Chapter 1 of 8 · In-Depth Reviews
Gastric stimulation
Introduction and Gastric Stimulation for Gastroparesis
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Gastric stimulation reduces symptoms of gastroparesis in children with persistent nausea and vomiting unresponsive to medical therapy.
Temporary endoscopic gastric stimulation testing can predict response before permanent laparoscopic or open placement.
Thoracoscopic sympathectomy extending to the lower stellate ganglion can reduce ICD shocks in patients with CPVT and hypertrophic cardiomyopathy.
Partial resection of the stellate ganglion should use clips and scissors; electric cautery may damage the remaining ganglion and cause Horner's syndrome.
Sympathectomy provides 100% compliance because patients cannot skip the intervention once performed.
Diaphragm pacing is a reasonable option for children with spinal cord injury, transverse myelitis, acute flaccid myelitis, or brainstem tumors, allowing ventilator independence.
Diaphragm pacing requires an intact phrenic nerve and phrenic motor neurons; diaphragm contraction with neurostimulation must be confirmed before implantation.
The youngest patient to receive diaphragm pacing was one year of age.
Biologic mesh is not suitable for bridging gaps in ventral hernia repair; it is only a temporary solution or reinforcement.
The best mesh for ventral hernia repair is macroporous monofilament lightweight polypropylene synthetic mesh such as Marlex, which performs well in contaminated fields in the retromuscular space.
Retrorectus repair is superior to laparoscopic underlay for ventral hernias.
Posterior component separation has less wound morbidity than anterior component separation while providing space for wide mesh overlap and minimal fixation.
Gastroesophageal disconnection (esophageal division with Roux-en-Y jejunal interposition) is effective for children with severe reflux who have failed Nissen fundoplication.
Gastroesophageal disconnection may be appropriate as a primary repair in patients at high risk for fundoplication failure.
Laparoscopic gastroesophageal disconnection can take 6 to 8 hours.
Patients who were taking full feeds by mouth preoperatively can continue to do so after gastroesophageal disconnection.
A five-variable prediction rule identifies children at low risk for intraabdominal injury after blunt trauma: no abdominal pain, normal abdominal exam, normal chest X-ray, normal AST, and normal pancreatic enzymes.
Children with only abdominal pain after blunt trauma have approximately 5% risk of abdominal injury and less than 0.3% risk of requiring intervention.
Children with abdominal wall trauma (e.g., handlebar injury) have approximately 15% risk of abdominal injury.
The low-risk group (55% of the trauma population) has less than 5% risk of any injury and less than 0.3% risk of injury requiring acute intervention; these patients may not need CT and can be observed or sent home with close follow-up.
The ATOMAC protocol recommends earlier blood transfusion: after 20 cc/kg crystalloid bolus, non-responders should receive 10–20 cc/kg blood rather than additional crystalloid.
Transfusion of 40 cc/kg blood (or 4 units) is an indication of non-operative management failure in solid organ injury; these patients should go to the operating room.
Patients with solid organ injury who respond to initial resuscitation and never require blood transfusion can be discharged the next day.
Stable solid organ injury patients should be admitted to the floor (not ICU) with vitals every 2–4 hours and hemoglobin at 6 hours; if hemoglobin remains above 7 and the patient is asymptomatic, they can be discharged.
The grade of solid organ injury is no longer the primary guide for management; clinical predictive factors are now used instead.
Volumetric chest CT has nearly 100% sensitivity for airway foreign body, including radiolucent objects.
Chest CT for suspected airway foreign body can eliminate unnecessary bronchoscopies in children with unclear history or respiratory virus symptoms.
Oral contrast is unnecessary for suspected bowel obstruction; fluid in the bowel serves as the contrast agent.
Omitting oral contrast speeds up CT acquisition and prevents nausea and vomiting in patients with bowel obstruction.
Repeat enema reduction attempts for intussusception are appropriate if there is movement of the intussusception toward the ileocecal valve.
Modern pediatric CT scans deliver 1–10 millisieverts of radiation, equivalent to one year of background radiation on Earth.
For pyloric stenosis resuscitation, if chloride is less than 85, give 3 boluses of fluid; if chloride is less than 97, give 2 boluses; if chloride is greater than 97 but bicarbonate is less than 33, give 1 bolus.
Traumatic or non-traumatic pneumomediastinum requires only chest X-ray; no further imaging is needed.
Intravenous glycopyrrolate (Robinol) improves closure rates of post-TEF repair leaks: 76% in the treatment group vs 29% in the placebo group.
Glycopyrrolate treatment reduced chest tube output in post-TEF leak patients: 124 mL in the treatment group vs 370 mL in the placebo group.
The Gips technique for pilonidal disease involves coring out pits with a trephine, evacuating granulation tissue and hair with a mosquito, curettage with a smaller trephine, flushing with saline then hydrogen peroxide, and leaving the wounds open and unpacked.
The Gips pilonidal procedure takes 3–5 minutes with minimal bleeding, no drains, no sutures, and no activity restrictions except avoiding swimming for two weeks.
For thoracoscopic lobectomy, the scope should be placed anterior to the scapula tip at the mid-axillary line, directly over the major fissure, not posterior to the scapula.
Placing the thoracoscope posterior to the scapula tip causes the surgeon to look back on themselves when working in the anterior fissure, creating a paradoxical view.
When sealing vessels during thoracoscopic lobectomy, seal proximally and distally, then make a small nick between the seals to confirm hemostasis before completing the division; do not use seal-and-divide devices.
Understanding segmental pulmonary anatomy helps predict vessel location and relationships during thoracoscopic lobectomy; for example, the superior segmental artery comes off the lower lobe with the bronchus directly below it.
Incomplete fissures should be approached layer-by-layer with a sealing device, similar to finger fracture technique in the liver, until structures are identified.
Contralateral main-stem intubation is the best and easiest method for single-lung ventilation during thoracoscopic lobectomy, superior to double-lumen tubes, bronchial blockers, or CO2 collapse.