Top to Bottom: A New Method for Assessing Adequacy of Laparoscopic Pyloromyotomy

Introduction: Hypertrophic pyloric stenosis is a commonly encountered pediatric surgical issue. Initially treated with open surgical techniques, many pediatric surgeons have adopted the minimally invasive approach using laparoscopy. However, some concerns exist that the rate of incomplete pyloromyotomy is elevated in laparoscopy. We propose a new technique to assess the adequacy of laparoscopic pyloromyotomy. Methods: Adequacy of laparoscopic pyloromyotomy was assessed by confirming that the top of the serosa on one side of the pylorus has adequate freedom to reach the bottom of the muscle on other side. A retrospective review of patients undergoing laparoscopic pyloromyotomy confirmed by this method from March 2012 to January 2016 was conducted. Demographics, laboratory values on admission, and postoperative outcomes were collected. Descriptive statistics was utilized. Results: Thirty-three patients were included. Median age was 30 days (interquartile range [IQR]: 24, 47). Median pylorus length and thickness were 19?mm (IQR 17.3, 21) and 4.5?mm (IQR: 4.0, 4.8), respectively. Median time to first full feed was 8.5 hours (IQR: 6.6, 15.6). Twenty-three (69%) patients had postoperative emesis. Median length of stay postoperation was 26.5 hours (IQR: 21.1, 44.7). There were no reoperations for incomplete pyloromyotomy and no infections. On follow-up, 1 patient had prolonged postoperative emesis that resolved without further intervention and 1 patient on peritoneal dialysis before surgery had an incisional hernia that required operation in the setting of bilateral inguinal hernias. Conclusion: In a small series, the top to bottom assessment appears to confirm adequacy of pyloromyotomy.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140155/1/lap.2016.0303.pd

Spontaneous bile duct perforation with cystic fibrosis and meconium ileus

Spontaneous bile duct perforation in the newborn is rare, with less than 150 cases reported. A term male newborn presented with abdominal distention and respiratory distress on the first day of life. Paracentesis revealed 420 mL of bile without succus or meconium, and laparoscopic washout and drainage was performed. A follow-up contrast enema several days later revealed a microcolon. The second operation confirmed the spontaneous bile duct perforation, but also revealed meconium ileus with ileal perforation and thick meconium. A sweat chloride study was abnormal and the patient was homozygous for the delta-F508 mutation. This is the first reported case of spontaneous bile duct perforation in association with meconium ileus or cystic fibrosis

Isolated cardiac tamponade following blunt trauma in an infant

This is a case of a 6-month old female with no prior medical history who presented to the emergency department following a high-speed motor collision with ejection of an improperly installed car seat. The patient was hemodynamically unstable with tachycardia, poor perfusion, and marks from the car seat. A focused assessment with sonography in trauma (FAST) ultrasound exam revealed no intraabdominal fluid, but evidence of cardiac tamponade which was confirmed by chest CT angiography. No cardiac or great vessel injury was present. A pericardial window was performed using a subxiphoid approach and 150 mLs of blood was drained resulting in immediate hemodynamic stabilization. The patient continued to improve from a cardiac stand point but her hospital course was complicated by iatrogenic right arm ischemia due to arterial line attempt. The patient was discharged after a 12-day hospital stay.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Unusual cause of acute lower extremity ischemia in a healthy 15-year-old female: A case report and review of popliteal artery aneurysm management in adolescents

Limb ischemia in healthy teenagers is unusual. While traumatic or iatrogenic injury is the most common etiologies of limb ischemia in the pediatric population, anatomic variants such as true aneurysms should be considered [1]. We report the second documented pediatric case of an idiopathic, isolated true popliteal aneurysm resulting in acute limb ischemia in a previously healthy 15-year-old female. We also review the proper evaluation and surgical management of this anatomic anomaly. In this case, surgical management included resection of the aneurysm, reconstruction with reverse saphenous vein grafting, and distal endarterectomies to restore adequate distal blood flow. Ultimately, this patient's limb and function were salvaged with minimal consequences

A case of traumatic rupture of a giant omphalocele and liver injury associated with transverse lie and preterm labor

Perinatal omphalocele rupture is a rare occurrence. We present a case of a baby delivered at 35 weeks with a known giant omphalocele, transverse lie, and the omphalocele downward in the birth canal who suffered rupture of the omphalocele and liver injury around the time of delivery. The pregnancy was complicated by one day of preterm labor, preterm premature rupture of the membranes, and the omphalocele was the presenting part. Despite pulmonary hypertension, rupture of the omphalocele, and a significant liver injury, individualized management with decompression of the liver hematoma allowed successful early closure with mesh followed by delayed reconstruction

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.12 month embargo; published 01 June 2020This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Severe pectus excavatum with tracheal compression presenting with chronic cough

While pectus excavatum is the most common congenital chest wall deformity in children, indications for surgical repair are still debated among experts. Some centers require demonstration of physiologic criteria prior to repair, even in the face of significant anatomic compression. We present a case of a 16-year-old male with severe pectus excavatum who presented with a 3-year history of a chronic barking cough and exercise-induced shortness of breath. Radiographic imaging demonstrated compression of the trachea and bilateral mainstem bronchi secondary to severe pectus excavatum deformity. Despite his severe pectus deformity, preoperative physiologic testing demonstrated normal to near-normal cardiopulmonary function. Minimally invasive repair of the chest wall defect (modified Nuss procedure) provided rapid alleviation of symptoms, and a significant improvement in quality of life.Open access journal.This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Evaluating abusive head trauma in children < 5 years old: Risk factors and the importance of the social history

Background: Abusive head trauma (AHT) is the leading cause traumatic death in children ≤ 5 years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent injury and death. This study assesses the clinical and social risks associated with fatal and non-fatal AHT. Methods: A single-institution, retrospective review of suspected AHT patients ≤ 5 years of age between 2010 and 2016 using a prospective hospital forensic registry data yielded demographic, clinical, family, psycho-social and other follow-up information. Descriptive statistics were used to look for differences between patients with AHT and accidental head trauma. Logistic regression estimated the adjusted odds ratios (AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate model sensitivity and specificity. Results: Forensic evaluations of 783 children age ≤ 5 years with head trauma met the inclusion criteria; 25 were fatal with median[IQR] age 23[4.5–39.0] months. Of 758 non-fatal patients, age was 7[3.0–11.0] months; 59.5% male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental, 181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included multiple fractures (Exp(β) = 9.9[p = 0.001]), bruising (Expβ = 5.7[p < 0.001]), subdural blood (Exp(β) = 5.3[p = 0.001]), seizures (Exp(β) = 4.9[p = 0.02]), lethargy/unresponsiveness (Exp(β) = 2.24[p = 0.02]), loss of consciousness (Exp(β) = 4.69[p = 0.001]), and unknown mechanism of injury (Exp(β) = 3.9[p = 0.001]); skull fracture reduced the risk of AHT by half (Exp(β) = 0.5[p = 0.011]). Social risks factors included prior police involvement (Exp(β) = 5.9[p = 0.001]), substance abuse (Exp(β) = 5.7[p = .001]), unknown number of adults in the home (Exp(β) = 4.1[p = 0.001]) and intimate partner violence (Exp(β) = 2.3[p = 0.02]). ROC area under the curve (AUC) = 0.90([95% CI = 0.86–0.93] p = .001) provides 73% sensitivity; 91% specificity. Conclusions: To improve surveillance of AHT, interviews should include and consider social factors including caregiver/household substance abuse, intimate partner violence, prior police involvement and household size. An unknown number of adults in home is associated with an increased risk of AHT. Study Type/Level of Evidence: Prognostic, Level III. © 2020 Elsevier Inc.12 month embargo; available online 25 October 2020This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]