Potter, D. Dean

Background: Motion-sparing approaches to scoliosis surgery such as vertebral body tethering (VBT) are growing in popularity. There is limited data evaluating motion preserving after the different tether approaches. We hypothesized that spinal motion would be preserved in both the sagittal and coronal planes in patients after thoracic, lumbar, and bilateral vertebral body tethering procedures. Methods: This was a retrospective comparison study of adolescent idiopathic scoliosis (AIS) patients who underwent VBT. Preoperative and postoperative coronal range of motion across the instrumented levels were compared using a standing microdose slot-scanning protocol. Flexion/extension radiographs were evaluated postoperatively to assess preserved sagittal arc of motion. Patients with known cord breakage were excluded. Results: The mean age at surgery was 12.9 years (range: 9.4 to 16.5) with mean follow-up period of 2.8 years. Skeletal maturity, defined as Risser sign ≥5, was observed in 29 patients. (26.9%). Overall, mean thoracic coronal arc of motion for postoperative VBT patients was 10 degrees in the thoracic spine and 20 degrees in the lumbar. This was a 59% (24 to 10 deg.) decrease in thoracic range of motion and a 51% (40 to 20 deg.) decrease in lumbar range of motion. Right-sided motion was greater in patients with thoracic instrumentation, whereas left-sided motion was greater in patients with lumbar instrumentation. In addition, patients also retained sagittal motion. Patients with single thoracic tethers had a total arc of motion of 22 degrees, whereas patients with single lumbar tethers had a total arc of motion of 25 degrees. It was noted that both groups had a greater degree of flexion than extension. Conclusions: Patients with single thoracic tethers saw a 60% decrease in the total coronal arc of motion. Patients with single lumbar tethers saw a 57% decrease in coronal motion. Patients had around 20 to 25-degree arc of motion preserved over the instrumented segments in the sagittal plane. Further work is needed to outline the functional benefits of motion preservation after VBT. Level of Evidence: Level III (retrospective cohort study).

BACKGROUND: Children continue to undergo right hemicolectomy (RHC) for neuroendocrine tumors (NET) of the appendix based on adult guidelines. Appendectomy alone is recommended for the pediatric population; however, there are no data on safety of this approach in the setting of positive margins. This study aimed to determine the association between tumor characteristics and survival in a national cohort, hypothesizing that survival would be excellent despite high-risk features including positive margins on appendectomy. STUDY DESIGN: Patients 18 years of age or younger with NET of the appendix were identified in the National Cancer Database from 2004 to 2022 using ICD-O-3 codes. Characteristics of patients who underwent definitive appendectomy vs RHC were compared using chi-square tests. Five-year survival was determined for appendectomy patients with and without high-risk size, margin, and lymph node (LN) features. RESULTS: Of 1,339 patients, 1,156 (86%) underwent appendectomy and 183 (14%) RHC. Median age in both groups was 15 (13 to 17) years. Patients who underwent RHC had larger tumors (24% vs 4%, greater than 2 cm, p < 0.001), more lymphovascular invasion (31% vs 10%, p < 0.001), and were more likely to undergo LN assessment (82% vs 10%, p < 0.001) with a higher LN positivity rate (31% vs 16%, p = 0.006). There was no difference in margins status (p = 0.76). The 5- and 10-year survival was excellent regardless of tumor characteristics for patients overall (99.9% and 99.4%, respectively) and for those who underwent definitive appendectomy (99.9% and 99.2%). CONCLUSIONS: These data further support appendectomy as definitive management for children with appendiceal NET. Additional resection does not confer a survival benefit even in the setting of positive margins.

Background: The purpose of this study was to report on 2-year results of vertebral body tethering (VBT), performed under a Food and Drug Administration protocol, to obtain insight into outcomes and complications. Methods: Forty prospectively enrolled patients with adolescent idiopathic scoliosis (AIS) who had a Sanders score of ≤4 or a Risser score of ≤2 underwent VBT for curves between 40° and 70°. Surgical, radiographic, and patient-reported outcomes were reviewed at a minimum 2-year follow-up. Results: Mean age at surgery was 13 (range, 10 to 16) years. The 40 patients were 90% female; 95% White, 2.5% other, and 2.5% unreported; and 92.5% non-Hispanic, 5% Hispanic, and 2.5% unreported. A mean of 8 (range, 5 to 12) levels were instrumented. Most patients were at Sanders 4 (65%) and Risser 0 (63%). Mean length of stay was 3 ± 1 days, estimated blood loss was 236 ± 158 (range, 25 to 740) mL, and operative time was 4.4 ± 1.4 hours. Mean correction of the major curve was 44% (range, 22% to 95%) on the 3-month standing radiograph, 49% at 1 year, and 46% (range, −10% to 93%) at 2 years. The mean major Cobb angle improved from 51° ± 8° (range, 40° to 70°) preoperatively to 27° ± 11° (range, 3° to 56°) at 2 years. Success at 2 years, defined by a Cobb angle of <35° and no reoperation, was seen in 30 patients (75%) and was associated with a mean Cobb angle of <35° on the first postoperative standing radiograph (p < 0.001). Twelve patients (30%) demonstrated improvement in the curve with growth. By 2 years, 2 (5%) of the patients underwent repeat surgery (1 release for overcorrection, 1 lumbar VBT for lumbar curve progression after thoracic VBT). The Scoliosis Research Society (SRS) satisfaction score improved 2 years following surgery (p < 0.001), but other SRS domains only remained stable over time. Beyond 2 years, 1 additional lumbar tether was required after thoracic VBT, 1 implant was removed, and 3 fusions were performed, for a 10% fusion rate and overall 20% reoperation rate at a mean of 3.8 ± 1.1 years of follow-up. The rate of cord breakage in the study population was 20%. Conclusions: In skeletally immature patients treated in the U.S. under a prospective Investigational Device Exemption, there was a 75% rate of successful outcomes at 2 years. Most correction was obtained at the time of surgery, and inadequate intraoperative curve correction was associated with a higher Cobb angle on the first postoperative standing radiograph and failure by 2 years. Level of Evidence: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Background: Bar stabilization during minimally invasive pectus excavatum repair (MIRPE) is critical to avoid dislodgement. Multiple techniques are described including stabilizers, wires, and sutures. This retrospective study compared bar movement and outcomes between existing techniques and ZipFix™, a biocompatible cable tie. Methods: Patients ≤20 years of age who underwent MIRPE with ZipFix between January 2021 and September 2022 were compared with historical controls who underwent repair by same surgeons between January 2018 and December 2020 using stabilizers or polydioxanone suture (PDS). Demographics, clinical details, and outcomes were compared using Kruskal–Wallis and chi-square tests. Results: Of the 116 patients who underwent repair, 45 had bars secured with ZipFix (39%) and 71 (61%) were historical controls (35 stabilizer, 36 PDS). Median (interquartile range) age was 15 (14–16) years and Haller index was 3.9 (3.6–4.5). Nine (8%) patients required two bars. Haller index and use of second bar were comparable between stabilization techniques ( P > .05). In total, 49 patients (40%) reported any pain at 1 month and this was similar between stabilization techniques ( P = .45). Median bar movement was greater for bars secured with PDS than with ZipFix or stabilizers at 1 month (5.5 versus 2.3 versus 3.3°, P = .010) and last follow-up (6.5 versus 2.1 versus 3.6°, P < .001). One patient whose bar was secured with PDS required revision for dislodgement. Conclusion: Pectus bar stabilization with ZipFix is a safe alternative to metal stabilizers and both techniques are superior to suture stabilization alone. The use of ZipFix may be preferred given its lower cost and ease of use.

Mesenchymal hamartoma is a benign tumor of the liver with a poorly understood pathogenesis. It is uncommon in older children, especially after 2 years of age. The signs and symptoms may be nonspecific; therefore, a high index of suspicion is required for diagnosis and treatment. We report a 5-year-old previously healthy male who presented with acute abdominal pain, fatigue, and fever. He was diagnosed with pneumonia initially and treated with antibiotics. A computed tomography (CT) scan done for evaluation of his persistent abdominal pain demonstrated a hepatic mass. Follow-up magnetic resonance imaging (MRI) of the liver demonstrated multiple serpiginous tubular-type structures, read as possible Caroli syndrome. He had a normal abdominal examination and normal biochemistries including alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, alkaline phosphatase, and alpha-fetoprotein. He was referred to our institution for second opinion. On further review of his imaging studies, the lesion was thought to be a mesenchymal hamartoma. He subsequently underwent resection of the mass. Pathology confirmed the diagnosis of mesenchymal hamartoma.

Abstract Background: Operative maneuvers to increase mesenteric length during ileal pouch-anal anastomosis (IPAA) are frequently utilized in adults, but limited data exist on the need for their use in children. Materials and Methods: A retrospective chart review of children (age <18) considered for IPAA creation at two affiliated tertiary referral centers from 2007 to 2017 was conducted, and patient factors, operative details, and 30-day postoperative complications were abstracted. Body mass index (BMI) was normalized to BMI percentile-for-age-and-sex and classified as underweight (BMI <5th percentile), healthy weight (5th ≤ BMI percentile <85th), or overweight/obese (BMI ≥85th percentile). Maneuvers were identified from operative notes. Univariate analysis and multivariable logistic regression were performed to determine independent factors associated with the use of maneuvers. Results: A total of 94 patients underwent attempt at IPAA creation, which was successful in 91 (97%). Fourteen (15%) of 91 patients were classified as overweight or obese. The 3 failures occurred secondary to inability to reach in 3 patients, with specific mention of patients' obesity in 2 and pouch ischemia in 1. Sixty (66%) patients required maneuvers to lengthen the mesentery. Overweight/obese patients required maneuvers more often than nonoverweight/obese patients (93% versus 61%, P = .03). There were no differences in 30-day maximum Clavien-Dindo scores between patients with and without maneuvers performed ( P = .83). Being overweight/obese was an independent risk factor for requiring maneuvers (odds ratio: 9.3, 95% confidence interval: 1.1–82.8) after adjusting for age, sex, height, operative stage, and surgeon. Conclusion: Surgeons should be prepared to perform mesenteric lengthening maneuvers when operating on pediatric patients to ensure minimal tension on the IPAA, and more so when operating on obese children. Whether these maneuvers have an impact on long-term pouch function is undetermined.

Abstract Purpose: Restoration of intestinal continuity by ileal pouch-anal anastomosis (IPAA) following subtotal colectomy may not require a temporary, protective ileostomy. Diversion contributes to patient discomfort, cost, and additional operative risk at the time of subsequent reversal. We compared the outcomes of pediatric patients undergoing modified two-stage to three-stage IPAA after recovering from subtotal colectomy. Methods: We reviewed children (age <18) who underwent IPAA creation for ulcerative or indeterminate colitis from January 1, 2007 to December 31, 2017. Patient characteristics, operative details, 30-day complications, and postoperative length of stay (LOS) were abstracted. Total LOS for the three-stage group included both the IPAA and the ileostomy reversal operations. Univariate comparisons between patients undergoing modified two-stage and three-stage operations were performed. Results: A total of 43 patients underwent IPAA after subtotal colectomy; 32 (74%) underwent a three-stage approach, and 11 (26%) had a modified two-stage approach. Operative approach was laparoscopic in 33 (77%), planned open in 9 (21%), and converted to open in 1 (2%). Single-incision technique was used in 12 of 33 (36%) laparoscopic cases. Modified two-stage procedures had shorter total median LOS (7 days versus 9 days, P = .005). Incidence of postoperative leak, readmission, return to the operating room, and maximum 30-day Clavien–Dindo scores at the time of IPAA creation did not differ between modified two- and three-stage approaches (all P > .05). Conclusion: The modified two-stage approach to IPAA creation resulted in fewer hospital days compared to the three-stage approach. Considering the risks and patient burdens of diversion, further research is needed to assist in decisions regarding protective ileostomy after completion proctectomy with IPAA.