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Maintenance of central venous access in patients with chronic medical conditions such as short bowel syndrome demands forethought and ingenuity. We describe an innovative technique for re-utilizing central venous access sites in patients who have chronic central venous access needs. Records of patients undergoing this technique were reviewed between August 2012 and December 2015. The technique involves "cutting-down" to the sterile fibrous tunnel that naturally forms around tunneled catheters. The fibrous sheath is then isolated and controlled much as would be done for a venous "cut-down." A separate exit site is then created for the new catheter and it is tunneled to the "cut-down" site per routine. The non-functioning catheter is then removed from the surgical field. The proximal fibrous sheath is finally cannulated either directly with the new catheter or with a wire/dilator system. This technique effectively re-uses the same venous access point while allowing for a complete change of the physical line and external site. Twenty attempts at this technique were made in twelve patients; six patients underwent the site re-utilization procedure multiple times. Re-using the fibrous tunnel to re-cycle the internal catheter site was successful in seventeen of twenty attempts. All patients had chronic conditions leading to difficult long-term central venous access [short bowel syndrome (6), hemophilia (2), cystic fibrosis (1), chronic need for central IV access (3)]. Indications for catheter replacement included catheter occlusion/mechanical failure/breakage (9), dislodgement (6), infection (1), and inadequate catheter length due to patient growth (4). Broviac/Hickman catheter sites were most commonly re-used (13; one failure); re-using a portcath site was successful in 5 of 7 attempts. There were no short term infections or mechanical complications. We describe a novel technique for salvaging tunneled central venous catheter access sites. This technique is well suited for patients with difficult and long-term central venous access needs, particularly those with chronic conditions such as intestinal failure. It is specifically useful when tunneled lines are broken, precipitated or clotted and unamenable to wiring. [ABSTRACT FROM AUTHOR]

Purpose: To determine the effect of trans-anastomotic tube (TAT) feeding on outcome following repair of congenital duodenal obstruction (CDO).Methods: Retrospective comparative study of all infants with CDO over 10 years. Data are median (range). Mann-Whitney U test and Fisher's exact test were used.Results: Of 55 infants with CDO (48 atresia, 7 stenosis), 17 were managed with a TAT, 38 without. Enteral feeds were commenced earlier in infants with a TAT compared to those without (TAT 2 days post-repair [1-4] vs. no-TAT 3 days post-repair [1-7]; p = 0.006). Infants with a TAT achieved full enteral feeds significantly sooner than those without (TAT 6 days post-repair [2-12] vs. no-TAT 9 days post-repair [3-36]; p = 0.005). Significantly fewer infants in the TAT group required central venous catheter (CVC) placement and parenteral nutrition (PN) than in the no-TAT group (TAT 2/17 vs. no-TAT 28/38, p < 0.0001). There were six CVC-related complications (5 infections, 1 PN extravasation) and four TATs became displaced and were removed before achieving full enteral feeds. One infant with a TAT with trisomy 21 and undiagnosed Hirschsprung disease developed an anastomotic leak and jejunal perforation requiring re-operation.Conclusions: A TAT significantly shortens time to full enteral feeds in infants with CDO significantly reducing the need for central venous access and PN. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to demonstrate the efficacy, safety and long-term advantages of catheter insertion via external jugular vein (EJV) cut down for implantable central venous port in children.Materials and Methods: Thirty-nine central venous ports were implanted with catheter insertion via subclavian puncture in the children (group 1) with average age of 4.2 years. Forty-three were done by inserting the catheter via EJV cut down in the children (group 2) with average age of 4.8 years. Ports remained functional for a total of 11,890 patient days in group 1 and 15,743 patient days in group 2.Results: The ports were unplanned removed in 28.2% of patients (11/39) in group 1 with comparison of 7.0% of patients (3/43; p < 0.01) in group 2. Five patients (12.8% of ports implanted) suffered an infectious complication in group 1 and just one patient (2.3% of ports implanted; p < 0.01) occurred in group 2. Permanent aspiration occlusion occurred in every two patients for each group with incidence of 5.1% in group 1 and 4.7% in group 2. Catheter fracture occurred in three patients in group 1 (7.7%). One case with catheter disconnected to the port was found in group 1 (2.6%). The disconnected catheter was removed from right ventricle by interventional therapy.Conclusion: Insertion of the catheter via the EJV cut down for implantable central venous port is significant better than insertion of the catheter via subclavian puncture in children. [ABSTRACT FROM AUTHOR]

With advances in neonatology, there is an increasing need for central vascular access in extremely small (<1,000 g) premature infants. Although the use of peripherally inserted central venous lines have become common practice, surgeons still frequently perform central venous line placements via cut-down in difficult access patients. The advantages of general anesthesia for vascular access procedures are obvious for optimal pain control and ideal operative exposure; however, extremely premature infants are at significant risk for prolonged endotracheal intubation with postoperative apneas. We report two cases where regional caudal anesthesia with bupivacaine and clonidine without intubation was successfully utilized at bedside during central venous line placements in premature infants weighing <600 g. The operative field was ideal with adequate motor and sensory block with caudal anesthesia and both infants received only oxygen by nasal cannula. [ABSTRACT FROM AUTHOR]

In infants and children requiring prolonged, multiple central venous (CV) catheterizations, the superior (SVC) and inferior vena cava may become thrombosed or stenotic, making CV access a difficult problem. Use of the iliac vein may be an acceptable alternative. We report a patient with thrombosis of the SVC in whom the external iliac vein was accessed through a retroperitoneal approach for placement of an implantable port. This technique is easy to perform, and there are no special materials or patient positioning required. [ABSTRACT FROM AUTHOR]