Sutures In Children Research Articles

Double J Ureteral stent removal in children non cystoscopically: A preferred innovation.

Objective: To determine the feasibility of non cystoscopic removal of double J ureteral (DJ) stent using a foley catheter with suture in children in terms of success rate, number of attempts required and complications. Study Design: Cross Sectional study. Setting: Department of Pediatric Surgery, Services Hospital, Lahore. Period: August 2022 to August 2023. Methods: All the children who underwent DJ stent placement for any urological procedure were included if DJ stent was seen in the bladder postoperatively. After informed consent, under sedation and aseptic measures, the foley catheter with suture already passed through its eye, was introduced per urethral after adequate lubrication. The foley was given five to six rotations in clockwise direction for right sided and anti-clockwise for left sided stents respectively and pulled out keeping traction on the suture. In case of three failed attempts, a cystoscope was introduced under general anesthesia and the stent was removed. Successful removal, number of attempts needed, time taken, and post removal complications were noted to determine feasibility of the procedure. Results: Out of twenty patients, 17 patients (85%) underwent successful removal of DJ stent. The failure rate was 15% as three patients required cystoscope assisted removal. In 13 patients (76.5%) DJ stent was removed in first attempt, whereas in 4(23.5%) patients it required two attempts. Mean time taken was 8.83±7.33 minutes. Complications were noted in 2 patients (10%). Conclusion: Removal of DJ stent in children without cystoscope, using a foley catheter with suture is a safe and feasible procedure with a high success rate and should be attempted in selected cases.

Enhancing educational experience through establishing a VR database in craniosynostosis: report from a single institute and systematic literature review.

Craniosynostosis is a type of skull deformity caused by premature ossification of cranial sutures in children. Given its variability and anatomical complexity, three-dimensional visualization is crucial for effective teaching and understanding. We developed a VR database with 3D models to depict these deformities and evaluated its impact on teaching efficiency, motivation, and memorability. We included all craniosynostosis cases with preoperative CT imaging treated at our institution from 2012 to 2022. Preoperative CT scans were imported into SpectoVR using a transfer function to visualize bony structures. Measurements, sub-segmentation, and anatomical teaching were performed in a fully immersive 3D VR experience using a headset. Teaching sessions were conducted in group settings where students and medical personnel explored and discussed the 3D models together, guided by a host. Participants' experiences were evaluated with a questionnaire assessing understanding, memorization, and motivation on a scale from 1 (poor) to 5 (outstanding). The questionnaire showed high satisfaction scores (mean 4.49 ± 0.25). Participants (n = 17) found the VR models comprehensible and navigable (mean 4.47 ± 0.62), with intuitive operation (mean 4.35 ± 0.79). Understanding pathology (mean 4.29 ± 0.77) and surgical procedures (mean 4.63 ± 0.5) was very satisfactory. The models improved anatomical visualization (mean 4.71 ± 0.47) and teaching effectiveness (mean 4.76 ± 0.56), with participants reporting enhanced comprehension and memorization, leading to an efficient learning process. Establishing a 3D VR database for teaching craniosynostosis shows advantages in understanding and memorization and increases motivation for the study process, thereby allowing for more efficient learning. Future applications in patient consent and teaching in other medical areas should be explored.

Stable fixation using absorbable sutures in craniofacial surgery in patients over 24 months of age—a retrospective study

PurposeIn craniofacial surgery, the stable fixation of transposed bone segments is crucial in order to ensure good long-term results. The use of absorbable material in fixation avoids the need for a second surgery, which would otherwise be required to remove osteosynthesis material. The authors of the present manuscript have already demonstrated that absorbable sutures ensure the stable fixation of bone segments in patients up to 24 months of age. However, it has thus far remained unclear whether stable fixation is possible in older patients by using only absorbable sutures due to the slower bone remodelling and prolonged healing time in this cohort.MethodFor the present study, osteosynthesis was performed in 50 patients ranging from 25.7 to 192.1 months of age (mean, 61.4 ± 21.7 months) using solely absorbable sutures (PDS II®, Ethicon, Germany). Post-operative stability and possible restrictions—such as foreign body reactions—were evaluated within clinical and radiological routine follow-ups.ResultsAll children demonstrated clinically and radiologically stable osteosynthesis both directly post-operatively and in follow-ups. No significant foreign body reaction could be seen.ConclusionThe present study demonstrates—for the first time—that absorbable sutures with a longer absorption period are also very well suited for the fixation of bone segments in patients over 24 months of age. The sole use of absorbable sutures in children over 24 months of age is a safe procedure with nearly no foreign body reactions. The procedure enables stable and highly cost-effective osteosynthesis without altering the osteotomy design.

The Effect of Hyrax-Type Rapid Maxillary Expansion with or without Laser Biostimulation on Mid Palatal Suture in Children with Posterior Crossbite

Purpose: The aim of the following study was to evaluate the use of low-level laser application on the width of the Mid palatal suture (MPS) after rapid maxillary expansion. Materials and methods: patients age range 10 ± 2.5 years were prospectively selected from outpatient clinic of the Orthodontic Department, Faculty of Dental Medicine for Girls, Al-Azhar University (Girls’ Branch). Each patient was examined, full diagnostic records and cone beam computed tomography (CBCT) were taken before appliance cementation (T0), after six months and at the end of retention phase (T1). The hyrax appliance was used for rapid maxillary expansion (RME). The activation protocol of the expansion screw was 2 full turns daily. The laser type used was the e Epic™ X diode laser system, 940 nm wavelength, 40 mW power, and 10 J/cm2 density. Results: No significant differences were found in the two areas between the control and the laser group. Conclusions: The mid palatal suture width showed no statistical significant differences between the control and laser group in anterior and posterior region.

The Effect of Hyrax-Type Rapid Maxillary Expansion with or without Laser Biostimulation on Mid Palatal Suture in Children with Posterior Crossbite

Purpose: The aim of the following study was to evaluate the use of low-level laser application on the width of the Mid palatal suture (MPS) after rapid maxillary expansion. Materials and methods: patients age range 10 ± 2.5 years were prospectively selected from outpatient clinic of the Orthodontic Department, Faculty of Dental Medicine for Girls, Al-Azhar University (Girls’ Branch). Each patient was examined, full diagnostic records and cone beam computed tomography (CBCT) were taken before appliance cementation (T0), after six months and at the end of retention phase (T1). The hyrax appliance was used for rapid maxillary expansion (RME). The activation protocol of the expansion screw was 2 full turns daily. The laser type used was the e Epic™ X diode laser system, 940 nm wavelength, 40 mW power, and 10 J/cm2 density. Results: No significant differences were found in the two areas between the control and the laser group. Conclusions: The mid palatal suture width showed no statistical significant differences between the control and laser group in anterior and posterior region.

Comparison of Craniosynostosis Surgery Outcomes Using Resorbable Plates and Screws versus Absorbable Sutures in Children with Craniosynostosis.

Previously, absorbable screw and plate systems were widely used in craniosynostosis surgery in Iran, but now, due to the establishment of economic sanctions, the importation of these tools into the country has become difficult. In this study, we compared the short-term complications of cranioplasty surgery in craniosynostosis using absorbable plate screws with absorbable sutures. In this cross-sectional study, 47 patients with a history of craniosynostosis who underwent cranioplasty at Tehran Mofid Hospital, Tehran, Iran from 2018 to 2021 were divided into two groups. For first group (31 patients) we used absorbable plate and screws, and for the second group (16 patients) absorbable sutures (PDS). All operations in both groups were performed by the identical surgical team. Patients followed up for consecutive post-operative examinations in the first and second weeks and 1, 3, and 6 months. Data were analyzed using SPSS software version 25. The results did not show any short-term or medium-term complications in either group. No recurrences were observed. In Whittaker classification, 63.8% were Class I, 29.8% were Class II, 6.4% were Class III, and 0% were Class IV. There was no statistically significant relationship between the type of treatment (screw and plate or absorbable suture) and higher Whitaker. There was also no statistically significant relationship between type of craniosynostosis and higher Whittaker. The absorbable sutures can be considered as valuable and cost-effective tools in the fixation of bone fragments in craniosynostosis surgeries by surgeons.

Intranasal ketamine for procedural sedation in children: An open-label multicenter clinical trial

IntroductionThere are limited options for pain and distress management in children undergoing minor procedures, without the burden of an intravenous line insertion. Prior to this study, we conducted a dose-escalation study and identified 6 mg/kg as a potentially optimal initial dose of intranasal ketamine. ObjectiveTo assess the efficacy and safety of intranasal ketamine at a dose of 6 mg/kg for procedural sedation to repair lacerations with sutures in children in the emergency department. MethodsWe conducted a single-arm, open-label multicenter clinical trial for intranasal ketamine for laceration repair with sutures in children aged 1 to 12 years. A convenience sample of 30 patients received 6 mg/kg of intranasal ketamine for their procedural sedation. The primary outcome was the proportion (95% CI) of patients who achieved an effective procedural sedation. ResultsWe recruited 30 patients from April 2018 to December 2019 in two pediatric emergency departments in Canada. Lacerations repaired were mostly facial in 21(70%) patients and longer than 2 cm in 20 (67%) patients. Sedation was effective in 18/30 (60% [95% CI 45, 80]) children and was suboptimal in 5 (17%) patients but procedure was completed in them with minimal difficulties. Sedation was poor in the remaining 7 (23%) patients, with 3 (10%) of them required additional sedative agents. No serious adverse events were reported. ConclusionsUsing a single dose of 6 mg/kg of intranasal Ketamine for laceration repair led to successful sedation in 60% of patients according to our a priori definition. An additional 17% of patients were considered suboptimal, but their procedure was still completed with minimal difficulty.Clinical trial registration: ClinicalTrials.gov (NCT03053947).

Epsilon Aminocaproic Acid's Safety and Efficacy in Pediatric Surgeries Including Craniosynostosis Repair: A Review of the Literature.

Craniosynostosis, the premature fusion of skull sutures in children, requires surgical correction. This procedure routinely requires allogeneic blood transfusions, which are associated with multiple risks of their own. Since 2008, antifibrinolytics tranexamic acid (TXA) and epsilon aminocaproic acid (EACA or Amicar) have been widely used. There is literature comparing the two agents in scoliosis and cardiothoracic surgery, but the literature comparing the two agents in pediatric craniofacial surgery (CF) is limited. Tranexamic acid use is more common in pediatric CF surgery and has been thoroughly studied; however, it costs about three times as much as EACA and has been associated with seizures. This study compiles the literature assessing the safety and efficacy of EACA in reducing blood loss and transfusion volumes in children and explores its potential use in pediatric CF surgery.Papers from 2000 to 2021 regarding the effectiveness and safety of EACA in Pediatric scoliosis, cardiothoracic, and craniosynostosis surgery were reviewed and compiled. Papers were found via searching PubMed and Cochrane databases with the key terms: Epsilon aminocaproic acid, EACA, Amicar, Tranexamic acid, TXA, craniosynostosis, scoliosis, cardiothoracic, and pediatric. Prospective studies, retrospective studies, and meta-analyses were included.Twenty-nine papers were identified as pertinent from the literature searched. Four were meta-analyses, 14 were retrospective, and 11 were prospective. Of these papers, seven were of cardiac surgery, 12 were of scoliosis, and nine were of craniosynostosis. During our search, EACA has been shown to consistently reduce blood transfusion volumes compared to control. However, it is not as effective when compared to TXA. EACA has a similar safety profile to TXA but has a reduced risk of seizures. There are not many studies of EACA in craniosynostosis repair, but the existing literature shows promising results for EACA's efficacy and safety, warranting more studies.

Effects of osteopathic techniques of balancing SEB and separating the front-ethmoid suture in children with narrow palate

The use of the disjunction by dentists, to solve the problem of narrow palate, allows to maintain flexible tissues and permeable sutures. The opening of the palatal suture by means of the dental disjunction confers greater freedom of movement to the upper jaw and the palatine but given the close relationship of this bones with the vomer, the ethmoid and even the spheno-basilar synchondrosis, it is hypothesized that osteopathy could contribute not only to accelerate the process of disjunction, but also to avoid the recurrences of it. The maneuvers proposed here take into consideration the cranial structures that are in direct relation with the bony palate.The aim is to analyze whether the osteopathic maneuver of the balancing of the spheno-basilar synchondrosis and the front-ethmoidal separation influence the angle of the sella turcica, the joint angle and the distance between the central fossae in children with narrow palate who use a disjunction.A controlled, randomized, longitudinal and double-blind clinical trial was conducted; with experimental group and control group and two external evaluators. Measurements have been made prior to treatment, and after 45. It was shown that the two osteopathic maneuvers used were sufficient to cause significant increases in the angle of the sella turcica and the joint, and the distance between fossa and fossa of the first permanent molars. Osteopathic interventions were performed before placing the circuit breaker, 15 days and 35 days later.

Possibilities of the ultrasonography in the diagnosis of craniosynostosis in children of the first year of life

Craniosynostosis is a premature closure of the skull sutures, manifested by deformation of the head requiring surgical treatment. An instrumental examination of the state of the cranial sutures is necessary for the differential diagnosis of craniosynostosis and benign positional deformities of the skull in infants. Traditionally, radiation methods, such as X-ray and computed tomography with three-dimensional reconstruction, are used for this purpose. Over the past two decades, we have accumulated a large amount of data on the high information content of the ultrasound method in assessing the state of the cranial sutures in children. Ultrasound examination is widely available, easy to perform, reproducible; it does not require sedation of the patient and does not carry radiation exposure, which is especially important when examining young children. A negative result of the study makes it possible to exclude the diagnosis of craniosynostosis, while the detection of suture fusion serves as an indication for referring the child to visit a surgeon and further examination. The ultrasound method should be more widely used as a screening method for detecting head deformity and suspicion of craniosynostosis in children of the first year of life.

Postoperative Visual Outcome: Sling procedure with prolene sutures in children with simple congenital ptosis.

ABSTRACTObjective:To assess the visual outcome after sling procedure using prolene sutures in children with simple congenital ptosis.Methods:A descriptive case series study was performed in the Department of Ophthalmology of Jinnah Post Graduate Medical Centre, for a duration of six months in which 20 patients aged 3-10 years were selected with either unilateral or bilateral congenital ptosis. They were thoroughly examined and visual acuity and degree of ptosis were measured pre-operatively. Frontalis sling surgery was performed using prolene sutures on all patients after which their visual acuity and degree of ptosis were measured once again after three months post-operatively. Data were analyzed using SPSS version 20.0. For qualitative variables, frequency and percentages were calculated. Mean and Standard deviation was commutated for the quantitative variable.Results:The mean age of the patients was 8.15±1.75. 11 (55%) male and 9 (45%) female participants were included in the study. Visual acuity improved in all the patients with all the patients attaining a visual acuity of 6/6 (n=12, 60%), 6/9 (n=7, 35%), and 6/12 (n=1, 5%). The degree of ptosis post-operatively was not found in any patient either.Conclusion:Sling procedure helped in eliminating ptosis and improved visual acuity in patients with simple congenital ptosis.

Routine use of non-absorbable sutures in bi-medial rectus recession as a measure to reduce the incidence of consecutive exotropia.

To evaluate the incidence of consecutive exotropia following bilateral medial rectus muscle recession surgery (BMR) for esotropia using non-absorbable compared with absorbable sutures in children undergoing strabismus surgery. A retrospective cohort study of all children with esotropia who underwent BMR by a single surgeon in a tertiary public hospital. As of February 2018, only non-absorbable sutures were used. The primary outcome was the incidence of consecutive exotropia. A total of 121 children were included in the analysis, 3.66 ± 2.62 years, 53% were male. In 80 children (66%) non-absorbable sutures were used (non-absorbable group) and in 41 children (34%) absorbable sutures were used (absorbable group). Consecutive exotropia (≥ 8 prism dioptres) occurred in ten children (24%) in the absorbable group and in three children (4%) in the non-absorbable group (OR = 8.28, 95% CI = 2.13-32.13; P = 0.002). This difference between groups remained significant after adjustment for potential confounders and follow-up time (HR = 4.98, 95% CI = 1.30-19.05, P = 0.019). Mean follow-up time was 22 and 12 months in the absorbable and non-absorbable groups, respectively (P < 0.001). Two children in the non-absorbable group had pyogenic granuloma that resolved after 3 months of topical steroidal therapy. Routine use of non-absorbable sutures in BMR surgery for esotropia may be a preferable alternative to absorbable sutures for the prevention of consecutive exotropia.

Comparative Analysis of Safety and Feasibility of Suture Versus Sutureless Pediatric Cataract Surgery.

To compare the safety, feasibility, and outcomes of clear corneal cataract surgery with or without sutures in children (2 to 8 years old) with congenital or developmental cataracts. One hundred seventy consecutive eligible eyes with pediatric cataracts were randomized into treatment groups depending on closure of clear corneal incisions: suture group and sutureless hydroclosure group (sutureless group). Patients were evaluated on days 1, 7, 30, and 90 postoperatively, with an emphasis on wound leakage from incisions and complications. Wound leakage from any corneal incisions was not observed in both groups. Shallow anterior chamber on the first postoperative day was observed in 2 and 3 eyes in the suture and sutureless groups, respectively (P = .48). Hypotony was not observed in any patients. Intraocular pressure measurements were comparable on follow-up visits (P > .05). Mean cylindrical error was significantly greater (P = .03) in the suture group than the sutureless group (1.01 and 0.74 diopters, respectively) after 1 month. One patient developed endophthalmitis after suture removal in the suture group. Sutureless hydroclosure of incisions is not inferior compared to suturing in pediatric cataracts. This avoids suture-related complications while reducing the astigmatic error and is thus potentially less amblyogenic. However, sutures must be used whenever the incision architecture is compromised. [J Pediatr Ophthalmol Strabismus. 2021;58(4):246-253.].

Magnetic resonance imaging analysis of human skull diploic venous anatomy.

Background: The skull diploic venous space (DVS) represents a potential route for cerebrospinal fluid (CSF) diversion and absorption in the treatment of hydrocephalus. The goal of this study was to carry out a detailed characterization of the drainage pattern of the DVS of the skull using high-resolution MRI, especially the diploic veins draining to the lacunae laterales (LLs) since the LLs constitute an important channel for the CSF to access the superior sagittal sinus and subsequently the systemic circulation. The objective was to identify those skull regions optimally suited for an intraosseous CSF diversion system.Methods: High-resolution, T1-weighted MRI scans from 20 adult and 16 pediatric subjects were selected for analysis. Skulls were divided into four regions, that is, frontal, parietal, temporal, and occipital. On each scan, a trained observer counted all diploic veins in every skull region. Each diploic vein was also followed to determine its final drainage pathway (i.e., dural venous sinus, dural vein, LL, or indeterminate).Results: In the adult age group, the frontal and occipital skull regions showed the highest number of diploic veins. However, the highest number of draining diploic veins connecting to the lacunae lateralis was found in the frontal and parietal skull region, just anterior and just posterior to the coronal suture. In the pediatric age group, the parietal skull region, just posterior to the coronal suture, showed the highest overall number of diploic veins and also the highest number of draining diploic veins connecting to the LL.Conclusion: This study suggested that diploic venous density across the skull varies with age, with more parietal diploic veins in the pediatric age range, and more occipital and frontal diploic veins in adults. If the DVS is ultimately used for CSF diversion, our anatomical data point to optimal sites for the insertion of specially designed intraosseous infusion devices for the treatment of hydrocephalus. Likely the optimal sites for CSF diversion would be the parietal region just posterior to the coronal suture in children, and in adults, frontal and/or parietal just anterior or just posterior to the coronal suture.

86 Intra-nasal ketamine for laceration repair in the Emergency Department: The DosINK studies

Abstract Introduction/Background Lacerations are common in children presenting to the emergency department (ED). Children can be uncooperative and in pain when repair with sutures is performed and may require procedural sedation. There is a growing interest in the intranasal (IN) route of administration for procedural sedation and pain control. In contrast to intravenous (IV) line placement, IN administration is relatively painless for the patient, is simple and rapid to administer by the healthcare provider and requires minimal training. Few studies have evaluated intranasal (IN) ketamine for procedural sedation in children, mostly for brief dental procedures, with doses between 3 to 9 mg/kg. Objectives We sought to determine the optimal IN ketamine dose for effective and safe procedural sedation for laceration repair with sutures in children aged 1 to 12 years presenting to the ED using a two-step (dosINK- 1 trial and dosINK-2 trial) dose-finding clinical trial design. Design/Methods We enrolled otherwise healthy children 1 to 12 years requiring PS for their laceration repair by sutures in the ED. DosINK-1 consisted in a single center 3 + 3 dose escalation trial design with an initial dose of 3 up to 9 mg/kg of IN ketamine. For each dose, 3 patients were enrolled. Escalation to the next dose was performed if sedation was unsuccessful without serious adverse event (SAE). This process was repeated until 6 consecutive patients reached adequate PS with a maximum of 1 SAE. The primary outcome was the optimal dose for adequate PS as per the PERC/PECARN consensus criteria. We subsequently conducted DosINK-2, a multicenter single-arm clinical trial. We enrolled a convenience sample of 30 children who all received the identified dose of IN ketamine from DosINK-1. The primary outcome was the proportion (95% CI) of patients who achieved adequate PS. Secondary outcomes included adverse events and parent, patient and physician satisfaction. Results In DosINK-1, 12 patients were recruited from April 2017 to March 2018 in one pediatric ED. Median age was 2.6 (interquartile range [IQR] 1.9, 3.7) years, 10 (85%) had facial laceration, and in 8 (67%) the laceration was &amp;gt;2 cm long. Sedation was adequate in 1/3 patients at doses of 3 and 4 mg/kg and in 3/3 patients at doses of 5 and 6 mg/kg, all without SAE. The identified dose of IN ketamine was 6 mg/kg. Nausea and vomiting in 4/12 (33%) patients were the only reported side effects. In DosINK-2, we recruited 30 patients from April 2018 to November 2019 in two pediatric EDs. The median age was 3.2 (IQR 1.9, 4.7) years; 21 (70%) had facial laceration, and in 20 (67%) the laceration was longer than 2 cm. Sedation was adequate in 18/30 (60% [95% CI 45, 80]) children, was suboptimal (procedure completed with minimal difficulties) in 6 (20%), was poor (struggle that interfered with procedure, competed with difficulty) in 3 (10%) and required additional sedative agents in 3 (10%) patients. Twenty-one (70%) physicians were willing to reuse IN ketamine at the same doses and 25 (83%) parents would agree to the same sedation in the future. Median time to return to baseline status was 58 min (IQR 33, 73). Two patients, including one who received supplemental IV ketamine, desaturated during the procedure and required oxygen by-mask and repositioning. After the procedure, 1(3%) patient had nausea, and 2(7%) vomited. Conclusion A single dose of 6 mg/kg of IN ketamine for PS during laceration repair by sutures in children in the ED was adequate in 60%(95% CI 45, 80). In an additional 20% PS was suboptimal, but procedures were completed with minimal difficulties only. IN ketamine, which saves painful IV insertion, was acceptable by most physicians and parents. An additional IN ketamine dose may further increase the proportion of adequate sedation, but its safety and efficacy should be examined.

Circummaxillary Sutures in Patients With Apert, Crouzon, and Pfeiffer Syndromes Compared to Nonsyndromic Children: Growth, Orthodontic, and Surgical Implications.

To evaluate patency of circummaxillary sutures in children with Apert, Crouzon, and Pfeiffer Syndromes and to compare it to a nonsyndromic matched control group. Case-control study. Tertiary care public hospital. Thirty-eight computed tomography (CT) scans of patients affected by syndromic craniofacial synostosis (13 patients with Apert syndrome, 20 patients with Crouzon syndrome, and 5 patients with Pfeiffer syndrome), average age 5 ± 2.8 years, range 1.9 to 12 years, were compared to age- and sex-matched control CTs of 38 nonsyndromic children. Computed tomography scans of the study group had to be performed prior to any midfacial surgery. Midpalatal suture, zygomaticomaxillary sutures, and pterigomaxillary sutures were evaluated and scored. The syndromic group showed a significant earlier ossification of all sutures compared to the nonsyndromic group. Significant differences were already present in early childhood and continued through adolescence. Based on the differences in terms of maxillary sutural ossification identified, midfacial hypoplasia does not seem to be only secondary to premature cranial base ossification, but also to primary synostosis of facial sutures, thus providing new insights into the pathogenesis of midface deficiency in children with craniofacial-synostosis. Care should be taken when planning any maxillary orthopedics, such as expansion or maxillary protraction, given the high frequency of early fusion of circummaxillary sutures.

LO50: Pain free laceration repairs using intra-nasal ketamine: DosINK 2 clinical trial

Introduction: Lacerations are common in children presenting to the emergency department (ED). They are often uncooperative when sutures are needed and may require procedural sedation. Few studies have evaluated intranasal (IN) ketamine for procedural sedation in children, with doses from 3 to 9 mg/kg used mostly for dental procedures. In a previous dose escalation trial, DosINK-1, 6 mg/kg was found to be the optimal IN ketamine dose for procedural sedation for sutures in children. In this trial, we aim to further evaluate the efficacy of this dose. Methods: We conducted a multicentre single-arm clinical trial. A convenience sample of 30 uncooperative children between 1 and 12 years (10 to 30 kg) with no cardiac or kidney disease, active respiratory infection, prior administration of opioid or sedative agents received 6 mg/kg of IN ketamine using an atomizer for their laceration repair with sutures in the ED. The primary outcome was defined as the proportion (95% CI) of patients who achieved an adequate procedural sedation evaluated with the PERC/PECARN consensus criteria. Results: Thirty patients were recruited from April 2018 to November 2019 in 2 pediatric ED. The median age was 3.2 (interquartile range(IQR), 1.9 to 4.7) years-old with laceration of more than 2 cm in 20 (67%) patients and in the face in 21 (70%) cases. Sedation was effective in 18 out of 30 children 60% (95%CI, 45 to 80), was suboptimal in 6 patients (20%) with a procedure completed with minimal difficulties, and unsuccessful in the remaining 6 (20%), all without serious adverse event. Similarly, 21/30 (70%) physicians were willing to reuse IN ketamine at the same doses and 25 parents (83%) would agree to the same sedation in the future. Median time to return to baseline status was 58 min (IQR, 33 to 73). One patient desaturated during the procedure and required transitory oxygen and repositioning. After the procedure, 1 (3%) patient had headache, 1 (3%) patient had nausea, and 2 (7%) patients vomited. Conclusion: A single dose of 6 mg/kg of IN Ketamine for laceration repair with sutures in uncooperative children is safe and facilitated the procedure in 60% (95%CI, 45 to 80) of patients, was suboptimal in 20% and unsuccessful in 20% of patients. As seen with IV ketamine, an available additional dose of IN ketamine for some children if needed could potentially increase proportion of successful sedation. However, the safety and efficacy of repeated doses needs to be addressed.

Efficacy of pillar suture for post-tonsillectomy morbidity in children: a meta-analysis

IntroductionSeveral surgical techniques have been used during tonsillectomy to reduce complications. ObjectivesTo assess the effects of pillar suture in conjunction with tonsillectomy as compared to tonsillectomy without suture in children. MethodsTwo authors independently searched five databases (PubMed, SCOPUS, Embase, the Web of Science, and the Cochrane database) for studies published as recent as December 2018. Of the included studies, we compared tonsillectomy and pillar suture in combination (suture groups) with tonsillectomy alone,without suture, (control group). Postoperative pain intensity and other morbidities (e.g., postoperative bleeding, palatal hematoma, discomfort, and pillar edema) were measured during the postoperative period. ResultsPostoperative bleeding [primary (OR = 0.47 [0.27; 0.81]) and secondary (OR = 0.14 [0.02; 0.78]) were significantly decreased in the pillar suture group compared to the control group. There were no significant differences between the two groups in postoperative pain at day 7 (SMD = −0.39 [−0.79; 0.00]), palatal hematoma (OR = 5.00 [0.22; 112.88]), palatal discomfort sensation (OR = 2.62 [0.60; 11.46]), site infection (OR = 5.27 [0.24; 113.35]), and velopharyngeal insufficiency (OR = 2.82 [0.11; 74.51]). By contrast, pillar edema (OR = 9.55 [4.29; 21.29]) was significantly increased in the pillar suture group compared to the control group. ConclusionsPillar suture combined with tonsillectomy may reduce postoperative bleeding incidence despite increasing pillar edema in pediatric tonsillectomy. Postoperative pain-relief, palatal hematoma, palatal discomfort sensation, site infection, and velopharyngeal insufficiency were not significantly altered compared to tonsillectomy alone. However, further studies are needed to corroborate the results of this study.

Retrospective study of open reduction and internal fixation of lateral humeral condyle fractures with absorbable screws and absorbable sutures in children.

Background:Lateral humeral condyle fractures are the second most common elbow fracture in children. Displaced and rotated fractures require stabilization and reduction. Kirschner wires (K-wires) are most commonly used in the fixation of these fractures. Here, we introduce a new fixation method that uses an absorbable screw. We aim to determine if it is feasible to treat lateral humeral condyle fractures with an absorbable screw by comparing functional outcomes following absorbable screw fixation vs. K-wire fixation.Methods:Between May 2007 and September 2010, 86 patients were treated with absorbable screws (43 patients) or K-wire (43 patients). All patients had been diagnosed with lateral condyle fractures that were classified as either Jacob type II (unstable) or III. One absorbable screw (3.5 mm-diameter) was used for fixation in 1 group, while two 1.6 to 1.8 mm K-wires were used in the other group. Patients were followed 6 months about the elbow function according to Broberg and Morrey standard. On 5–7 years, the patients were followed about the carrying angle (valgus deformities and varus deformities), range of motion (flexion loss and extension loss), prominent lateral condyle, symptomatic implants, and fishtail deformity.Results:Anatomic reduction was achieved in all patients. Each group had one radial nerve injury that were present preoperatively. Nerve function recovered spontaneously within 3 to 4 weeks of surgery in both patients. No patient developed necrosis of the capitulum in both groups. Nine patients in K-wires group and 2 in absorbable screw group developed symptomatic implants (P = .048). On the sixth month, there was no significant difference on elbow function according to Broberg and Morrey standard. On 5 to 7 years (average, 6.7 ± 1.3 years), valgus deformities was 6.8 ± 1.2 vs 5.7 ± 0.8, varus deformities was 7.2 ± 1.5 vs 5.1 ± 1.9, flexion loss was 12.4 ± 2.2 vs 9.5 ± 3.1, extension loss was 11.1 ± 3.1 vs 10.2 ± 2.7, prominent lateral condyle was 27.9% vs 37.2%, fishtail deformity was 7.3% vs 4.9%, no significant difference between these groups.Conclusions:Open reduction with absorbable screw fixation is feasible and safe for the treatment of lateral condyle fractures of the humerus in children.Level of Evidence:Therapeutic III.

Successful outcomes in laparoscopic pyeloplasty using knotless self-anchoring barbed suture in children

Laparoscopic pyeloplasty for ureteropelvic junction obstruction in children has gained increasing importance over the last decade. Intracorporeal knot tying still remains a technical challenge for the surgeon. Self-anchoring suture incorporates a new concept for tissue approximation and reduces intracorporeal knot tying problems. There are very few reports on self-anchoring knotless suture and its application for laparoscopic pyeloplasty in children. We present our results of a series of consecutive children undergoing laparoscopic pyeloplasty with knotless barbed sutures. We prospectively evaluate 15 consecutive patients who underwent laparoscopic pyeloplasty with knotless barbed sutures (V-LocTM, Covidien) for ureteropelvic anastomosis. The decision of the operation was given by pediatric nephrology-urology-radiologic imaging diagnostic team, and all patients were operated by a single surgeon. Pyeloplasty was performed without pelvic reduction, and the anastomosis was made by barbed sutures using running fashion. The mean age of the patients were 5.39 (3 months-17 years). Two cases had undergone a right-sided pyeloplasty, and thirteen had undergone a left-sided pyeloplasty. The duration of the operative procedure was 60-110min. Neither intraoperative nor postoperative complication was encountered in any of the cases. Patients were followed by ultrasonographic evaluation. The anteroposterior diameter (AP) diameter of renal pelvis and hydronephrosis grade Society for Fetal Urology (SFU) are significantly different when compared with pre-operative and postoperative period (p=0.001 and p=0.001, respectively). Owing to the renal parenchymal thickness change by age pre-operative and postoperative thickness comparison is adjusted by age, because age is considered as a covariate (confounder variable). We observed statistically significant (p=0.003) difference in parenchymal thickness in all cases. Follow-up periods of the 15 consecutive pediatric pyeloplasty cases were 6-54 months. In the present study, successful outcome of the laparoscopic pyeloplasty using barbed suture was shown for the first time in children in literature. We believe that successful outcome of laparoscopic pyeloplasty could be achieved by eliminating knots and less manipulation on the wound edge also minimizes tissue injury during the procedure.