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Background: The classic operation for medically refractory Crohn's pancolitis is colectomy with end ileostomy. Ileorectal anastomosis (IRA) in this setting has not been well studied in children. In this study, we review our experience and outcomes with IRA in children with severe Crohn's Disease (CD). Methods: A single-center retrospective study was performed by reviewing the patient charts between 2017 and 2022. Before colectomy, disease severity was assessed by poor response to biologic medication and corticosteroids, the presence of serious comorbidities and history of C. difficile infection (CDI). Proctoscopy was done before IRA, and rectal histopathology at the time of IRA was reviewed. Postoperative complications, time from colectomy to anastomosis, and number of bowel movements were recorded. Results: 6 patients with pancolitis underwent laparoscopic total colectomy with end ileostomy and subsequent IRA. All patients were refractory to biologics and/or steroids. 4 patients had history of CDI. Mean age at the time of surgery was 16 ± 1 years. Postoperative course was complicated by AKI in 1 patient, pancreatitis in 1 patient, and rectal bleeding in 2 patients. A mean 274±130 days elapsed between colectomy and IRA. There were no complications or recurrent flares after IRA over the mean 356 ± 227 days follow-up. Patients had a mean of 5 bowel movements/day after IRA. Conclusion: IRA should be considered after colectomy for medically refractory CD in selected patients. A larger prospective study is necessary before recommendation for IRA as standard treatment. Level of Evidence: N/A

Background Short bowel syndrome and its resultant nutritional deficiencies are the most common cause of intestinal failure. Significant intestinal lengthening using intraluminal springs is feasible in porcine models using an external plication technique. We hypothesize that an internal plication technique will yield significant intestinal lengthening, which may lead to future endoscopic spring placement. Methods Uncompressed springs measuring 7.5 cm with a diameter of 1.0 cm were compressed to 2.0 cm. A gelatin-encapsulated compressed nitinol spring was inserted into the jejunal lumen of juvenile pigs and held in place with endoluminal sutures just proximal and distal to the spring-containing segment. A control segment distal to the spring was marked. Pigs were euthanized on postoperative day 7. Spring and control segments were collected for analyses. Results There was an average lengthening by 72% of the spring segment compared to the control segment. Two out of 7 springs stayed within both sets of plications and doubled in length. Histology showed normal mucosal integrity of the spring segment and plicated areas with similar muscular thickness but increased crypt depth and villus length compared to the control segment. Conclusion Internal plication resulted in significant bowel lengthening. Five springs had slipped through proximal, distal or both sets of plications, resulting in less lengthening than those that remained fixed. A more consistent methodology for endoluminal suturing is needed to produce more lengthening.

BackgroundShort bowel syndrome and its resultant nutritional deficiencies are the most common cause of intestinal failure. Significant intestinal lengthening using intraluminal springs is feasible in porcine models using an external plication technique. We hypothesize that an internal plication technique will yield significant intestinal lengthening, which may lead to future endoscopic spring placement.MethodsUncompressed springs measuring 7.5 cm with a diameter of 1.0 cm were compressed to 2.0 cm. A gelatin-encapsulated compressed nitinol spring was inserted into the jejunal lumen of juvenile pigs and held in place with endoluminal sutures just proximal and distal to the spring-containing segment. A control segment distal to the spring was marked. Pigs were euthanized on postoperative day 7. Spring and control segments were collected for analyses.ResultsThere was an average lengthening by 72% of the spring segment compared to the control segment. Two out of 7 springs stayed within both sets of plications and doubled in length. Histology showed normal mucosal integrity of the spring segment and plicated areas with similar muscular thickness but increased crypt depth and villus length compared to the control segment.ConclusionInternal plication resulted in significant bowel lengthening. Five springs had slipped through proximal, distal or both sets of plications, resulting in less lengthening than those that remained fixed. A more consistent methodology for endoluminal suturing is needed to produce more lengthening.

BACKGROUND: Coronary arteriovenous fistula is a rare congenital or acquired abnormal connection between a coronary artery and any of the great vessels or any of the heart chambers. Most of them are diagnosed during routine coronary angiography. CASE REPORT: This case report illustrates a successful surgical ligating of multiple right coronary artery and circumflex artery fistulas to coronary sinus. CONCLUSION: According to our experience and literature review, it can be concluded that to prevent potential complications in various cases of coronary arteriovenous fistula, early surgical management, just after their condition has been diagnosed, is the best choice

Background: Administrating premedication for children undergoing outpatient ophthalmologic procedures to reduce costs and increase efficiency is very important. The mostly used drugs for premedication are midazolam and ketamine. In this study, we compared the effectiveness of combined oral midazolam and ketamine with oral midazolam alone in outpatient pediatric ophthalmologic surgeries. Methods: In this double-blinded randomized clinical trial study, 136 children aged 6 months to 6 years undergoing outpatient ophthalmologic procedures with class I or II in American Society of Anesthesiologists (ASA) scale and without systemic disease were enrolled. Children were randomly divided in two groups. Thirty minutes before operation, group 1 received oral midazolam 0.5 mg/kg and group 2 received oral midazolam 0.25 mg/kg with ketamine 2.5 mg/kg. Medications were mixed with strawberry-flavored juice with volume of up to 0.5 ml/kg. In both groups, children’s basic behavior, acceptance of premedication, anxiolysis (30 minutes after premedication), sedation at 10, 20, and 30 minutes after premedication, parental separation behavior (30 minutes after premedication), children’s puncture behavior, number of attempts for venipuncture, puncture duration, post-anesthetic arousal stage at the end of anesthesia and recovery duration were be compared. Any complication like nausea and vomiting were also recorded. Findings: There were significant differences between two groups in sedation score and children's puncture behavior score. There were no significant differences between the two groups regarding the children’s behavior type, acceptance, anxiolysis, parental separation, and arousal stage behavior scores. Numbers of attempts for venipuncture, puncture duration and recovery variables were similar in the two groups. Nausea was seen in one child in both groups. 2 children in combination group vomited. Conclusion: Oral premedication with low dose combination of midazolam and ketamine makes earlier and more effective sedation and better puncture behavior than oral midazolam alone.

OBJECTIVES/GOALS: Minor procedures are anxiety-provoking and/or painful for children. Virtual reality (VR) is an emerging technology in medicine and largely has been used as an adjunct to analgesia and opioids. This study reviews the institutional use of VR in lieu of pharmacology and general anesthesia (GA) to perform minor procedures in a pediatric population. METHODS/STUDY POPULATION: A retrospective chart review was performed on all patients that presented to our institution from 2019 to 2022 for hormone implant placement, exchange, or removal with VR distraction. Demographic and procedure information was recorded. The primary outcome was successful procedure completion without requiring pharmacologic sedation or analgesia. RESULTS/ANTICIPATED RESULTS: A total of 111 patients underwent the following minor procedures with VR only. 14 patients underwent more than one procedure resulting in a total of 126 procedures. The mean age was 11.3 ± 3.6 years. 43 patients were female, 23 were female to male, 6 were non-binary, 7 were male, and 32 were male to female. 58% had private insurance. The most common diagnosis was precocious puberty (54%) followed by gender dysphoria (46%). The most common procedure was implant placement (72%). 69% of procedures were performed in the clinic and 31% in a procedural room. All procedures were completed without requiring sedation or GA. None of the patients required intravenous catheter placement for the procedure. No intra-procedural complications were recorded. DISCUSSION/SIGNIFICANCE: Despite the current trend toward minimizing GA and sedation in children, there is no widely accepted substitute. VR is a feasible option that can spare children from sedation or GA for minor procedures. This can enable procedures to be transitioned into more resource efficient settings and improve pediatric patient experience.

Following publication of the original article [1], the authors reported error on the images/figures used which also resulted in un-sequential order. The updated figures and captions are provided below.

Abstract Background Total colonic and small bowel aganglionosis (TCSA) occurs in less than 1% of all Hirschsprung’s disease patients. Currently, the mainstay of treatment is surgery. However, in patients with TCSA, functional outcomes are often poor. A characteristic transition zone in TCSA can be difficult to identify which may complicate surgery and may often require multiple operations. Case presentation We present the case of a male infant who was diagnosed with biopsy-proven total colonic aganglionosis with extensive small bowel involvement as a neonate. The patient was diverted at one month of age based on leveling biopsies at 10 cm from the Ligament of Treitz. At 7 months of age, during stoma revision for a prolapsed stoma, intra-operative peristalsis was observed in nearly the entire length of the previously aganglionic bowel, and subsequent biopsies demonstrated the appearance of mature ganglion cells in a previously aganglionic segment. Conclusions TCSA remains a major challenge for pediatric surgeons. Our case introduces new controversy to our understanding of aganglionosis. Our observations warrant further research into the possibility of post-natal ganglion maturation and encourage surgeons to consider a more conservative surgical approach.