 40 weeks corrected gestational age and \u3c 21 years of age with moderate or severe TBI (presenting GCS \u3c 13) admitted between January 2016 and December 2021 were included. Primary study outcome was presence of AKI (defined by pediatric Kidney Disease: Improving Global Outcomes criteria) within 7 days of hospitalization and compared between patients with and without hyperchloremia (serum chloride ≥ 110 mEq/L). RESULTS: Fifty-two children were included. Mean age was 5.75 (S.D. 5.4) years; 60% were male (31/52); and mean presenting GCS was 6 (S.D. 2.9). Thirty-seven patients (71%) developed hyperchloremia with a mean peak chloride of 125 (S.D. 12.0) mEq/L and mean difference between peak and presenting chloride of 16 (S.D. 12.7) mEq/L. Twenty-three patients (44%) developed AKI; of those with hyperchloremia, 62% (23/37) developed AKI, while among those without hyperchloremia, 0% (0/15) developed AKI (difference 62%, 95% CI 42-82%, p \u3c 0.001). Attributable risk of hyperchloremia leading to AKI was 62.2 (95% CI 46.5-77.8, p = 0.0015). CONCLUSION: Hyperchloremia is common in the management of pediatric TBI and is associated with development of AKI. Risk appears to be associated with both the height of serum chloride and duration of hyperchloremia

Endoscopic treatment with Deflux for refluxing duplex systems

PURPOSE: The aim of this study was to review the experience of a single institution with the endoscopic Deflux (Q-Med Scandinavia, Uppsala, Sweden) procedure and assess its effectiveness in the treatment of refluxing duplex systems. MATERIALS AND METHODS: A retrospective review of all patients that underwent endoscopic Deflux treatment for vesicoureteral reflux (VUR) in duplex systems between June 2003 and July 2007 was performed. Data collection included: age, gender, side of refluxing ureter, preoperative radiologic grade of VUR on a voiding cystourethrogram (VCUG), presence of VUR on a radionuclide VCUG 3 months postprocedure, volume of Deflux injected, number of Deflux injections performed per patient, and number of patients that underwent reimplantation surgery. RESULTS: Sixteen patients with duplex systems, two being bilateral, for a total of 18 duplex ureteral systems, underwent the Deflux procedure. Grades of reflux were as follows: grade II: 4 ureters; grade III: 8 ureters; grade IV: 4 ureters; and grade V: 2 ureters. Deflux injection volume ranged from 0.28 to 1.5 cc (mean, 0.84). Fourteen ureteral systems required one injection, three required two injections, and one required three injections. The overall success rate of the procedure after a maximum of three injections was 94%. One patient with preoperative unilateral grade V reflux had persistent high-grade reflux after two injections and opted to proceed with surgical reimplantation. The mean follow-up was 24 months (mean, 6-48). CONCLUSIONS: We conclude that the Deflux procedure is a safe, effective minimally invasive treatment alternative for patients with refluxing duplex systems

Geographic distribution of community-acquired methicillin-resistant Staphylococcus aureus soft tissue infections

PURPOSE: The goal of this study is to look at the geographic growth patterns of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections in our local region and to determine if specific geographic areas are at increased risk. METHODS: After Institution Review Board approval (132603-3), a retrospective chart review was conducted of 614 patients who underwent incision and drainage of an abscess by a single pediatric surgical practice from January 2004 to December 2008. In addition, previously published data from 195 patients who underwent incision and drainage of an abscess from January 2000 to December 2003 were reviewed. RESULTS: The most commonly cultured organism found in the pediatric population undergoing incision and drainage was S aureus (n = 388), of which 258 (66%) were methicillin resistant. This is a 21% increase from the rate of MRSA cultures identified from 2000 to 2003. Geographic information system space-time analysis showed that a cluster of 14 MRSA cases was located within a 1.44-km radius between 2000 and 2003, and 5 separate clusters of more than 20 MRSA infection cases each were identified in 3 separate cities over the 8-year time span using geographic information system spatial analysis (P value = .001). CONCLUSION: Methicillin-resistant S aureus has now become the most prevalent organism isolated from cultures of community-acquired abscesses requiring incision and drainage in the pediatric population in our local region. Significant clustering of MRSA infections has appeared in several different cities within our geographic region. Copyright © 2011 Elsevier Inc. All rights reserved

Prosthetic mesh contamination during NOTES(®) transgastric hernia repair: A randomized controlled trial with swine explants

PURPOSE: Natural Orifice Translumenal Endoscopic Surgery (NOTES(®)) is a developing field in minimally invasive surgery that has been applied across a wide range of procedures; however, infectious concerns remain. Most of the applications have been for extraction, rather than reconstructive procedures. Prosthetic hernia repair, is a constructive procedure, has the unique challenge of avoiding contamination and infection of a permanent implant. Utilizing a novel device, we hypothesize that we can significantly reduce or eliminate prosthetic contamination during a transgastric approach for delivery of a clinically relevant, permanent, synthetic prosthetic. METHODS: 20 swine explants of stomach with attached esophagus were prepared by placing an ultraviolet (UV) light sensitive gel within the lumen of the stomach. Each stomach then underwent endoscopic gastrotomy utilizing a needle, wire guide, and 18-mm balloon dilator. A 10 × 15 cm polypropylene prosthetic was rolled and tied with a 2-0 silk suture, and delivered with one of two methods. Group A (control) utilized a snare to grasp the prosthetic adjacent to the endoscope, which was used to drag it through the gastrotomy. Group B (device) utilized a modified esophageal stent delivery system to deliver the prosthetic through the gastrotomy. Each prosthetic was then digitally photographed with UV illumination, with the contaminated areas illuminating brightly. Software analysis was performed on the photographs to quantify areas of contamination for each group. Statistical analysis was performed using a two-tailed t test with unequal variance. RESULTS: Group A demonstrated a mean of 57 % of the surface area of the prosthetic contaminated with UV light sensitive gel. Group B (experimental group) showed a mean of 0.01 % of the surface area contaminated (p \u3c 0.0001). 95 % confidence intervals indicated that the unprotected delivery technique exposes approximately 6,000 times more of the surface area to contamination than the delivery device. CONCLUSION: Use of this modified stent delivery system can nearly eliminate prosthetic contamination when placed via a transgastric approach in a swine explants model. Theoretically, the reduced inoculum size would reduce or eliminate clinical infection. Since the inoculum size required for clinical prosthetic infection for intraperitoneal mesh is unknown, further study is warranted to test the ability to eliminate clinical infection related to prosthetic delivery with this technique