Reduction in blood product transfusion requirements with early on-ECMO repair of congenital diaphragmatic hernia

Background For infants with severe congenital diaphragmatic hernia (CDH) stabilized with extracorporeal membrane oxygenation (ECMO), early repair on ECMO improves outcome; however when compared to operative repair after ECMO, repair on ECMO is associated with increase bleeding risk and need for blood product transfusions. Methods A retrospective review of 54 patients with CDH placed on ECMO prior to CDH repair was performed. For the subset of patients repaired on ECMO, analysis comparing those repaired early (within 48 h of cannulation) and late (beyond 48 h) on ECMO was performed. Outcomes of interest included survival to discharge, days on ECMO, and postoperative blood product utilization. Results When compared to those patients repaired prior to 48 h of ECMO initiation, 57.7% of patients survived versus 40.9% of late repair patients. For those repaired early, blood product utilization was significantly less. Early repair patients received a median of 72 mL/kg packed red blood cells (PRBC) and 75 mL/kg platelets compared to 151.9 mL/kg and 98.7 mL/kg, respectively (p < 0.05 respectively). There was no difference in median days on ECMO (p = 0.38). Conclusion Our data supports prior reports of improved outcome with repair with 48 h of ECMO initiation and suggests early repair on ECMO is associated with less bleeding and decreased blood product requirement in the postoperative period.

Risk Factors for Gastrointestinal Leak after Perforated Peptic Ulcer Disease Operative Repair

Background There are limited studies regarding the impact of post-operative leak on perforated peptic ulcer disease (PPUD) and conflicting results regarding routine drain placement in operative repair of PPUD. This study aims to identify risk factors for gastrointestinal leak after operative repair of PPUD to better guide intra-operative decisions about drain placement. Methods We performed a retrospective cohort study at a tertiary care center from 2008 to 2019, identifying 175 patients who underwent operative repair of PPUD. Results Patients who developed a leak (17%) were compared to patients who did not. Both hypoalbuminemia (albumin < 3.5 g/dL) ( P = .03) and duodenal ulcers ( P < .01) were identified as significant risk factors for leak. No significant difference was found between leak and no leak groups for AAST disease severity grade, repair technique, or pre-operative use of tobacco, alcohol, or steroids. Post-operative leaks were associated with prolonged hospital stay (29 days compared to 10, P < .01), increased complication rates (77% compared to 48%, P < .01), and increased re-operation rates (73% compared to 26%, <0.01). No difference was identified in patient characteristics or operative leak rates between patients who had drains placed at the index operation and those that did not. Discussion Leak after operative PPUD repair is associated with significant post-operative morbidity. Hypoalbuminemia and duodenal perforations are significant risk factors for post-operative leaks.

Common pulmonary vein atresia

A 4-hour-old infant with profound cyanosis on an alprostadil infusion was urgently transferred to Rady Children’s Hospital with suspected CHD. Upon arrival, urgent echocardiography was performed but could not confirm the presence of discrete pulmonary veins or pulmonary venous drainage. Given the difficulty in delineating the anatomy, a cardiac CT scan was performed and demonstrated a nearly atretic common pulmonary vein with multiple small collaterals that drained to systemic veins. Due to the high risk of mortality associated with operative repair, the decision was made to proceed with compassionate withdrawal of care. The described anatomy of common pulmonary vein atresia remains rare, and to our knowledge, fewer than 40 cases have been reported in the literature. Albeit rare, common pulmonary vein atresia should be considered in the differential diagnosis of a severely cyanotic neonate.

Open reduction and internal fixation of metacarpal fractures using a thermoplastic splint as a surgical instrument

Adequate positioning of the hand is a critical step in hand fracture operative repair that can impact both the clinical outcome and the efficiency of the operation. In this paper, we introduce the use of a thermoplastic splint with an added thumb stabilizing component as a means to increase the surgeon’s autonomy and to streamline the patient care pathway. The thermoplastic splint is custom fabricated preoperatively by the specialist hand therapist. The splint is used prior, during, and post operation with minimal modification. The thumb component assists maintaining the forearm in a stable pronated position whilst drilling and affixing metal work. This is demonstrated in the video of removal of metal work and open reduction and internal fixation of a metacarpal fracture.

Parachute-Induced Pectoralis Major Tears in Military Servicemembers: What Is the Functional Recovery?

Background: Although the most common injury mechanism for pectoralis major (PM) tears is an eccentric loading mechanism typically caused by bench pressing, within the military, there is a unique injury mechanism associated with airborne operations. The results of operative repair for these parachute-induced PM tears have not been previously reported. Purpose/Hypothesis: To assess the functional outcomes in military servicemembers undergoing operative repair of parachute-induced PM tears. We hypothesized that functional recovery would be impaired with delayed surgical intervention. Study Design: Cohort study; Level of evidence, 3. Methods: Included were active duty military servicemembers who underwent operative repair for PM tears caused by a parachute-induced mechanism. Charts were reviewed to identify characteristic, injury, and surgical variables. Patients completed the functional outcome assessment with the Disabilities of the Arm, Shoulder and Hand (DASH) and the American Shoulder and Elbow Surgeons (ASES) questionnaires. Outcomes were compared between patients treated within 6 weeks of injury and those treated beyond 6 weeks. Results: Of the 68 identified PM tears, 25 were the result of parachute-induced mechanisms. A total of 13 patients consented and completed the functional outcome assessment. The mean patient age was 30.6 ± 6.4 years, and the mean follow-up period was 5.46 ± 1.26 years. Ten patients underwent repair within 6 weeks of injury, and the remaining 3 patients underwent repair at a mean of 338 days after injury (95% CI, -42.8 to 718.8 days), a significant difference between groups ( P = .006). All 13 patients were able to return to military duties at a mean of 6 months from injury. Patients treated within 6 weeks of injury had significantly higher functional outcomes (DASH score, 6.17 vs 26.67; P = .018; ASES score, 85.97 vs 49.5; P = .008), with greater strength performance compared with preinjury (bench press, 90.58% vs 38.95%; P = .0057; push-ups, 81.9% vs 23.8%; P = .023) compared with patients treated beyond 6 weeks of injury. Conclusion: Operative repair of parachute-induced PM tears within 6 weeks of injury provided a superior functional and strength recovery when compared with delayed surgical repair. Acute repair should be recommended for military servicemembers who experience this unique injury mechanism.

Congenital Lumbar Hernia in an 8-Month-Old Boy

Congenital lumbar hernias are uncommonly seen in the pediatric age group, with only about 60 cases reported in the literature. It is usually accompanied by a multitude of congenital anomalies involving different organ systems of the body. For instance, it may involve the ribs, spine, muscles, and the kidneys. Herein, we report a case of congenital lumbar hernia in an 8-month-old boy who underwent an operative repair using a mesh with an uneventful outcome.