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Purpose Open pyloromyotomy remains as the criterion standard treatment for hypertrophic pyloric stenosis with the laparoscopic approach rapidly gaining adoption. We present a prospective, randomized trial between the 2 approaches. Methods After institutional review board approval, 98 patients with hypertrophic pyloric stenosis were consecutively randomized to either open or laparoscopic pyloromyotomy. Postoperative and hospital course were evaluated by review of the hospital records and long-term follow-up with scripted telephone survey using Likert scales. The length of operating room time, surgical procedure, postoperative stay, time to refeeding, and complications were evaluated. Secondary outcomes of cosmetic results and parental satisfaction were determined. Results Ninety-eight patients were enrolled during a 4-year period. There were no significant differences between 2 groups on all primary outcomes. There were 3 complications in the open group—a wound dehiscence, a surgical site infection, and a gastric serosal tear—and 2 complications in the laparoscopic group—mucosal perforation and a suture granuloma. In long-term follow-up on 72 patients (56 months), parents described significant cosmetic results with laparoscopic approach. Conclusions There was no difference in operating time, hospital stay, or refeeding patterns between open and laparoscopic pyloromyotomy. The complication rates were similar between the 2 methods. However, long-term cosmetic results were significantly superior in the laparoscopic group.

Purpose Our objective is to describe the changing incidence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and its treatment within East Tennessee. Methods A retrospective chart review of 245 patients treated with incision and drainage of soft tissue infections from March 2000 to September 2005 was completed. Consent was obtained from our local institutional review board. Forty patients were excluded because no cultures were recorded or because they failed the criteria for the diagnosis of CA-MRSA. We examined our data using χ 2 analysis. P value of less than .05 was considered statistically significant. Results The most common organism cultured was CA-MRSA (33%; 67 of 205). Non–CA-MRSA accounted for 4% (9 of 205). The age of patients ranged from 1 month to 21 years, with a mean age of 6.5 years. Stratified by year, the incidence of positive cultures for CA-MRSA has increased 159% since 2004 and 868% since 2003. In addition, the average age of patients has decreased from 8.3 years in 2000 to 6.1 years in 2005. Conclusions Community-acquired MRSA has emerged as the dominant source of soft tissue infection requiring incision and drainage regardless of site in East Tennessee. This has caused a change in the choice of empiric antibiotic treatment of soft tissue abscesses in our region. These infections now account for the third most common reportable disease to the Department of Health in East Tennessee.

Purpose The finding of isolated free intraperitoneal fluid (FIPF) on computed tomography of the abdomen (CTA) in children after blunt trauma is of unclear clinical significance and raises suspicion for a solid or hollow viscus injury. In our institution, pediatric blunt trauma patients presenting with isolated FIPF on CTA who are hemodynamically stable and have no peritoneal signs on initial physical examination (iPE) have been historically approached nonoperatively. We reviewed our level 1 trauma center experience with this subset of the trauma population and sought to (1) justify an initial nonoperative approach and (2) identify early predictors of the eventual need for surgical exploration. Methods Data on all trauma patients less than 14 years of age admitted to our hospital from 2001 to 2006 after Blunt Abdominal Trauma (BAT) whose screening CTA showed FIPF and no other radiographic signs of solid or hollow viscus injury were retrieved from the local trauma registry. Clinical progress, operative findings, and follow-up were obtained by hospital and office chart review, as well as telephone contact. Mechanism of injury (MOI); Injury Severity Score (ISS); Revised Trauma Score; Pediatric Trauma Score (PTS); the presence of abdominal tenderness or external signs of injury on iPE; and quantity, location, and density of the FIPF were statistically analyzed as possible early predictors of the eventual need for surgical exploration. Results A total of 670 children admitted to our institution after blunt trauma were evaluated with CTA during the time of enrollment. Isolated FIPF was found in 94 individuals (14%). Mean age was 9.7 (±SD 3.2) years; 52% were males. Motor vehicle crash was the most common MOI. Mean PTS was 10.6 (±SD 1.8). Mean ISS was 10.2 (±SD 7.2). Free intraperitoneal fluid was most commonly found in only one intraperitoneal region (93%). Most patients (97%) were discharged home without undergoing a surgical procedure. Three other patients developed peritonitis on serial physical examination and were surgically explored. Hollow viscus injuries were found in 2 of these individuals and treated with primary repair or segmental bowel resection. All surgical patients enjoyed a full recovery, with no postoperative complications. The presence of abdominal tenderness on iPE and the quantity of FIPF on initial CTA were the only studied variables to reach statistical significance as predictors of the eventual need for operative intervention. Follow-up after hospital discharge was obtained in 46.8% (44/94) and averaged 124.9 weeks. Conclusion To the best of our knowledge, this is the largest series of pediatric blunt trauma patients with isolated FIPF on CTA ever reported. Our findings justify an initial nonoperative approach for the management of these individuals. Abdominal tenderness on iPE and the quantity of FIPF on initial CTA were predictors of the eventual need for operative intervention.

Purpose Gallbladder disease is increasingly affecting the pediatric population. The advent of new technology in the 1980s, specifically, hepatobiliary scintigraphy and laparoscopic cholecystectomy, gave a dramatic rise in both the diagnosis and treatment of biliary disease in the pediatric population. The purpose of this study was to determine ( a ) whether laparoscopic cholecystectomy for biliary dyskinesia is efficacious in the treatment of children with biliary colic and ( b ) the ability of cholescintigraphy to predict which patients may benefit from an operative intervention. Methods We performed a retrospective review of the records of all patients (N = 184) who underwent laparoscopic cholecystectomy, correlating postoperative results with degree of dyskinesia (percentage of ejection fraction), histopathology, associated gastrointestinal diagnoses, age, and sex. Biliary dyskinesia was defined by ultrasonography without evidence of cholelithiasis with clinical diagnosis of biliary colic. Results Of the 184 patients who underwent laparoscopic cholecystectomy, 117 had a diagnosis of biliary dyskinesia and 108 were available for follow-up. Mean follow-up was 8.3 months. One hundred patients (92.6%) reported resolution or improvement of preoperative symptoms (64.8% reported complete resolution and 27.8% reported improvement in symptoms). The mean age of the patients was 14.1 years. No correlation was seen for degree of dyskinesia, histopathology, age, and sex. Patients with a preoperative diagnosis of gastroesophageal reflux were more likely to report resolution of symptoms, although this finding was not statistically significant. There was no major complication; 1 patient suffered a prolonged ileus, 1 patient suffered a wound infection, and 1 patient required incisional hernia repair. Conclusion Laparoscopic cholecystectomy is safe, efficacious, and durable in children suffering from biliary dyskinesia.

Portal venous gas associated with hypertrophic pyloric stenosis is a rare finding. We describe an atypical radiologic finding discovered on abdominal ultrasound and computed tomographic scan in an infant with hypertrophic pyloric stenosis. Portal venous gas in the setting of hypertrophic pyloric stenosis constitutes a benign incidental finding for which surgical treatment should not be postponed.