Florence Julien-Marsollier

Background: Reducing postoperative opioid consumption has become a significant challenge in perioperative pain management, particularly within the framework of Enhanced Recovery After Surgery protocols and the associated risk of prolonged opioid dependence. The primary objective of this study was to evaluate whether remifentanil administration guided by intraoperative nociception monitoring with the Analgesia Nociception Index (ANI) during surgery for adolescent idiopathic scoliosis reduces postoperative morphine consumption at day 1. The secondary objective was the incidence of persistent postoperative pain 6 months after surgery. Methods: The current study, a multicenter randomized controlled trial, was conducted between October 2020 and June 2023. Eligible children were randomly assigned to receive intraoperative remifentanil administration guided either by hemodynamic parameters (control group) or by the Analgesia Nociception Index (intervention group). Comparison of postoperative morphine use was adjusted to the use of nonopioid analgesics. Results: Overall, 247 patients were included, and 244 were randomized (120 in the ANI group and 123 in the control group). Postoperative morphine consumption at day 1 was similar in both groups (median [25%; 75% interquartile range], 0.4 [0.3; 0.8] vs . 0.4 [0.3; 0.5] in the ANI and control groups, respectively; median difference [95% CI] = −0.005[−0.10 to 0.09] mg · kg ⁻¹ ; P = 0.93). Intraoperative remifentanil administration decreased in the ANI group (mean difference [95% CI], 9.5 [4 to 15] μg ·kg ⁻¹ , P < 0.001). ANI-guided intraoperative remifentanil administration did not result in differences in secondary outcomes. Conclusions: The administration of remifentanil guided by intraoperative nociception monitoring during adolescent idiopathic scoliosis did not result in a reduction of postoperative opioid consumption.

Purpose: Multiple osteotomies are frequently associated with single-event multi-level surgery (SEMLS) in children with cerebral palsy (CP). However, appropriate management of perioperative blood loss is crucial for decreasing the length of hospital stay and early rehabilitation. Tranexamic acid (TxA) has been proven to significantly reduce perioperative bleeding in multiple major orthopedic surgeries. The aim of this study was to investigate the effectiveness of TxA in decreasing blood loss in children with CP undergoing SEMLS procedures. Materials and Methods: Between September 2016 and September 2022, 101 consecutive children with CP who underwent SEMLS were identified—50 patients did not receive TxA peri-operatively (Control Group, from September 2016 to September 2018), and 51 patients received TxA (TxA Group since September 2018). Bleeding, hemoglobin levels, transfusion rate, length of hospital stay and postoperative hematocrit were compared between the groups. The predictive factors of blood transfusion were determined. Results: The transfusion rate significantly decreased in the TxA Group (43.3% vs. 4%, p < 0.001). The use of TxA and epidural analgesia were the identified factors for a significant transfusion rate decrease. Bleeding (estimated red cell loss) was decreased in the TxA group in comparison to the control group 22.3 [17.3–27.3] versus 33.78 [27.4–40.2], p < 0.05). The hospital length of stay significantly decreased in the TxA group (7.3 vs. 6 days, p = 0.01). No TxA-related complications occurred in any of the patients. Conclusions: A blood loss prevention strategy based on a low dose of TxA in children scheduled for SEMLS significantly decreased bleeding and transfusion rates, allowing an earlier discharge from the hospital for patients.

Background: Same-day discharge after a cholecystectomy is a common practice in the adult population and has been demonstrated as safe and viable for children as well. However, there is a lack of comprehensive teaching models for pediatric cholecystectomy. Drawing inspiration from standardized outpatient procedures, this study aimed to assess the clinical outcomes and feasibility of teaching programs and an Enhanced Recovery After Surgery (ERAS) protocol following ambulatory laparoscopic cholecystectomy in pediatric patients. Methods: In 2015, an ERAS pathway for laparoscopic cholecystectomy (LC) was implemented, focusing on admission procedures, surgery timing, anesthetic choices, analgesia, postoperative feeding, mobilization, and pain assessment. Day-case surgery was not applicable for acute cholecystitis, choledochal lithiasis, sickle cell disease, and hereditary spherocytosis cases. The protocol was employed for a group of attending surgeons and fellows, as well as a group of residents under the supervision of experienced surgeons. A retrospective analysis was conducted to evaluate the feasibility and effectiveness of ambulatory cholecystectomy in children and its utilization in training pediatric surgical trainees. Results: Between 2015 and 2020, a total of 33 patients were included from a cohort of 162 children who underwent LC, with 15 children operated on by senior surgeons and 18 by young surgeons. The primary diagnoses were symptomatic gallbladder lithiasis (n = 32) and biliary dyskinesia (n = 1). The median age at the time of surgery was 11.3 years (interquartile range (IQR) 4.9–18), and the median duration of surgery was 54 min (IQR 13–145). One intraoperative complication occurred, involving gallbladder rupture and the dissemination of lithiasis into the peritoneal cavity. Three patients (9%) required an overnight stay, while no postoperative complications or readmissions within 30 days were observed. ERAS was successfully implemented in 30 patients (91%). No significant differences in surgical outcomes were noted between senior and young surgeons. At an average follow-up of 55 months, no long-term sequelae were identified. Conclusions: These findings align with the current trend of increasing use of outpatient laparoscopic cholecystectomy and underscore its feasibility in the pediatric population. The application of a structured ERAS protocol appears viable and practical for training the next generation of pediatric surgeons. Level of Evidence: Level III.

Purpose Patient blood management has been recently emphasized to avoid perioperative blood transfusion in AIS surgery. Hydroxyapatite charged collagen sponge (HCS) is a bone substitute material made of collagen and ceramized hydroxyapatite, with associated haemostatic properties. The goal of this study was to assess the impact of HCS in the perioperative blood loss in AIS surgery. Methods After IRB approval, all AIS patients undergoing primary correction were prospectively included over a 15-month period. Patients receiving HCS at the end of the procedure were compared to a control group (matched for age, gender, and fusion levels) without any haemostatic agent or bone substitute. The same perioperative blood saving strategies were used in both groups. Two subfascial drains were used for 48 h in all patients. Perioperative blood loss and transfusion rates were analysed. Results A total of 34 patients were included in each group. No difference in drainage volume was observed at day 1, but the reduction was statistically different at day 3 (1135 mL [800–1640] versus 930 [480–1510], p = 0.028, 0.63 ml/Kg/h [0.4–0.92] versus 0.46 [0.29–0.7], p = 0.042). Multivariate analysis found that the use of HCS was associated with a decrease in the postoperative blood loss (OR = 1.17 [1.10–1.25]). The transfusion rate was lower in the HCS group [0 (0% vs. 3(8.8%), p = 0.076)]. No infection occurred, and no complication was reported. Conclusion With 27% reduction in drain volume, hydroxyapatite charged collagen sponge can be considered as a blood salving strategy in AIS surgery. The role of the biomaterial in fusion rate still needs to be further assessed.

Aims: Opioid-reduced anesthesia (ORA) was suggested to decrease morphine consumption after adolescent idiopathic scoliosis (AIS) surgery and incidence of chronic pain. Materials & methods: A prospe...