INTRODUCTION:Minimally invasive repair of pectus excavatum (MIRPE) is associated with significant postoperative pain, and opioid use remains common despite Enhanced Recovery After Surgery (ERAS) protocols. Cryoanalgesia has emerged as a promising adjunct to improve pain control, but its comparative effectiveness within established ERAS pathways remains incompletely defined. We aimed to evaluate opioid use and recovery outcomes following cryoneurolysis compared to a thoracic epidural-based ERAS protocol. METHODS:We performed a retrospective cohort study of pediatric and young adult patients undergoing MIRPE from 2017 to 2024. Outcomes included inpatient opioid use and outpatient opioid prescribing (MME/kg), length of stay (LOS), and postoperative care utilization. Groups were compared using appropriate univariate tests, and multivariable models adjusted for age, Haller index, and calendar year of surgery. RESULTS:Among 245 patients (median age 16.0 years), 124 (50.6%) received cryoanalgesia. Baseline characteristics were similar between groups. Cryoanalgesia was associated with significantly reduced opioid use and prescribing (inpatient: 6.10 vs. 18.55 MME/kg; outpatient: 1.70 vs. 7.91 MME/kg; both P < 0.0001) and shorter LOS (2.01 vs. 3.25 days, P < 0.0001), with these associations remaining significant after adjustment for age, Haller index, and calendar year of surgery. Routine outpatient care needs and surgical complication rates were similar between groups. Cryoanalgesia was associated with a modest increase in unplanned postoperative visits, without a difference in the proportion of patients affected (28.1% without cryoanalgesia vs 22.6% with cryoanalgesia, P = 0.322). CONCLUSION:Cryoneurolysis was associated with substantial reductions in opioid use and shorter hospitalization without increased routine follow-up. A modest increase in unplanned visits warrants further study. These findings support cryoanalgesia as an effective adjunct to multimodal pain management in MIRPE. IRB APPROVAL STATEMENT:This protocol was approved by the Institutional Review Board at Mass General Brigham, and a waiver of informed consent for medical records review was obtained (Protocol #: 2025P001162).

A 21-year-old man presented with severe abdominal pain four days after undergoing upper endoscopy with duodenal biopsies and was found to have an intramural duodenal hematoma. Symptoms progressed after attempts at diet advancement, and repeat imaging showed an enlarging hematoma with duodenal obstruction. The patient was managed with arterial embolization followed by laparoscopic surgical evacuation of the hematoma. This is the first report of an enlarging duodenal hematoma managed by this combination approach. While surgical interventions have previously been reserved for the most severe cases, we review the literature on minimally invasive approaches to manage this rare endoscopic complication.

A 15-month old male presented with several months of abdominal distension. After undergoing thorough workup, he was found to have an intraabdominal mass on imaging. He underwent exploratory laparotomy and resection of a mesenteric mass along with a loop of associated small bowel. On pathology, the mass was consistent with a hibernoma. In retrospect, the mass may have been present on prenatal ultrasound. Hibernomas are rare, adipocytic tumors of brown fat origin. There have been less than 20 cases of pediatric hibernomas reported in the English literature. Moreover, there have been no previous reports of mesenteric hibernomas in children or those recognized on prenatal imaging. While lipomatous abdominal tumors are exceedingly rare in the neonatal population, this case report highlights that unusual volume of intra-abdominal fat seen on prenatal ultrasound may warrant repeat evaluation in the perinatal period.

Dysphagia is a growing problem among premature and medically complicated infants and children. In 2020, Lawlor et al. published a comprehensive review of the diagnosis and management of children with dysphagia. We wanted to expand on this review by describing what happens to children whose dysphagia does not improve by routine management. Our introduction describes what we know about pediatric dysphagia, and what questions families ask us (and we ask ourselves) when children do not respond to conventional medical treatments. We then describe three cases of dysphagia as diagnostic dilemmas and highlight the importance of a multi-disciplinary approach to manage these children and answering these questions. We incorporate clinical reasoning from our own aerodigestive team (otolaryngology, pediatric pulmonary and pediatric gastro enterology) as well as from experts in pediatric general surgery and neurosurgery to describe our approach to diagnosing and managing these children.

BACKGROUND:PCA- and block-based enhanced recovery after surgery (ERAS) pathways have been shown to decrease hospital length of stay (HLOS) and opiate use following Nuss Repair for Pectus Excavatum (NRPE). No thoracic epidural-based ERAS pathway has demonstrated similar benefits. METHODS:In this pre-post single-center study, data were retrospectively collected for patients ≤ 21 years undergoing NRPE from May 2015 to August 2019. Univariate and multivariate methods were used to evaluate whether implementation of a thoracic epidural-based ERAS in April 2017 was associated with HLOS, opiate use, or pain scores. RESULTS:There were 110 patients: 35 pre- and 75 post-ERAS. HLOS decreased from median 4.8 (1.1) to 3.3 (0.6) days with ERAS (p < 0.001). Use of rescue intravenous opiates decreased from 35.3% pre- to 9.3% with ERAS (p = 0.013). When adjusted for baseline characteristics, ERAS was associated with a 1.3 ± 0.2 day decrease in HLOS and 0.188 times the odds of rescue intravenous opiate use (p = 0.011). CONCLUSIONS:Pain scores, ED visits, and readmissions did not change with ERAS (p > 0.05). Implementation of a thoracic epidural-based ERAS following NRPE was associated with decreased HLOS and need for any rescue intravenous opiates without a change in pain scores, ED visits, or readmission.

The management of velopharyngeal insufficiency (VPI) in patients with 22q11.2 deletion syndrome (22q11DS) poses a significant clinical challenge due to presence of a large velopharyngeal gap and a relatively high rate of internal carotid artery (ICA) medialization. To our knowledge, we are the first group to have successfully managed VPI in a series of seven pediatric patients with 22q11DS with medialized ICAs via a novel surgical technique involving carotid artery mobilization followed by pharyngeal flap insertion. Thus far, we have found this technique to be reliably safe with no significant morbidity and caregivers have reported postoperative improvement in speech, swallowing and nasal regurgitation symptoms. Herein, we provide a detailed description of our novel surgical approach, including an instructional video, for correction of VPI in patients with medialized ICAs, who have previously had limited management options.

INTRODUCTION:22q11.2 deletion syndrome is the most common microdeletion syndrome in children. Many patients with this disease develop craniofacial defects including cleft palate, bifid uvula, and velopharyngeal insufficiency. Our study adds to the current body of literature by describing a novel technique of carotid mobilization performed in conjunction with pharyngeal flap surgery in patients with extensive medialization of the carotid artery.METHODS:Carotid artery mobilization followed by insertion of a superiorly based pharyngeal flap was performed on two patients, a 10-year-old girl and a 5-year-old boy, with 22q11.2 deletion syndrome concurrent with velopharyngeal insufficiency.RESULTS:Neither patient experienced significant post-operative issues. Following the procedure, parents of both patients noted significant speech and voice improvement. Both patients had improvements in VPI Effects On Life Outcome (VELO) scores, nasometry, and production of paragraph passages following surgery.CONCLUSIONS:Our study describes a novel surgical treatment for children with 22q11.2 deletion syndrome with significant velopharyngeal insufficiency (VPI). The procedure wherein is characterized by an extensive mobilization of the carotid artery followed by implantation of a pharyngeal flap. This technique resulted in no significant intra-operative bleeding, and was measured to be successful as noted by nasometry scores and changes in pre- and post-op VELO scores.

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Children and young adults with ulcerative colitis tend to present with more extensive colonic disease than an adult population. The need for surgical intervention in the pediatric population with ulcerative colitis occurs earlier after diagnosis and has a greater incidence than a comparably matched adult population with an estimated need for colectomy at 5 years following diagnosis of 14–20%. Perhaps, even more than the adult population, there is a desire to restore intestinal continuity for the pediatric patient to achieve as healthy and normal quality of life as possible. With surgery playing such a prominent role in the treatment of ulcerative colitis in this age group, an understanding of the surgical treatment options that are available is important. The surgeon’s awareness of the complexities of the different operations associated with proctocolectomy and reestablishing intestinal continuity may help to avoid early complications and minimize the risk of less than ideal long-term outcomes.

Dr. Charumathi Baskaran (Pediatrics): An 8-year-old boy was seen in an outpatient clinic of this hospital because of an enlarging mass in the right breast. One week before this presentation, the patient was seen by a pediatrician at another medical facility for a routine annual examination. He had a history of a mass in his right breast that had been present for 18 months and had recently enlarged. On examination, a round, mobile mass was palpable under the right areola. He was referred to the pediatric endocrinology clinic of this hospital. One week later, at the visit to the endocrinology clinic, the patient’s parents reported that, approximately 18 months earlier, they had noted a mass under the right nipple that was not associated with discharge. The mass had reportedly enlarged in the 6 months before this presentation, and growth of fine pubic hair was also noted. The patient had seasonal allergies and eczema and was otherwise well. He had a history of normal growth and development. His only medication was topical triamcinolone cream for eczema; his childhood vaccinations were current. He had no known allergies to medications. He lived with his parents and younger sibling and was doing well in second grade. His maternal grandfather had asthma, his maternal grandmother had hypercholesterolemia, and his paternal grandmother had breast cancer (which had been diagnosed when she was 70 years of age); his parents and younger sibling were healthy. On examination, the patient did not have dysmorphic features. The blood pressure was 110/70 mm Hg, the pulse 86 beats per minute, the height 131 cm (68th percentile), the weight 28.4 kg (72nd percentile), and the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) 16.5 (66th percentile). The abdomen was soft and had some palpable bowel loops. A firm, mobile mass (2 cm by 2 cm) was present under the right areola and was not adherent to the skin. A small amount of soft breast tissue was palpable on the left side. Fine, straight, lightly pigmented hairs were present on the lower mons pubis, and on close inspection, very scant fine, light axillary hairs were also present. The testes had an estimated volume of 3 ml; the phallus was prepubertal. The remainder of the examination was normal. Findings on a radiograph of the left hand were From the Departments of Pediatrics (M.M., A.M.F.), Radiology (P.S.), Pediatric Surgery (D.P.R.), and Pathology (D.C.S.), Massachusetts General Hospital, and the Departments of Pediatrics (M.M., A.M.F.), Radiology (P.S.), Pediatric Surgery (D.P.R.), and Pathology (D.C.S.), Harvard Medical School — both in Boston.

A 9-year-old girl with chronic constipation was seen in the gastroenterology clinic because of increasingly frequent episodes of abdominal pain with associated nonbilious vomiting. A diagnosis was made.

An 8-year-old boy presented with a mass in the right breast that had been present for 18 months and had enlarged during the previous 6 months. On examination, a firm, mobile mass (2 cm by 2 cm) was present under the right areola. Diagnostic procedures were performed.

Congenital obstructions and anomalies of the pediatric airway are rare problems that may be associated with mild symptoms or critical stenoses that may be life threatening in the first few days of life. This review provides an overview of the embryologic development of the airway, different congenital anomalies associated with airway development, and surgical correction that may be associated with good long-term outcome.

A 4-year-old boy was admitted to this hospital because of fever and abdominal pain. Imaging revealed a periappendiceal mass; purulent fluid was aspirated, and symptoms resolved with antibiotics. One week later, pain recurred. A diagnostic procedure was performed.

PURPOSE:This study aim was to review outcomes of pediatric patients after restorative proctocolectomy with or without a protective ileostomy in the treatment of ulcerative colitis and polyposis syndromes.METHODS:All patients who underwent rectal mucosectomy with ileal pouch reservoir and hand-sewn ileal pouch anal anastomosis (IPAA) during 19-year period were reviewed retrospectively.RESULTS:Eighty-three patients with ulcerative colitis and 7 patients with polyposis syndromes (ages 2.0-21.8 years) were reviewed. Sixty-eight patients underwent IPAA without diverting ileostomy. Fifty-six patients underwent restorative proctocolectomy as single-stage procedures, and 12 had abdominal colectomy and subsequent definitive IPAA without diverting ileostomy. Nineteen patients had IPAA with diverting ileostomy and subsequent closure of ileostomy. Three-stage procedures were performed in 3 cases. An ileal pouch leak or pelvic abscess occurred in 2 patients. Surgical pouch revision for retraction, efferent limb syndrome, prolapse, pouchitis, or perirectal infections occurred in 19 (6/62 J-pouch, 13/28 S-pouch). Fourteen patients (5/22 with diversion, 9/68 without diversion) developed small bowel obstruction. Overall, daytime and nighttime continence was excellent with rare nocturnal evacuations.CONCLUSIONS:Restorative proctocolectomy without protective ileostomy is not associated with an increased morbidity, even in patients with active colitis, and may be appropriate most patients.

Surgery for large prostate rhabdoyasarcoma in children is a challenging procedure. We discussed the value of pubic symphysiotomy in affected patients. The symphysiotomy approach was used in two children with a large rhabdomyosarcoma of the prostate. In each case, the initial exposure was obtained through a lower midline incision, but, due to technical difficulties, resulting from the size of the tumor, surgery was completed via a symphysiotomy approach. In each case, the bladder was preserved and a radical prostatectomy was facilitated by the excellent exposure provided by the symphysiotomy. The patients have been followed for 6 years and 26 months, respectively. Both are tumor free. Neither has developed orthopedic complications. In conclusion, the symphysiotomy approach, for large prostate rhabdomyosarcoma in children, results in an excellent surgical exposure, thus, facilitating the performance of a radical prostatectomy with bladder preservation. Orthopedic complications have not developed throughout the follow up period.