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We hypothesize that in testicular torsion, the duration of symptoms (DoS) better correlates with predicting testicular viability than minimizing the "time-to-treat" (TtT) after presentation to a medical facility.Medical records of male pediatric patients treated for suspected diagnosis of testicular torsion in the emergency department (ED) from January 1, 2016, to December 31, 2018, were retrospectively evaluated. Forty-one patients met inclusion criteria. Statistical analysis compared testicular viability based on TtT, DoS, and site of initial presentation.Testicular salvage rates for patients presenting directly to our ED was 56.3% with an average TtT of 2.5 h versus 77.8% and 1.96 h, respectively, for transferred patients. Overall testicular survival was not statistically impacted by the difference in TtT. Comparing DoS, an 84% testicular salvage rate (DoS24 h) versus a 15.4% salvage rate (DoS24 h) was shown in patients presenting directly to our ED (P ≤ 0.0001). Within the total population (n = 41), a significant difference was also shown (P ≤ 0.0001) when comparing overall testicular salvage rates in patients presenting with24 h versus24 h total DoS (84% versus 25%).These data reveal that an alternative predictor of testicular salvage rates is a DoS24 h. This is a meaningful metric when providing accurate preoperating counseling to parents and may be a better focus of quality improvement efforts surrounding this topic.

Background Video-assisted transumbilical appendectomy (VATA) is a combination of laparoscopic and open techniques and is not widely used in children. We are reporting our most recent experience with this technique. Methods After the institutional review board approval, the charts of patients who underwent VATA between December 2003 and October 2004 were retrospectively reviewed. All children presenting with a preoperative diagnosis of appendicitis were candidates. A 10-mm trocar was placed in the umbilicus. An operating laparoscope was used for mobilizing the appendix. The appendix was delivered through the umbilicus. A standard extracorporeal appendectomy was performed. The umbilical ring was closed and the wound irrigated. Demographic and outcome data were collected and is presented as mean ± SD. Results Sixty-one males and 50 females underwent VATA (n = 111). Age and weight were 11 ± 3.2 years and 49 ± 22 kg, respectively. Six patients had previous abdominal surgery. Operative time was 36 ± 24 minutes (range, 9-140 minutes). An additional trocar was placed in 2 patients, and 2 patients were converted to open. Five patients had additional procedures. Appendicitis was classified intraoperatively as acute (n = 44), suppurative (n = 5), gangrenous (n = 8), ruptured (n = 30), appendiceal colic (n = 13), and other (n = 11). Preoperative antibiotics were given to 95 patients and were continued in 35 patients postoperatively. Length of stay was 1.8 ± 1.7 days (range, 1-11 days). Length of follow-up was 13 ± 6.3 days (n = 90). Complications included intra-abdominal abscess (n = 1) and wound infection (n = 7). Conclusions Video-assisted transumbilical appendectomy minimizes equipment needs, thus, potentially reducing cost. Simple and complex appendectomies can be performed even if the patient has had previous abdominal surgery. Our complication rate was low, and our operating times and length of stay were short. Video-assisted transumbilical appendectomy is a safe and effective technique in children and can be used in lieu of the 3-trocar laparoscopic technique.

Children restrained with lap belts may sustain severe injuries. We investigated the frequency of each type of injury associated with seatbelt contusions. The medical records of all trauma patients with ICD-9 codes for abdominal wall contusions from January 1, 1999, to December 31, 2001, were reviewed. All patients with seatbelt contusions were included in the study. Age, seat position, weight, restraint-type, sex, and mechanism of injury were noted. There were 1447 admissions for trauma over the 3-year period. Forty-six patients (ages 4-13) had a seatbelt contusion. Thirty-three wore lap belts, and 13 wore lap and shoulder harnesses. Twenty-two children required abdominal exploration. Small bowel injuries were the most common intra-abdominal injuries. Facial injuries were the most common associated injuries. Forty-eight per cent of children with seatbelt contusions in our institution required surgery. The smaller patients tend to have higher frequency of abdominal injuries. The presence of seatbelt contusion indicates the possibility of severe internal injuries.

Foreign bodies of the esophagus are a common problem in children, with the majority of these foreign bodies being coins. Because there are various methods for managing esophageal coins, we retrospectively reviewed our experience of the past 4 years to establish a safe and cost-effective protocol for their management. From January 1987 to December 1990, 57 children were managed for esophageal coins in our institution. Nineteen children were managed endoscopically under general anesthesia, with a mean patient cost of $1,982 (excluding the surgeon and anesthesiologist charge). Thirty-eight children were managed with Foley balloon extraction or esophageal bougienage in the emergency department with a mean patient cost of $149 (excluding surgeon charge). Both methods were 100% effective, and there were no complications in either group. Rigid criteria were used in selecting patients for balloon extraction and bougienage. These were: (1) duration less than 24 hours; (2) no respiratory distress; and (3) no history of esophageal disease or surgery. Using these criteria, 16 of the 19 patients managed endoscopically could have safely and effectively been managed in the emergency department with a net savings of $1,833 per patient. We conclude that Foley balloon extraction and bougienage of esophageal coins in selected children is both safe and cost-effective. A protocol for managing children with esophageal coins is presented, and the techniques of Foley balloon extraction and esophageal bougienage are reviewed.

Tracheostomy in infants and children is associated with a high rate of accidental decannulation in the early postoperative period. Eighty-eight patients underwent tracheostomy from 1980 to 1985, and 22 were sutured in place. Accidental decannulation occurred in 31.8% of the nonsutured and 4.5% of the sutured tracheostomies. We advocate suturing tracheostomy tubes in place in infants and children and describe a simple suture technique for this purpose.