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Long-gap esophageal atresia is one of the most challenging diseases in the field of pediatric surgery. There is no optimal therapy, and thus many potential therapies and techniques are being actively explored, both in animal models and in neonates. This article will review the available experimental treatment options with a focus on novel techniques.

PURPOSE Inguinal hernia repairs are among the most common operations performed by pediatric surgeons. Laparoscopic high ligation is a popular technique, but its recurrence rate in adolescents is unknown. We hypothesized that recurrence after laparoscopic high ligation in adolescents would be similar to open repair (1.8%-6.3%). METHODS We evaluated adolescent patients (12-18 years old at the time of surgery) who underwent laparoscopic high ligation across eleven hospitals. At least six months postoperatively, they were contacted by telephone for follow-up. Variables analyzed included demographics, operative details, recurrence, and other complications. RESULTS A total of 144 patients were enrolled. One hospital (n=9) had a recurrence rate of 44.4%, compared to 3.0% (4/135) for the other hospitals. By accounting for 50.0% of recurrences, it represented a statistical outlier and was excluded, leaving 135 patients for analysis. The median age was 14 years, and 63.7% were male. Recurrence with the excluded center was 5.6% (8/144). Use of absorbable suture (OR 42.67, CI 4.41-412.90, p

Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has been associated with faster recovery, earlier extubation, and decreased morbidity. Nevertheless, thoracoscopic repair is rarely attempted in the post-extracorporeal membrane oxygenation (ECMO) patient. Commonly cited reasons for not attempting thoracoscopy include concerns that the patients' respiratory status is too tenuous to tolerate insufflation pressures or that presumed defect size is so large that it precludes thoracoscopic repair. Our purpose is to review our experience with post-ECMO thoracoscopic CDH repair and evaluate the success of this approach.We performed retrospective analysis of attempted thoracoscopic CDH repairs after ECMO decannulation at our institution from 2001 to 2015. Primary outcome was rate of conversion. Secondary outcomes were intraoperative end-tidal COWe identified 21 post-ECMO patients in whom thoracoscopic CDH repair was attempted. Thoracoscopic repair was successfully completed in 28%. No patients had reported intolerance to insufflation at 3-7 mmHg. Average end-tidal COThoracoscopic CDH repair is both safe and feasible after ECMO with no increase in operative morbidity or mortality. Insufflation pressures of 3-7 mmHg are well tolerated without undue increase in end-tidal CO

Laparoscopy is a safe and effective technique in the repair of inguinal hernias. This article describes the different laparoscopic herniorrhaphy technique, as well as controversial topics, such as premature infants, contralateral repair, and incarcerated hernias.

Like all physicians, the young pediatric surgeon must deal with an ever-growing body of scientific knowledge. The overabundance of new medical information which must be digested by practicing surgeons is reaching a breaking point such that radical adaptations will be required on the part of textbook publishing companies, medical societies, and peer-reviewed journals. This article first delves into the details of the problem in its current state and then draws on the authors' experience in innovations in medical education to prepare readers for the changing landscape of medical publishing as well as to inspire further modernization of the field. Included are a variety of interim solutions to the tremendous knowledge gap encountered.

Many pediatric centers admit patients following incision and drainage (ID) of soft-tissue abscesses. The purpose of this study is to assess the safety and efficacy of the same-day discharge following ID.Retrospective review was performed of children aged 3 months-4 years who underwent operative ID of an abscess followed by same-day discharge. Patients receiving antibiotics within 2 weeks of presentation were excluded. Treatment failure was defined as readmission or repeat procedure related to the initial abscess. Statistical analysis was performed using Wilcoxon Rank-Sum and Fisher's Exact tests.There were 442 procedures performed in 408 patients. Mean age was 1.8 years. Fever was noted in 25.8%. Of those who had a white blood cell (WBC) count drawn, 59.7% had leukocytosis. Mean time from procedure to discharge was 2.3 h, and 85.0% were discharged with oral antibiotics. Treatment failure occurred in four (0.9%) and ten (2.3%) patients at 14 and 30 days, respectively. Mean WBC count was higher in the 14-day treatment failure group (24.1 versus 16.3; p = 0.10). In patients with leukocytosis, there were 2 (1.4%) treatment failures compared to none in those without leukocytosis.Same-day discharge after ID of abscess in diaper-age children is safe and effective.

Indirect inguinal hernias are the most commonly incarcerated hernias in children, with a higher incidence in low birth weight and premature infants. Contralateral groin exploration to evaluate for a patent processus vaginalis or subclinical hernia is controversial, given that most never progress to clinical hernias. Most indirect inguinal hernias can be reduced nonoperatively. It is recommended to repair them in a timely fashion, even in premature infants. Laparoscopic repair of incarcerated inguinal hernia repair is considered a safe and effective alternative to conventional open herniorrhaphy. Other incarcerated pediatric hernias are extremely rare and may be managed effectively with laparoscopy.

Telemedicine and surgical telementoring strive to provide equal access to specialized healthcare, regardless of patient location. It also aims to provide providers in remote locations real-time, second opinions from more experienced physicians who are otherwise not readily available. The goal of this study is to gauge the public perception of this technology in the pediatric population.Patient families in our pediatric surgery and gastroenterology clinics were asked to complete a seven-question survey after being shown a 1-minute video describing telemedicine and surgical telementoring.A total of 129 people were surveyed. Among respondents, 89% were amenable to telemedicine for routine physician visit, 70% said "yes" for a postoperative visit, and 67% agreed to telemedicine and telementoring as a way to be evaluated by a specialist. Regarding surgical telementoring, 49% would consider it for their child, 58% would consider it for themselves, and 10% said "yes" for themselves, but "no" for their child. In addition, 24% and 19% were unsure about surgical telementoring for their child and themselves, respectively. Those with history of surgery without complications were more likely to say "yes" than "no" to telemedicine for a postoperative visit and surgical telementoring. Although a higher proportion of those with an annual income of$100K said "no" to surgical telementoring for their child and themselves, this was not statistically significant (P = .23 and .25, respectively). Desire to see a physician in person was cited by 63% as a reason against telemedicine, although 35% reported concern about a physician's competence as a reason against surgical telementoring.Overall, surgical telementoring was only supported by about half of the respondents. We predict that with increased education about surgical telementoring, this technology will have increased public support in the pediatric population.

Purpose “Early on-ECMO” repair of CDH entails repair within 48–72 h of cannulation in an effort to optimize pulmonary physiology, shorten ECMO duration, and, ultimately, improve survival. This study evaluated the effect of early on-ECMO repair as compared to leaving patients unrepaired during ECMO. Methods The CDH Study Group database was queried for CDH patients requiring ECMO who either underwent repair within the first 72 h after cannulation or remained unrepaired on ECMO. Primary outcomes were survival to decannulation and ECMO duration. Results A total of 248 patients underwent early repair and 922 remained unrepaired on ECMO. The early repair group had increased risk factors for poor outcomes, including higher odds of cardiac defects and thoracic liver location, and lower odds of hernia sac presence. Nonetheless, ECMO survival for the early repair group was 87.1% compared to 78.4% in the unrepaired group (p = 0.002). However, the early repair group had a longer median ECMO duration than the unrepaired group (240.6 vs 196.8 h, p = 0.001). Conclusion While early ECMO repair does not shorten ECMO duration, it results in increased survival to decannulation as compared to those unrepaired on ECMO. This suggests that there may be a physiologic benefit leading to increased ECMO survival in a subset of patients undergoing on-ECMO repair over those designated to undergo post-ECMO repair. Level of evidence Level III.

Optimal timing of congenital diaphragmatic hernia (CDH) repair in patients requiring extracorporeal membrane oxygenation (ECMO) remains controversial. The “late ECMO repair” is an approach where the patient, once deemed stable for decannulation, is repaired while still on ECMO to enable expeditious return to ECMO if surgery induces instability. The goal of this study was to investigate the potential benefit of this approach by evaluating the rate of return to ECMO after repair. The CDH Study Group database was used to analyze CDH patients requiring ECMO support. The primary outcome was return to ECMO within 72 h of CDH repair among those repaired following ECMO decannulation (“post-ECMO” patients). Secondary outcomes were death within 72 h of repair and cumulative death and return to ECMO rate. A total of 668 patients were repaired post-ECMO decannulation. Six patients (0.9%) in the post-ECMO group required return to ECMO within 72 h of surgery and a total of 19 (2.8%) died or returned to ECMO within 72 h of surgery. The rate of return to ECMO and death following CDH repair is extremely low and does not justify the risks inherent to “on-ECMO” repair. Patients stable to come off ECMO should undergo repair after decannulation.

When discussing new trends in pediatric surgery, the tendency is to focus on novel surgical technology and techniques. However, it is equally important to examine how the practicing surgeon stays abreast in an ever-changing field. This article serves as a brief guide to the future of surgical education for the attending surgeon. Broadly, advances in surgical education consist of new methods of filtration and delivery of knowledge.

It is unclear whether simple diverticulectomy, rather than segmental bowel resection (SBR), is adequate treatment for gastrointestinal bleeding (GIB) secondary to Meckel diverticulum (MD). There is concern that ulcers in the adjacent bowel may continue to bleed if only the diverticulum is removed. This study seeks to determine if diverticulectomy is satisfactory treatment for bleeding MD. A multi-institution, retrospective review was performed for patients with a diagnosis of MD and GIB who underwent simple diverticulectomy or small bowel resection. Exclusion criteria were comorbid surgical conditions and other causes of GIB. The primary outcome was post-operative bleeding during the initial hospitalization. Secondary outcomes were bleeding after discharge, transfusion or additional procedure requirement, re-admission, and overall complications. There were 59 patients who met study criteria (42 diverticulectomy, 17 SBR). One patient in the SBR group had early post-operative bleeding (p = 0.288). There was one re-admission (p = 0.288) and three total complications in the SBR group (p = 0.021). There were no cases of bleeding or other complications in the diverticulectomy group. This study suggests that simple diverticulectomy is adequate for treatment of GIB caused by MD. Furthermore, diverticulectomy appears to have a lower overall complication rate.

This report describes a temporary retrograde occlusion technique for control of a high-flow tracheo-esophageal fistula in a critically ill, premature infant born at 29 weeks’ gestational age, with a diagnosis of type C (Gross) esophageal atresia and tetralogy of Fallot (TOF). This procedure is a useful bridging maneuver before definitive surgical correction for extremely low birth weight, unstable neonates with tracheo-esophageal fistula who are suffering from associated malformations.

There is little consensus on optimal management for congenital diaphragmatic hernia extracorporeal membrane oxygenation (CDH ECMO) patients. Meaningful comparisons of the various approaches have been limited due to the low number of cases in institutions. In addition, the multidisciplinary reliance and rigid institutional framework of ECMO serve to further limit exposure to alternative practices. The goal of this study is to survey the international pediatric surgery community to describe the current practice trends.A survey was electronically distributed to the international pediatric surgical community. The results were evaluated using statistical analysis.A total of 123 pediatric surgeons completed the survey, of whom 89% work at institutions offering both venoatrial (VA) and venovenous (VV) ECMO. Although 69% perform VA ECMO for CDH, only 46% felt VA was the "optimal method." Among VV proponents, 21% believe the rate of VV to VA conversion to be5% and 16% believe it to be30% compared with 0% and 40% in VA proponents. Distribution of timing of repair: 46% post-ECMO repair, 22% early ECMO repair, 15% whenever stabilized on ECMO, and 14% late ECMO repair. Sixty-four percent (71/111) would perform an ECMO CDH repair in the unweanable patient and 27% (30/111) report successful decannulation after repair of a patient who was unweanable on ECMO for 2 weeks. Ninety-two percent do not perform exit-to-ECMO.There are significant practice variations in the management of CDH ECMO. Majority of pediatric surgeons perform VA ECMO in CDH patients; however, a significant percentage of those believe VV to be more optimal. This discrepancy is not accounted for by the VA-only institutions. Although post-ECMO CDH repair is the most common approach, the majority would perform a repair "on ECMO" if the patient was unweanable. In addition, although many pediatric surgeons believe the "last ditch repair" for the unweanable patient to be futile, 27% have reported success. Exit-to-ECMO for CDH remains a minority practice.

Post-operative antibiotics are often utilized for skin and soft tissue infection (SSTI) requiring surgical incision and drainage (ID). We propose that antibiotics are unnecessary following ID.Patients aged 3months to 6years with SSTI of the buttocks, groin, thigh, and/or labia requiring ID were prospectively enrolled. The primary outcome was the proportion of patients requiring re-drainage and/or antibiotics for SSTI recurrence, within 30days. Follow-up consisted of a 30-day phone call, with optional 2-week office visit, combined with chart review for patients lost to follow-up. A one-sample binomial proportion with 95% confidence interval (CI) was used to examine non-inferiority for rate of treatment success, using previously published success rates for patients receiving antibiotics post-operatively (95.9%, with a 7% margin of equivalence).A total of 92 patients were enrolled. All patients received pre-operative antibiotics. There was one treatment failure (success rate 0.989, CI 0.941-0.999). The recurrence rate was noninferior to previously-published data for patients receiving postoperative antibiotics (p0.001). Subgroup analysis of patients who completed 30-day follow-up yielded a success rate of 0.973, CI 0.858-0.999 and evidence of non-inferiority (p=0.04).Post-operative management excluding antibiotics should be considered for patients who undergo ID for SSTI.Level II (prospective cohort study with80% follow-up).

Background Wandering spleen is a rare clinical entity caused by absence of the spleen's peritoneal attachments, allowing the spleen to move freely within the peritoneal cavity [1]. This disease is most commonly seen in children and young women [1, 2]. Affected individuals are predisposed to complications including splenic torsion, splenic infarction, and pancreatic necrosis [3, 4]. Patients may present with constipation, an abdominal mass, swelling, or acute abdominal pain if splenic torsion has occurred [4]. Wandering spleen is difficult to diagnose without imaging, as symptoms are non-specific or may be absent. Imaging studies to confirm the diagnosis may include computed tomography (CT) scan or duplex ultrasonography [5]. Definitive management of a wandering spleen is primarily surgical [2]. Splenectomy is the preferred treatment in patients who present with an acute splenic infarction [2, 6]. Splenopexy, however, is first line treatment for patients with a non-infarcted wandering spleen [2, 7, 8]. Case presentation In this video, we present a case of an 11 year old male with a symptomatic wandering spleen who was treated at our institution with laparoscopic splenopexy. The patient had a history of arthrogryposis multiplex congenita and presented with recurrent, episodic abdominal pain, nausea, and vomiting. The diagnosis was confirmed by CT scan which demonstrated the spleen in the right lower quadrant. We performed laparoscopic splenopexy by encircling the spleen with polyglactin 910 woven mesh and attaching the mesh to the left lateral abdominal wall with absorbable tacks. Discussion Our surgical technique for splenopexy was successful and the patient returned home on postoperative day four. No significant complications occurred. This video demonstrates this technique and highlights the key steps. Splenopexy by encircling the spleen with polyglactin 910 mesh is feasible, preserves splenic function, and can be performed with standard laparoscopic equipment. Tacks or transfascial sutures are a potential option for securing mesh.

This article is designed to guide pediatric surgeons in the evaluation and stabilization of blunt head and cervical spine injuries in pediatric patients. Trauma remains the number one cause of morbidity and mortality among children, and the incidence of head injuries continues to rise. Cervical spine injuries, on the other hand, are unusual but can be devastating if missed. This article highlights the pathophysiology unique to pediatric head and cervical spine trauma as well as keys to clinical and diagnostic evaluation.

Long gap pure esophageal atresia (LGPEA) is a congenital disorder in which the esophagus is in discontinuity, and the proximal and distal ends cannot be anastomosed in a primary fashion. No animal model for pure esophageal atresia exists. Here we describe a survival animal model for LGPEA, which will ultimately serve to test novel devices and techniques to restore continuity. A non-survival study was first conducted in six rabbits to refine a protocol for the survival model. An open gastrostomy tube was placed, followed by a partial esophagectomy. Next, a survival study was performed with seven rabbits in which the same procedures were performed. Finally, the procedure was optimized in domestic swine. Despite developing the techniques and gaining valuable information in the non-survival study, none of the rabbits in the survival portion of the study lived beyond post-operative day four. Due to this complication with the rabbit, the LGPEA model was attempted in a porcine model. The pig survived to post-operative day ten, and was healthy enough to be used for further study. A porcine model of long gap pure esophageal atresia was developed which is effective and feasible to be used for testing new methods of treatment of LGPEA.

Although recurrence remains one of the most feared complications following congenital diaphragmatic hernia (CDH) repair, there are minimal data on the optimal surgical approach to these complex situations. The purpose of this study was to survey the international pediatric surgery community to ascertain practice patterns for both minimally invasive (MIS) and open approaches for recurrent CDH.A survey was e-mailed to members of an online community of pediatric surgeons. The questionnaire elicited surgeons' clinical experience, the continent in which they practice, and their surgical approach (laparotomy, thoracotomy, laparoscopy, or thoracoscopy) to five clinical cases, including initial and recurrent Bochdalek hernias. Fisher's exact test and chi-square test were used for statistical analysis.Two-hundred eighty pediatric surgeons responded to the survey. In total, 52.1% of surgeons chose an MIS approach for an initial repair of left CDH with the younger surgeons more likely to use an MIS approach. For the recurrence scenarios, 42.5%-55.5% of these surgeons would attempt an MIS repair after a recurrence. Specifically, thoracoscopy was favored over laparoscopy following both prior laparotomy (30.0% versus 7.5%) and prior right thoracoscopy (26.4% versus 10.0%), less favored following thoracotomy (9.3% versus 18.9%), and relatively similar proportions following prior left thoracoscopy (17.5% versus 16.4%). Laparotomy was the preferred open approach both for initial presentation and all recurrence scenarios. Among surgeons who would treat initial CDH with an open procedure, between 10.4% and 17.9% would switch to an MIS approach, most commonly after prior failed laparotomy.Approximately half surgeons who approach initial left CDH in an MIS manner would attempt an MIS approach for recurrence. The tendency to approach CDH recurrence from the opposite body cavity as the initial repair clearly impacted the surgical approach. This was particularly pronounced for MIS repairs, whereas for open approach, laparotomy remained, by far, the most popular in all scenarios.

While adult bowel anastomoses are typically performed with staplers, neonatal small bowel anastomoses have traditionally been performed in a hand-sewn manner due to the large size of surgical staplers. The purpose of this study was to compare stapled anastomosis using a newly available, 5-mm laparoscopic stapler to a hand-sewn anastomosis in an open animal model.Twenty anastomoses were performed by two general surgery residents (10 stapled and 10 hand-sewn) in an adult New Zealand white rabbit. The small bowel was divided with a scalpel. Surgical technique was alternated between single-layer hand-sewn and stapled anastomoses. Each anastomosis was resected for ex vivo testing. Measurements collected were outer diameter of the bowel before division, time to perform the anastomosis, anastomosis inner diameter (ID), and leak test. IDs were measured by cutting the anastomosis in cross-section, taking a photograph, and measuring the diameter by computer software. In addition, the surgeons qualitatively evaluated the anastomoses for hemostasis and overall quality. Statistical significance was determined using the Student's t-test.There were statistically significant differences between stapled and hand-sewn anastomosis, respectively, for average operative time (4 minutes 2 seconds versus 16 minutes 6 seconds, P .01) and anastomosis ID (8.2 versus 3.7 mm, P .01). There was one leak in the stapled group, which occurred at overlapping staple lines closing the enterotomy. A second stapled anastomosis required suture reinforcement, again at the enterotomy closure, due to operator error. Starting diameter, leak rate, hemostasis, and anastomosis quality were not statistically significant.In a neonatal open animal model, a 5-mm stapled anastomosis is an acceptable alternative to hand-sewn small bowel anastomosis. The stapler is faster and creates a larger diameter anastomosis, however, there was one leak when closing the enterotomy in the stapled group and overlapping staple lines should be avoided.

Surgical treatment of inguinal hernias in adolescents is controversial as these patients do not fit into the traditional pediatric and adult populations. We aimed to compare the preferences of adult general surgeons and pediatric surgeons in managing adolescents by conducting a survey through social media. A poll was posted on the International Hernia Collaboration Group Facebook page as well as the Facebook page for the authoring pediatric surgeon. The poll gave scenarios of a 16-year-old male with an inguinal hernia and asked surgeons to select one of five listed procedures to repair the hernia: high ligation (open or laparoscopic), mesh repair (open or laparoscopic) or open muscle repair. The four scenarios differed in the diameter of the internal ring (1 vs. 4 cm) and the BMI of the patient (20 vs. 35). Fisher’s exact test was implemented for statistical analysis. In total, 43 (67 %) adult surgeons and 21 (33 %) pediatric surgeons responded. In the routine adolescent (normal BMI, small defect), 65 % of adult surgeons chose adult-type repairs (mesh or muscle repairs) whereas 86 % of pediatric surgeons chose pediatric-type repairs (high ligation). When the size of the defect increased, 100 % of adult surgeons and 81 % of pediatric surgeons selected an adult-type repair, suggesting agreement. When the patient was obese, there was a tendency to prefer laparoscopy. In all patient scenarios, the answers were significantly different between pediatric and adult surgeons (p

Surgical telementoring, consisting of an expert surgeon guiding a less experienced surgeon through advanced or novel cases from a remote location, is an evolving technology which has potential to become an integral part of surgical practice. This study sought to apprise the attitudes of rural general surgeons toward the possible benefits and applications of surgical telementoring in their practices. A survey assessing demographics and attitudes toward telementoring was e-mailed to members of the American College of Surgeons (ACS) Advisory Council for Rural Surgery and posted to the ACS website in areas targeting rural surgeons. A link to a webpage with a description of surgical telementoring and brief demonstrative video were included with the survey. There were 159 respondents, with 82.3 % of them practicing in communities smaller than 50,000 people. Overall, 78.6 % felt that telementoring would be useful to their practice, and 69.8 % thought it would benefit their hospitals. There was no correlation between years of practice and perceived usefulness of surgical telementoring. When asked the single most useful, or primary, application of surgical telementoring there was a split between learning new techniques (46.5 %) and intraoperative assistance with unexpected findings (39.0 %). When asked to select all applications in which they would be interested in using telementoring from a list of possible uses, surgeons most frequently selected: intraoperative consultation for unexpected findings (67.7 %), trauma consultation (32.9 %), and laparoscopic colectomy (32.9 %). Surgical telementoring is on the verge of widespread use but industry and surgical societies remain ambivalent about supporting its implementation due to concerns over lack of interest. This study demonstrates interest among rural surgeons. While there are differing opinions regarding compensation of the telementoring, the most common, single interest in the use of surgical telementoring was for learning new techniques or skill sets.