Stoma Complications in Infants with NEC

Up to 50% of infants with NEC require surgical intervention, which generally consists of exploration of the abdomen, bowel resection, and stoma formation. The bowel used for formation of the stoma is frequently of marginal viability, and the infants are usually systemically ill during this emergent procedure.

Aguayo et al [Journal of Surgical Research (2009) 157(2):275-8] performed a retrospective study to assess the factors associated with an increased risk of stomal complications in infants undergoing operative intervention for NEC. The authors noted a 43% rate of stomal complications (5% retraction, 5% Skin excoriation, 8% prolapse, 7% necrosis, 15% stricture, 3% parastomal hernias). They also noted a significant increase in risk of complications with lower gestational age and lower preoperative weight.

Intestinal stomas, although potentially life saving, have a surprisingly high rate of complications. They should be created with meticulous technique in order to help decrease the risk of morbid complications and need for revision.

When is prophylaxis against infectious endocarditis indicated?

Infectious endocarditis (IE) occurs when nonbacterial thrombotic endocarditis (NBTE) becomes infected after an episode of transient bacteremia. NBTE results from platelet/fibrin deposition at areas of abnormal and turbulent blood flow. Any event that can cause transient bacteremia (eg. violation of the GI tract) can transform NBTE to IE.

The AHA recommendations for endocarditis prophylaxis were modified in 2007 [Circulation (2007);116:1736-54) in light of the understanding that most IE results from random episodes of bacteremia not related to specific procedures and the concern for the potential harmful effects of unwarranted antibiotic administration

Only patients with specific cardiac IE risk factors [table] should be considered for prophylactic antibiotic administration.

Recommendations for respiratory tract procedures:
Single pre-procedure antibiotic dose (Cefazolin/clindamycin/ceftriaxone or Vanco if MRSA suspected) for any procedure expected to violate (incision/biopsy) the mucosa or for procedures intended to treat an existing infection (drainage of empyema/abscess).

Recommendations for GI or GU tract procedures:
Single pre-procedure antibiotic dose effective against enterococci should be used, when indicated, since these are the only organisms likely to cause IE.
Prophylaxis is NOT indicated for diagnostic GI/GU procedures (endoscopy, cycstoscopy etc..).

When patients are receiving antibiotics for a GI/GU infection or to prevent wound infection, it is suggested that the antibiotics used include an agent effective against enterococci (PCN, ampicillin, piperacillin, or Vanco).

Recommendations for infected skin/skin structure/musculoskeletal tissue
Only staph and B-hemolytic strep are likely causes of IE in this situation. Prudent to use antistaphylococcal agents.

Laparoscopic contralateral groin exploration: is it cost effective

The authors addressed the cost effectiveness of laparoscopic exploration of the contralateral groin in children undergoing inguinal hernia repairs. lap exploration identified a 10% (8/78) rate of contralateral patent processus vaginalis. Assuming all substantial PPV's (defined by the authors as those that could admit a scope, those whose distal aspect could not be visualized, and those that result in gas reaching the scrotum) eventually became hernias, the authors estimated the total cost of contralateral exploration/repair vs. repair when clinical hernias developed in the 8 patients with PPV to be $13,080 and $20,440, respectively. Thus they concluded that contralateral exploration and repair is a cost effective approach to inguinal hernias in children. This did not take into account the expense of the use of laparoscopic instruments.

Lee et al. Journal of Pediatric Surgery (2010);45:793-795

A picture is worth a "silk glove" sign?

How often do we make decisions to fix a hernia based on what the parents describe? have you ever ordered an u/s to check when you couldn't feel a hernia or a "silk glove"? How about just ask the parents to take a picture and email/text it to you to confirm?

A study by Kawaguchi et al (JPS 2009;44:2327-9) looked at 23 patients who underwent surgery based on history and a photograph sent by the parents showing the hernia. All patients underwent operative repair and were noted to have a hernia. two patients who's photographs were not consistent with an inguinal hernia were observed, and were not found to have hernias on follow up.

The use of digital photographs can potentially avoid unnecessary repeat office visits as well as wrong side surgery if the parents' description of a non palpable hernia is not correct.