Closure In Children Research Articles

Left and right ventricular speckle tracking study before and after percutaneous atrial septal defect closure in children

ObjectivesTo analyze the acute and short-term deformation changes of both right (RV) and left (LV) ventricular wall before and after transcatheter closure of atrial septal defect (ASD) secundum in children. Outcome measuresTo determine the feasibility of tissue Doppler and myocardial deformation imaging for evaluating RV and LV functions in children undergoing transcatheter ASD closure. Patients and methodsA prospective study was performed for 32 children with hemodynamic significant ASD secundum before and 6 months after percutaneous ASD closure in the Pediatric Cardiology Division of Specialized Pediatric Hospital, Cairo University. Speckle tracking echocardiography (STE) of LV and RV global analysis (longitudinal and circumferential strain) before and after ASD transcatheter closure was performed. ResultsThe mean age of the patients was 6.01 ± 3.19 (range: 3–9) years with a female to male ratio of 1.3:1. There was an improvement in the RV and LV myocardial performance index (MPI) 6 months post-ASD closure (RVMPI = 0.46 ± 0.069 vs. 0.38 ± 0.05, p < 0.0001; LVMPI = 0.49 ± 0.12 vs. 0.38 ± 0.08, p < 0.0001, respectively). By 2D STE, there was a significant improvement in the RV global longitudinal strain (GLS) 6 months post-ASD closure (−20.17 ± 3.14% vs. −25.86 ± 5.02%, p < 0.0001). There was a significant increase in the LV end-diastolic volume (EDV) and LV end-systolic volume (ESV) using 4D STE after device closure (LVEDV = 32.96 ± 10.99 mL vs. 44.024 ± 14.9017 mL, p < 0.0001; LVESV = 15.16 ± 6.08 mL vs. 21.76 ± 8.34 mL, p < 0.0001, respectively). Additionally, there was a significant improvement in the LV GLS after device occlusion (−19.17 ± 3.67% vs. −22.36 ± 4.72%, p = 0.009) using 4D TomTec software. There was a significant decrease in the RVEDV (54.65 ± 10.05 mL vs. 15.73 ± 8.67 mL) and RV stroke volume (25.15 ± 6.36 vs. 20.06 ± 7.2) after device occlusion using 4D TomTec software. ConclusionBy using 4D STE, the LV GLS was significantly improved; in contrast, by 2D STE, the RV volume overload decreased and the RV GLS was improved on short term after transcatheter ASD secundum closure in children.

Echocardiographic Prediction of Left Ventricular Dysfunction After Transcatheter Patent Ductus Arteriosus Closure in Children.

Objectives: To evaluate the change of left ventricular (LV) systolic function after transcatheter patent ductus arteriosus (PDA) closure in children, and to identify whether echocardiography parameters could be the predictors of LV dysfunction post-PDA closure if present.Methods: This study enrolled 191 pediatric PDA patients, and all of them underwent successful transcatheter PDA closure between January 2016 and December 2018. The patent ductus arteriosus diameter (PDAd), aortic root diameter (AOd), left atrial diameter (LAd), right ventricular outflow tract dimension (RVOT), LV end-diastolic dimension (LVEDD), and LV end-systolic dimension (LVESD) were all measured by echocardiography at pre-closure, post-closure (within 24 h after the procedure), and follow-up (3 months after the procedure). The ratio of PDAd to AOd (PDAd/AOd), the ratio of LAd to AOd (LAd/AOd), the left ventricular ejection fraction (LVEF), and the fractional shortening (FS) were calculated.Results: The LAd, LVESD, LVEDD, FS, and LVEF decreased significantly in the 24 h after closure, compared to pre-closure levels. However, all echocardiography parameters recovered to pre-closure levels at 3 months after PDA closure in all patients. Moreover, the pre-closure LAd, LVEF, PDAd/AOd, and LAd/AOd were higher in the patients with post-closure LV systolic dysfunction than in those without post-closure LV systolic dysfunction. Furthermore, the pre-closure LVEF, PDAd/AOd, and LAd/AOd were correlated with the post-closure LVEF, and pre-closure LVEF ≤ 66.5%, PDAd/AOd ≥ 0.28, and LAd/AOd ≥ 1.54 predict the post-closure LV systolic dysfunction.Conclusion: Transcatheter closure of PDA causes a significant deterioration in LV systolic function early after PDA closure, which recovered completely within 3 months of post-closure in children. Pre-closure LVEF, PDAd/AOd, and LAd/AOd can be the predictors of post-closure left ventricular systolic dysfunction.

Accuracy of imaging fusion between echocardiography and fluoroscopy in percutaneous atrial septal defect closure in children

Imaging fusion between echocardiography and fluoroscopy is now available in the catheterization laboratory. We aim to test the feasibility and accuracy of imaging fusion in a pediatric population. Thirty-one patients (26 kgs [21–37]) underwent percutaneous atrial septal defect (ASD) closure were prospectively included. Occluder device's screw, visualized on both echocardiography and fluoroscopy images was used as a reference tool. Bias was measured between a marker positioned on the device screw visualized on echocardiography and the fluoroscopic screw image on the fusion screen (distance 1). Another bias was measured between the screw on 3D echocardiographic image and the screw on fluoroscopic image (distance 2). The 2 distances were measured on 4 orthogonal views in end-systolic and end-diastolic frames. Fusion and marker positioning were feasible in real-time in all cases. In 5 cases (16.1%), there was a transient loss of the automatic tracking of the probe during the procedure. Quality of imaging fusion was rated good in all cases. On the fusion screen, systolic and diastolic first distances were 0.5 [0.3–1] and 2 mm [1.5–2.5] ( P < 0.0001). The marker positioned from echocardiography screen was fixed on fusion screen and did not follow the systole-diastolic translation of the screw. Systolic and diastolic second distances were 0.5 [0–0.5] and 2 mm [1.5–2.5] ( P < 0.0001). Echocardiographic-fluoroscopic imaging fusion is feasible, safe and accurate in children above 20 kgs. This innovate technic offers a new real-time imaging guiding modality in the catheterization laboratory with potential interest in complex procedures as well as for fellow training.

Ultrasound detection and closure of contralateral patent processus vaginalis in pediatric patients with unilateral inguinal hernia and hydrocele: a longitudinal study to prove efficacy in avoiding contralateral hernia development.

Open herniotomy has been the gold standard of pediatric hernia treatment with the advantages of simplicity in surgical technique, fast post operative recovery, and minimal recurrence rate, but its inability to prevent hernia development from a contralateral patent processus vaginalis (PPV) after a unilateral herniotomy is its major drawback. By contrast, laparoscopic hernia repair has the advantage of contralateral internal ring inspection, and, therefore, has become popular in recent years, although open herniotomy is still the favorable surgical technique among many surgeons. A simple and reliable tool to detect contralateral PPV will be valuable to surgeons who practice conventional open hernia surgery on children, although ultrasound has been applied for this purpose, but there is no long-term data to support such application. The author performed a preoperative ultrasound on the contralateral groins of children undergoing unilateral herniotomy or PPV ligation. If the ultrasound showed no evidence of contralateral PPV, no contralateral surgery was performed. Those patients were then followed up after a long period of time to see whether contralateral hernia or hydrocele was developed or not. 322 pediatric patients were studied from 2006 to 2012. In 96 of the cases (30%), contralateral PPV were identified with ultrasound, and 95% of which were affirmed intraoperatively. In the remaining 226 patients who were without evidence of contralateral PPV, only unilateral surgeries were offered. One of these patients later developed contralateral hernia and required another surgery. The remaining patients were phoned up after a median period of 9years. 114 of them could be contacted and none of them had developed contralateral hernia or hydrocele. Ultrasound groin is a valuable tool as an adjunct in pediatric hernia management by detecting contralateral PPV with high accuracy. Surgeon can offer unilateral or bilateral hernia surgery according to the ultrasound finding, and the incidence of contralateral hernia development is negligible. Preoperative ultrasound groin with selective contralateral PPV closure in children can be an alternative to routine laparoscopic hernia repair in avoiding contralateral hernia or hydrocele development. Level 3. Retrospective study.

Wire-frame integrity of patch-like Gore devices following atrial septal defect closure.

To assess the structural integrity of the patch-like Gore Septal Occluder (GSO) used for device closure of secundum-type atrial septal defects (ASD II) in pediatric patients. GSO has shown to be effective and safe for ASD device closure in children and adolescents. Single-center, retrospective mid- to long-term follow-up of all children and adolescents with a GSO in situ (≥12 months). Periprocedural data and follow-up data were evaluated, including chest X-rays to assess the GSO's wire-frame morphology. Ninety-one consecutive patients were enrolled with a median age and weight of 5 years (range 2-18) and 20 kg (range 11-95) at implantation. ASD anatomy included 64 single and 27 multi-fenestrated defects, with 39 patients having small retro-aortic rims (≤4 mm). Median follow-up period was 42.5 months (range 12-74). Chest X-rays were available in 80 children: in 74 of them, the GSO's visualization on X-ray enabled us to reliably assess the wire-frame structure. Wire-frame fracture (WFF) was ultimately detected in five of the 74 patients (6.8%); however, those occluders appeared stably anchored and well aligned to both sides of the septum, and no free wire fragments had escaped the GSO matrix. Thus, no further treatment was required. Our data confirm that the GSO is safe and effective for ASD closure. Despite its lightweight construction, the GSO seems to offer reliable mechanical durability. Wire-frame fractures occur, but the free wire-ends appear to have remained stable within the GSO matrix without any clinical sequelae so far.

Reversibility of Pulmonary Hypertension Following Surgical Atrial Septal Defect Closure in Children with Down Syndrome.

BACKGROUNDMany Down syndrome (DS) patients have an atrial septal defect (ASD) and associated pulmonary hypertension (PH) from early childhood. ASD closure in DS patients with PH is often controversial due to concerns regarding exacerbation of PH. The aim of this study was to investigate the clinical outcome following surgical ASD closure in children with DS.METHODSWe retrospectively reviewed the medical records of DS patients who underwent surgical ASD patch closure from January 2000 to December 2016.RESULTSA total of 15 patients underwent surgery for ASD. Prior to ASD patch closure, nine patients were diagnosed with PH, three of whom took medications for PH. The mean age of patients at ASD patch closure was 17.3 months, and the mean diameter of the ASD was 10.2 mm. Three patients who took medications for severe PH underwent ASD patch closure at ages 7, 12, and 25 months. Two patients continued medication for an additional 13 and 21 months, and one patient remained on medication 52 months after ASD closure. PH did not recur following discontinuation of selective pulmonary vasodilators in two patients. Although a moderate degree of PH remained in one patient due to a chronic lung problem, it was improved compared to before ASD closure. No PH was observed in the remaining 12 patients following ASD closure.CONCLUSIONSA large ASD can be closed even in DS patients with severe PH during early childhood with the support of multiple selective pulmonary vasodilators.

Outcomes following surgical closure of secundum atrial septal defect in children < 15 kg – A dual center experience

In children with a body weight < 15 kg, secundum ASD closure is usually achieved through a surgical approach as their low weight may expose them to a higher risk of complications associated with percutaneous closure. However, reports about the outcome following surgical ASD closure in children < 15 kg are scarce. Medical records of all children < 15 kg who underwent isolated secundum ASD surgical closure between 2010 and 2017 in 2 French tertiary centers (Bordeaux University Hospital, Necker Hospital, Paris, France) were reviewed retrospectively. Fifty-six children were included (mean age 19 ± 10 months and mean weight 9 ± 3 kg at time of surgery). The mean ASD size was 17 ± 4 mm. Indications for surgical closure were the right heart enlargement (56/56, 100%), failure to thrive (26/56, 46.4%), dyspnea (18/56, 32.1%) and recurrent respiratory infections (7/56, 12.5%). Thirteen children (23%) underwent cardiac catheterization before surgery which showed a mean Qp/Qs of 2.3 ± 0.7 and mean RVPi of 1.3 ± 0.8 UW.m 2 . The surgical approach was sternotomy in 83.9% of cases (mean duration of extracorporeal circulation = 61 ± 3 and aortic cross-clamping = 23 ± 8 minutes). The mean duration of hospital stay was 7 ± 5 days. No complications were observed during the perioperative period. After discharge, 54/56 (96.4%) were asymptomatic in the first month. After a median follow-up of 8 months (range: 0–90), no long-term complications were noted. Surgical closure of a secundum ASD in children < 15 kg of body weight is a safe technique which allows clinical improvement of patients. Randomized and comparative studies between surgery and catheterization are needed to assess the value of percutaneous closure in this population.

Feasibility, Safety and Accuracy of Echocardiography-Fluoroscopy Imaging Fusion During Percutaneous Atrial Septal Defect Closure in Children

Imaging fusion between echocardiography and fluoroscopy was recently developed. The aim of this study was to assess its feasibility and accuracy during pediatric cardiac catheterization. Thirty-one patients (median weight, 26kg; interquartile range [IQR], 21-37kg) who underwent percutaneous atrial septal defect closure were prospectively included. The feasibility and accuracy of various imaging fusion modalities (live two-dimensional, live color two-dimensional, live three-dimensional and markers) with EchoNavigator software were assessed. To assess the accuracy of spatial registration of the echocardiogram on the fluoroscopic image, the occluder screw, an object that appeared on each image, was used as a reference tool, and the distance between the two when fused was measured. A distance was measured on the fusion screen between a marker positioned on the screw from the echocardiography screen and from the fluoroscopy screen (distance 1). Another distance was measured on the fusion screen between the screw visualized by three-dimensional echocardiography and by fluoroscopy (distance 2). The two distances were measured on four C-arm orientations in end-systolic and end-diastolic frames. Fusion and marker positioning were feasible in real time in all cases. On the fusion screen, median systolic and diastolic distance 1 were 0.5mm (IQR, 0.3-1mm) and 2mm (IQR, 1.5-2.5mm; P<.0001), respectively. The marker positioned from the echocardiography screen was fixed on the fusion screen anddid not follow the movement of the screw. Median systolic and diastolic distance 2 were 0.5mm (IQR, 0-0.5mm) and 2mm (IQR, 1.5-2.5mm; P<.0001), respectively. Echocardiographic fluoroscopic imaging fusion is feasible, safe, and accurate in children weighting >20kg. This technique offers a new method of imaging guidance in the catheterization laboratory for complex procedures and training.

Transcatheter closure of atrial septal defects type 2 in children under three years of age.

Atrial septal defect (ASD) type 2, according to current standards, is closed percutaneously usually after the child has reached the age of four to five years. There are limited data regarding such treatment in younger infants. We sought to evaluate the feasibility, safety, and efficacy of percutaneous ASD closure in children under three years of age. The research group consisted of 157 children less than three years old with haemodynamically significant ASD, who underwent effective transcatheter ASD closure in a single tertiary centre between 1999 and 2014. The mean procedural age of the treated children was 2.2 years and mean weight was 12.5 kg. In all cases nitinol wire mesh devices were applied (mostly Amplatzer Septal Occluders). ASD was closed using standard technique (except a few cases wherein the left disc of the implant was inserted initially into the right pulmonary vein to prevent oblique position of the device). Procedure-related complications were divided into major and minor ones. Atrial septal defect was closed in 149 children: 97 with a single ASD and 52 with double/multiple ASD. The procedure was abandoned in eight patients (three with single and five with double/multiple ASD). No death or implant embolisation occurred during the procedure or follow-up, and there was one case of major postprocedural complications. Normalisation of the right ventricular diameter occurred in all patients during one-year follow-up. In the majority of children acceleration of physical development and resolution of accompanying morbidity were observed in follow-up. Percutaneous ASD closure can be performed safely in children under three years of age with low risk of peri- or postprocedural complications.

Liberal Use of Delayed Sternal Closure in Children Is Not Associated With Increased Morbidity

Delayed sternal closure (DSC) is often employed to optimize hemodynamics following pediatric cardiac surgery. Prior reports have suggested that DSC may be associated with increased morbidity. We sought to analyze the impact of a liberal policy of DSC on surgical outcomes at our center. We retrospectively evaluated the clinical course of 1,000 consecutive patients between July 2005 and June 2015 whose sternum was electively left open following pediatric cardiac surgery. Data are presented as mean and standard error (parametric) or median and quartiles (nonparametric). Receiver-operating characteristic curve analysis was undertaken to identify significant points of inflection. A p less than 0.05 was considered significant. An a priori decision to leave the sternum open is made when complex surgery, especially in neonates and usually involving circulatory arrest, is expected to result in postoperative hemodynamic instability. Age at index surgery for the 1,000 patients was 7 (interquartile range [IQR], 3 to 19) days and weight 3.3 (IQR, 2.8 to 3.7) kg. There were 816 (82%) neonates and 569 (57%) boys. Index operations included 332 (33%) Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category 5, 483 (48%) STAT category 4, and 185 (19%) STAT category 3 procedures. A total of 103 (10%) patients required postoperative extracorporeal support. Following hemodynamic recovery, DSC was undertaken 3 (IQR, 2 to 4) days postoperatively and in 98.3% patients was performed in the intensive care unit. Overall, mortality was 6.3% and major Society of Thoracic Surgeons morbidity was 21.6%. There were 42(4.2%) positive mediastinal surveillance cultures at the time of DSC, with the most common organism being coagulase-negative staphylococcus. Fifty-nine (5.9%) clinical sternal and mediastinal wound infections and a total of 117 infectious complications were encountered in 94 patients. Using Society of Thoracic Surgeons database outcome as benchmark, mortality and length of stay in our patients were comparable when analyzed by STAT categories or for the 2 most common index procedures (eg, Norwood and arterial switch operations). Receiver-operating characteristic curve analysis showed that 5 days of open sternum had a weak, but statistically significant, correlation with incidence of infectious complications (area under the curve, 0.56; p=0.002). The need for DSC 5 or more days after theindex procedure was observed in 177 (18%) patients and was not associated with increased wound infection.It was, however, independently associated on multiple regression analysis with major morbidity (odds ratio, 1.7; 95% confidence interval, 1.2 to 2.5; p= 0.002) and, in the subset of 897 patients who did not requireextracorporeal support, with increased mortality (odds ratio, 2.2; 95% confidence interval, 1.3 to 3.6; p=0.003). A liberal policy of DSC does not adversely affect surgical outcomes, including infectious complications and length of stay. We submit that need for DSC should not, by itself, be considered a source of morbidity.

Rapid Improvement of Pulmonary Functions in Children After Transcatheter Closure of an Atrial Septal Defect.

There are very few studies in the literature on respiratory system functions and complications of children with an atrial septal defect (ASD). The aim of this study is to investigate the pulmonary functions and pulmonary complications before and after transcatheter closure in children with an ASD. In this study, pulmonary function test parameters of 30 ASD patients between 5 and 18years of age who were eligible to be treated by transcatheter ASD closure were compared with 30 healthy children. The patients undergoing transcatheter ASD closure received pulmonary function tests (PFT) at baseline (1 day before ASD closure), and 3months after the procedure. Forced vital capacity (FVC), forced expired volume in 1s (FEV1), peak expiratory flow, and mean forced expiratory flow during the middle half of FVC were measured. The mean age of the 30 ASD patients was 9.59±3.1years; and 20 (66.6%) were female and 10 (33.3%) were male. The mean age of the control group was 10.15±2.21years, and 19 (63.3%) were girls and 11 (36.6%) were males. ASD patients had significantly reduced FVC (73.11±24.6%; 86.05±26.1; p=0.001, respectively), and FEV1 (81.34±26.2% and 99.2±19.6%; p=0.001; respectively) at baseline. But significant improvement was observed in FVC values in the 3rd-month post-closure comparison of the patient group with the control group (73.11±24.6%; and 88.36±14.5%; p=0.01, respectively); FEV1 values (81.34±26% and 99.54±18.2%; p=0.005, respectively) and mean forced expiratory flow between 25 and 75% of vital capacity (MEF25-75) values (94.6±33.4% and 124.2±-24.1%; p=0.01, respectively) were also improved. There was no statistically significant relationship between the PFT measurements at baseline and after closure of the defect and age at transcatheter closure, gender, body height, body weight, ASD diameter, Q p/Q s, right ventricle systolic pressure, or mean pulmonary artery pressure values. At the 3rd month of ASD closure, there was no significant difference in the comparison of the PFT values of the patient and control group. Disturbance in the significant flow limitation of the peripheral airway of ASD patients was observed with PFT. Better pulmonary outcomes were observed in ASD patients after transcatheter closure.

Transthoracic echocardiography is a safe alternative for assessment and guidance of transcatheter closure of secundum atrial septal defect in children.

2D-transesophageal echocardiography (TEE) is routinely performed to guide percutaneous ASD closure in children. We aimed to assess whether two-dimensional (2D)-transthoracic echocardiography (TTE) is a safe alternative for assessment and guidance of atrial septal defect (ASD) closure in unselected children. We performed a retrospective single-center study including 389 consecutive children aged less than 15-year-old who underwent percutaneous ASD closure under 2D-TEE (1998-2005, n=133) or 2D-TTE (2005-2014, n=256). A balloon calibration was performed in all cases for the Amplatz Septal Occluder choice. ASDs were larger and rims deficiencies were more frequent in the TTE-guided group. The procedure was successful in 376 patients [96.7%; 95% confidence interval (CI), 94.4-98.2%]. The success rate tended to be higher in the TTE- versus TEE-guided group (98.0% versus 94.0%, P=0.069). Device migration occurred in 4 patients (1.0%; 95% CI: 0.3-1.6%), all after TEE-guided procedure (P=0.013). Early major adverse events were observed in 5 patients (1.3%; 95% CI: 0.4-3.0%), all in the TEE group (P=0.004). Fluroroscopic time and irradiation dose were not different among the 2 groups (P=0.450 and P=0.130 respectively). After a median follow-up of 7 years (range, 1-16 years), no adverse events was reported. One (0.3%, 95% CI: 0-1.4%) 12-year-old patient developed atrial fibrillation 5 years after the procedure. Pregnancies were uneventful in 72 cases. When a balloon sizing is performed, 2D-TTE imaging is as efficient as 2D-TEE to guide percutaneous ASD closure in children. The procedure can safely be done in spontaneously breathing children under TTE guidance alone in experienced centers.

Multicenter midterm follow-up results using the gore septal occluder for atrial septal defect closure in pediatric patients.

To assess the safety and efficacy of the Gore Septal Occluder (GSO) used for device-closure of significant secundum-type atrial septal defects (ASD II) focusing on pediatric patients. The GSO is a patch-like double disc device. Due to its design, it is assumed to be safe, even when implanted in ASDs with deficient retro-aortic rims. Multicenter retrospective analysis of consecutive children and adolescents with a GSO in situ for at least 12 months according to a 1- to 4-year midterm follow-up. Hundred and seventy three pediatric patients were enrolled. At implantation, median age was 6 years (range 0.7-17.9), median body weight and length were 21 kg (6.4-95) and 119 cm (65-193). Median follow-up period was 20 months (range 12-51). ASD anatomy was comprised of single defects in 131 patients (76%), multi-fenestrated defects in 42 (24%), and deficient retro-aortic rims in 33 (19%). Follow-up confirmed an overall closure-rate of 95.4%. Small residual shunts were reported in eight patients (4.6%) without need for any re-intervention. Complications were classified as minor events both during the initial procedure (9 patients, 5.2%) and on follow-up (another 9 patients), including transient AV block II in three patients (1.8%) and four snare-retrievals (2.4%) during the initial procedure. Periprocedural and midterm follow-up data have shown the GSO to be effective and safe for ASD device closure in children and adolescents. GSO may be considered the first-choice device in deficient retro-aortic rims and multi-fenestrated defects, when covering most of the atrial septum is necessary. © 2016 Wiley Periodicals, Inc.

Surgical site infection after stoma closure in children: outcomes and predictors

BackgroundSurgical site infection (SSI) is a burdensome complication following intestinal stoma closure, with reported rates ranging from 0% to 40%. We aimed to identify risk factors for SSI in children undergoing stoma closure. Materials and methodsUsing 2012-2014 NSQIP Pediatric data, we identified patients aged 0-18 years undergoing stoma closure. Demographic, clinical, and 30-day outcome characteristics between children with and without SSI were compared. A multivariable logistic model was used to identify predictors of SSI. ResultsAmong 2110 children who underwent stoma closure, 7.6% developed SSI. Patients who developed SSI had significantly longer time in the operating room, longer anesthesia times, longer total operation times, and longer lengths of stay (all P ≤ 0.01). Patients who developed SSI postoperatively had significantly higher rates of postoperative complications, including need for postoperative ventilation, sepsis, need for nutritional support on discharge, unplanned reoperation, unplanned readmission, postoperative lengths of stay >30 days, and transfusion within 72 hours after the start of surgery (all P ≤ 0.018). There was a significant relationship between operation time and SSI probability. Specifically, operation time greater than 105 minutes was associated with a higher SSI risk. On adjusted multivariable analyses, age, cardiac risk factors, Hirschsprung disease, and operation time greater than 105 minutes were independently predictive of SSI. ConclusionsLonger operation time, age, Hirschsprung disease, and cardiac risk factors are associated with an increased risk for SSI after stoma closure. Studies of perioperative adjuncts to reduce SSI in high-risk children based on expected procedure length and other preoperative characteristics are warranted.

Interventional Closure of Secundum Type Atrial Septal Defects in Infants Less Than 10 Kilograms: Indications and Procedural Outcome.

This study set out to assess indications, feasibility, complications, and clinical outcome of percutaneous transcatheter device closure of atrial septal defects (ASDs) in infants with a bodyweight below 10 kg. Retrospective single center chart and echocardiography review study from 8/2005-12/2013. Twenty-eight children with ASD (13 female) with a median age of 1.15 years (0.2-2.8) and a median weight of 7.2 kg (4.5-9.9) were analyzed. Indications for early ASD closure were failure to thrive (n = 15, 54%), bronchopulmonary dysplasia (BPD) with supplemental oxygen dependency (n = 7, 25%), and genetic syndromes with suspected pulmonary hypertension (n = 12, 43%). Device implantation was successful in all patients without any periprocedural mortality or major complication. Clinical outcome after a median follow-up period of 2.1 years (0.25-7.3) revealed no residual shunt and a significant decrease of right ventricular volume load. Patients with pulmonary hypertension experienced a significant reduction of pulmonary artery/RV pressure. Patients also showed decreased supplemental oxygen dependency and less cardiac medications, but no significant "catch-up growth" in those with failure to thrive. Interventional ASD closure in children weighing less than 10 kg can be performed without any additional major risks and shows a favorable outcome, especially in selected patients with significant non cardiac co-morbidities.

Ostium secundum atrial septal defect percutaneous closure in children: is it always a simple procedure?

Ostium secundum atrial septal defect percutaneous closure in children: is it always a simple procedure?

Expression of connexin 26 and connexin 43 is reduced in Hirschsprung's disease

BackgroundDespite having an optimal pull-through operation, some children with Hirschsprung's disease (HSCR) continue to experience persistent bowel symptoms. Coordinated colonic electrical activity depends on intercellular communication between the enteric nerves, interstitial cells of Cajal (ICCs), smooth muscle cells, and fibroblast-like (platelet-derived growth factor receptor-alpha-positive) cells. Gap junctions are low-resistance channels composed of connexin (Cx) proteins which couple cells electrically and chemically. We aimed to evaluate the expression patterns of Cx26, Cx36, and Cx43 in the colon of children with HSCR and in healthy control colon. Materials and methodsEntire resected colonic specimens were collected from children undergoing pull-through surgery for HSCR (n = 10). Colonic controls were collected at colostomy closure in children with imperforate anus (n = 8). Distribution of Cx26, Cx36, and Cx43 was assessed using double-labeled immunofluorescence and confocal microscopy. Protein expression was quantified using Western blot analysis. ResultsSparse punctate Cx36 expression was seen in the myenteric plexus in nerve trunks and some platelet-derived growth factor receptor-alpha-positive cell and ICC fibers. Cx26 was similarly distributed, although it was not coexpressed in ICCs. Cx43 was only coexpressed with ICCs in the myenteric plexus. Expression of Cx26 and Cx43 was markedly reduced in the aganglionic colon in HSCR compared to controls, while Cx26 expression was also moderately reduced in the ganglionic bowel in HSCR. ConclusionsReduced expression of Cx26 and Cx43 is implicated in the pathophysiology of colonic dysmotility in the aganglionic bowel as well as, in the case of Cx26, the ganglionic bowel in HSCR.

Tracheocutaneous fistula closure in children

ObjectiveSystematic review of surgical techniques for tracheocutaneous fistula closure in children and successful closure or development of adverse events. Data sourcesPubMed, EMBASE, Web of Science, and Cochrane Library. Review methodsA medical librarian was utilized to perform a systematic review. ResultsFourteen studies were identified. Eight studies reported outcomes for primary closure alone; one discussed results for secondary closure alone; and five included a combination of children who underwent either primary and secondary closure alone. No difference between surgical techniques was identified for effectiveness of closure (RR = 1.03, 95% CI: 0.97 to 1.10) and major (RR = 1.68, 95% CI: 0.56 to 5.05) or minor complications (RR = 1.28, 95% CI: 0.50 to 3.27). No mortalities were identified. ConclusionsBoth primary and secondary closure techniques for persistent tracheocutaneous fistulas in children are effective and associated with acceptable rates of complications. Given the available evidence, neither approach appears to be superior. Considerations for decision making in surgical approach may include family and social considerations, facility resource utilization, and cost differential. Further investigation may be directed at improving patient selection.

Salvage of a failed open gastrocutaneous fistula repair with an endoscopic over-the-scope clip

Abstract Once enteral access via gastrostomy tube (G-tube) is no longer indicated, the tube is typically removed in clinic with a high probability of spontaneous closure. When spontaneous closure is not achieved, the formation of a gastrocutaneous fistula (GCF) is possible. The incidence of GCF is directly related with the length of time the tube has been placed. When conservative management fails, surgical intervention is the standard treatment. Endoscopic techniques have been described for primary closure of GCF in adults including banding and cauterizing of the fistula tract with placement of a standard endoscopic clip. Over-the-scope clips (OTSC) have recently been reported in primary GCF closure in children (Wright et al., 2015). In patients with skin irritation surrounding a GCF making surgical repair difficult, endoscopic OTSC closure provides particular benefit. It is our belief that this is the first case report of endoscopically salvaging a leak from a failed open GCF repair.

Transcatheter Closure of Atrial Septal Defects using the GORE(®) Septal Occluder in Children Less Than 10 kg of Body Weight.

The GORE(®) Septal Occluder (GSO) is a well-evaluated device for interventional ASD closure with closure rates comparable to the Amplatzer(®) Septal Occluder (ASO), but there are no published reports of its use in small children weighing less than 10 kg. This may be due to the necessity of a large-sized introducing sheath of at least 10 Fr and therefore the assumed risk of complications in vascular access. The GSO is an alternative option for interventional ASD closure in children weighing less than 10 kg. Fourteen infants and children with a median body weight 8900 g (range 6350-9650 g) underwent successful ASD closure using the GSO. The closure was performed under fluoroscopic and transthoracic echocardiographic guidance. Postprocedure, the vessels passed by the occluder and delivery catheter were examined by duplex sonography. The median ASD diameter was 11 mm (5-17 mm), and the median GSO size was 22.5 mm (15-30 mm), whereas the median ASO left disc size that would have been recommended was 25 mm (17-31 mm). All ASDs were successfully closed. During a median follow-up of 1.57 years (range 0.5-4.2), no complications like erosion, embolization, arrhythmias, or vascular injuries occurred. Although using a 10-Fr introducer sheath, no vascular complications were detected. Our data suggest that the small usable size as well as the soft and flexible design of the device allows successful use of the GSO in young children.