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Obesity is a worldwide epidemic, and surgical weight loss operations have been performed for over 20 years. Laparoscopic sleeve gastrectomy was first performed as part of the biliopancreatic diversion over 30 years ago. Recently, laparoscopic sleeve gastrectomy has led to excellent excess weight loss with limited morbidity, especially compared to Roux-en-Y gastric bypass. In adolescents, laparoscopic sleeve gastrectomy is an excellent option to provide excess weight loss and remission of comorbid conditions without long-term malabsorptive risks., (© 2013 Published by Elsevier Inc.)

Introduction: Our previous work demonstrated that the transforming-growth factor (TGF) β pathway plays a central role in the liver fibrosis associated with experimental biliary atresia (BA). To confirm these findings in humans, we performed an in silico analysis of publicly available microarray data from liver specimens from children with BA, with the hypothesis that the TGF-β pathway would be dysregulated., Methods: We analyzed publicly available liver gene expression microarray data from 47 infants with BA. We re-analyzed the microarray image files and clinical data to compare gene expression differences between the fibrogenic and inflammatory cohorts identified in the initial study. Targets from the microarray analysis were confirmed using the animal model of BA., Results: Analysis of variance (ANOVA) detected 6903 transcripts (2822 distinct genes) differentially regulated between groups (p < 0.01; fold change >1.2). We used a targeted approach to identified a subgroup of 24 TGF-β-related transcripts. Expressions for procollagen transcripts were increased in the fibrogenic group (1.2-fold to 1.4-fold); expression of matrix metalloproteinase (MMP)-7 was similarly increased 2-fold, while MMP-9 and plasminogen activator inhibitor-1 were decreased 2-fold and 3-fold respectively. Integrins β5 (1.18-fold) and β8 (1.84-fold) also demonstrated increased expression in the fibrogenic group. Increased expression of β5 (3-fold) and β8 (5-fold) as well as Smad-3 (4-fold) and Smad interacting protein (SIP)-1 (3.5-fold) mRNA was confirmed in experimental BA. Phosphorylated Smad-3 protein in the experimental group was also nearly twice that of the control group, further implicating the TGF-β pathway., Conclusion: Gene transcripts for known upstream and downstream TGF-β mediators are differentially expressed in liver specimens from children with BA and a fibrogenic gene signature. The same integrins that were dysregulated in the human specimens were also found to be up-regulated in our animal BA model, as were other intermediaries in the TGF-β pathway. Further investigation into whether these mediators may be attractive targets for future therapy in children with BA is warranted., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Neonatal extracorporeal membrane oxygenation (ECMO) has been widely used for the last 25 y. The impact of ethno-demographic changes on ECMO outcomes has not been fully examined. We evaluated the Extracorporeal Life Support Organization registry over a 21-y period to understand these trends., Methods: A retrospective review of all neonates undergoing noncardiac ECMO in the United States between the years 1990 and 2010 was conducted based on the years of available live birth census data. Demographic, clinical, and outcome data were collated. Patient specifics, ECMO type, ECMO length, arterial blood gases, and mortality were analyzed. Univariate, bivariate, and multivariate analyses were then performed. Changes in ethnic composition of neonates on ECMO were compared with similar ethnic trend in available U.S. live birth data., Results: Data were available for 18,130 neonates. Comparing ethnicity by year, the proportion of Caucasian neonates requiring ECMO dropped from 64.3% in 1990 to 49.5% in 2010, while African-American and Hispanic neonates on ECMO increased from 21.1% and 11.1% to 26.1% and 17.4%, respectively (P < 0.001). By diagnosis, congenital diaphragmatic hernia surpassed meconium aspiration syndrome as the leading indication for ECMO compared with 1990 (congenital diaphragmatic hernia, 21.5%-28.4%; meconium aspiration syndrome, 47.0%-15.7%; P < 0.05). ECMO mortality nearly doubled, from 18.5% to 34.0% over the study period. On adjusted analysis, African-Americans were 17% less likely to die on ECMO compared with Caucasian neonates., Conclusions: Neonates of ethnic minorities continue to disproportionally require ECMO support in comparison to their birth rates. Although ethnicity alone does not impact the outcome of these newborns, the increased requirement of ECMO may highlight the need for targeted education, improved prenatal care, and decision making in these groups., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: As the obesity epidemic takes its toll on patients stricken with the disease and our health care system, debate continues regarding the use of weight loss surgery and its long-term consequences, especially for adolescents. One subset of patients regarding whom there is increased controversy is adolescents with extreme obesity (BMI > 60 kg/m(2)) because the risk of complications in this weight category is higher than for others undergoing bariatric surgery. Several strategies have been suggested for this patient group, including staged operations, combined operations, intragastric balloon use, and endoluminal sleeve placement. However, the device options are often not available to adolescents, and there are no data regarding staged or combined procedures in this age group., Methods: All adolescents with BMI >60 kg/m(2) referred to our program were evaluated for inpatient medical weight loss prior to laparoscopic sleeve gastrectomy. The program utilizes a multidisciplinary approach with a protein-sparing modified fast diet, exercise, and behavioral modification., Results: Three patients completed the program, and each achieved significant preoperative weight loss through the inpatient program and successfully underwent bariatric surgery., Conclusions: Presurgical weight loss via an inpatient program for adolescents with a BMI >60 kg/m(2) results in total weight loss comparable to a primary surgical procedure alone, with the benefit of decreasing the perioperative risk.

Objectives: To determine the current rate of inpatient bariatric surgical procedures among adolescents and to analyze national trends of use from 2000 to 2009., Design: Retrospective cross-sectional study., Setting: Discharge data obtained from the Healthcare Cost and Utilization Project Kids' Inpatient Database, 2000 through 2009., Participants: Adolescents (defined herein as individuals aged 10-19 years) undergoing inpatient bariatric procedures., Intervention: Inpatient bariatric surgery., Main Outcome Measures: The primary outcome measure was the national population-based bariatric procedure rate. The secondary outcome measures were trends in procedure rates and type, demographics, complication rate, length of stay, and hospital charges from 2000 through 2009., Results: The inpatient bariatric procedure rate increased from 0.8 per 100 000 in 2000 to 2.3 per 100 000 in 2003 (328 vs 987 procedures) but did not change significantly in 2006 (2.2 per 100 000) or 2009 (2.4 per 100 000), with 925 vs 1009 procedures. The use of laparoscopic adjustable gastric banding approached one-third (32.1%) of all procedures by 2009. The cohort was predominantly female and older than 17 years. The prevalence of comorbidities increased from 2003 (49.3%) to 2009 (58.6%) (P = .002), while the complication rate remained low and the in-hospital length of stay decreased by approximately 1 day (P < .001). Increasing numbers of patients had Medicaid as their primary payer source; however, most (68.3% in 2009) had private insurance., Conclusions: Despite the worsening childhood obesity epidemic, the rate of inpatient bariatric procedures among adolescents has plateaued since 2003. The predominant procedure type has changed to minimally invasive techniques, including laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass. Trends show low complication rates and decreasing length of stay, despite increasing comorbid conditions among patients.

A 3-year-old boy with familial long QT syndrome type 2 presented with recurrent syncope despite adequate beta-blocker therapy. Two family members had experienced sudden cardiac arrest, and one other relative had experienced sudden cardiac death. Given the high risk for ventricular arrhythmia/syncope, the decision was made to perform primary cardiac denervation therapy through a minimally invasive approach without concomitant automatic cardioverter-defibrillator implantation. Using video-assisted thoracoscopic surgery, the left-sided sympathetic ganglia from T2-T5 were identified, and dissection along the sympathetic chain with transection of the corresponding rami along T2-T5 in addition to the lower half of the stellate ganglion was performed. The chest tube was removed on day 1 after surgery, and the patient was discharged on postoperative day 4. During 14 months of follow-up evaluation, no intervening episodes of ventricular arrhythmia or syncope and no symptoms of Horner's syndrome were noted.

Based on their clinical impression, the authors hypothesized that children with obesity may more commonly present with perforated appendicitis. Therefore, the authors reviewed their experience from 2008 to 2010 to determine whether obesity affected the clinical presentation of appendicitis. Variables studied were height, weight, use of diagnostic imaging, and clinical findings of appendicitis at presentation. Outcomes assessed were length of stay and complication rate. The study identified 319 patients with appendicitis. Children with obesity were more likely (P = .026) to present with perforation (28/62, 45%) than nonobese patients (78/257, 30%). Neither length of stay nor complication rate was affected by the presence of obesity. The data suggest that children with obesity are more likely to present with perforated appendicitis. This finding suggests that the diagnosis of appendicitis may be more difficult in obese patients or their presentation may be delayed. Practitioners should have heightened awareness in children with obesity and symptoms of abdominal pain.

Giant inguinoscrotal hernias are a rare entity seen largely in the adult population. Presentation in the child is more unusual, with only one case previously documented. As there is scant literature regarding these hernias in children, their management may be challenging. Here, we present the case of a newborn born with giant bilateral inguinal hernias complicated by in utero perforation and meconium peritonitis managed by laparoscopy and then laparotomy for repair. The case illustrates several points that may be useful for pediatric surgeons who may encounter this condition.

Background: Obesity has been identified as one of the most important public health concerns in both children and adolescents. Unfortunately, even the most comprehensive and aggressive multidisciplinary weight management programs have shown only modest weight loss results. There has been increasing enthusiasm for bariatric surgery for adolescent patients with morbid obesity. Because of the relatively high morbidity and mortality associated with gastric bypass surgery, we have begun to explore laparoscopic sleeve gastrectomy as an alternative. We hypothesized that it would be a safe and effective short-term strategy., Methods: We have prospectively collected data from all patients undergoing bariatric surgery at our institution since the inception of our adolescent weight loss surgery program in January 2010. Baseline data collected included age, gender, race/ethnicity, height, weight, body mass index, and comorbid conditions. Postoperative data collected included the type of operation, length of stay, operative morbidity, the need for reoperation, and percent excess weight loss and body mass index at 3-month intervals., Results: Twenty-three patients have undergone laparoscopic sleeve gastrectomy at our institution since January 2010. Of these, 18 were female and 5 were male. The mean age was 17.3 ± 1.5 years of age. The mean preoperative weight was 149 ± 30 kg with a body mass index of 52 ± 9 kg/m(2). There were no intraoperative complications, and the only postoperative complication has been pancreatitis in 1 patient. The mean length of stay was 2.2 ± 1.1 days. The mean follow-up was 10.9 ± 7.4 months. The percent excess weight loss at 3 months, 6 months, and 1 year postoperatively was 32%, 38%, and 40%, respectively, in those who had reached these time points., Conclusion: Laparoscopic sleeve gastrectomy is a safe operation for adolescent patients with morbid obesity and represents an effective early treatment strategy with approximately 40% excess weight loss at 6 months and 1 year of follow-up. Because of the minimal morbidity associated with laparoscopic sleeve gastrectomy, it may be the optimal non-device surgical option for this select group of adolescent patients., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background: As the Fundamentals of Research and Career Development Course (FRCDC) is conducted internationally, questions have arisen regarding the cultural appropriateness of the United States (US) course. We therefore assessed the US-based teaching methodology during the FRCDC in Abuja, Nigeria. We hypothesized that the US-based instructional methods would be effective., Methods: Twenty questions were distributed to attendees of the FRCDC prior to commencement. The same 20 questions were administered at the conclusion of the course after random reordering. Differences between the pre- and post-test results were assessed for normalcy and compared using the paired t-test., Results: There were 89 attendees, of whom 60 completed the pre-test and 77 completed the post-test. The pre-test group answered 12.3 ± 2.6 questions correctly, which improved to 15.0 ± 2.6 in the post-test group (P < 0.001). On the pre-test, the least common correct answers were for questions regarding type 1 and 2 error (16.7% correct), the definition of health services and outcomes research (26.7%), and how to best address missing data (26.7%). On the post-test, the questions with the least common correct answers were regarding the definition of health services and outcomes research (35%), and the components of an NIH grant (37.7%)., Conclusions: Our results suggest that the FRCDC in Nigeria as given by US faculty has short-term efficacy. Attendees were able to improve their scores despite the cultural differences between them and the lecturers. Our next goal will be to demonstrate long-term efficacy at future courses in the region using similar questionnaire strategies., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: The inaugural Fundamentals of Surgical Research Course was held in Sierra Leone in conjunction with the West African College of Surgeons (WACS). We subsequently performed a formal assessment of the academic needs of West African surgeons to plan for future courses, and hypothesized that they would differ from the goals of the U.S. course., Methods: A survey was distributed via email to members of the WACS and returned by the same mechanism. It consisted of 6 questions addressing specific elements of the inaugural course, and potential new topics for future courses., Results: Over half (53%, 25/47) of the respondents had not attended the inaugural course, while 85% (40/47) planned on attending the next course. Respondents identified least useful topics from the initial course as "Molecular Biology: Tools of the Trade" (45%, 21/47) and "Getting Promoted" (23%, 11/47). The least popular potential new topics were "Use and Abuse of Administrative Databases" (9%, 4/47), "Animal Models" (21%, 10/47), and "Genomics and Proteomics" (21%, 10/47)., Conclusions: The self-reported academic needs of West African surgeons are oriented toward clinical research. Basic and translational research topics are of secondary interest to the majority of respondents. Future courses in this region must address specific local needs., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Hepatic fibrosis leading to cirrhosis is the major morbidity in patients with biliary atresia (BA). This fibrosis is due to an imbalance in extracellular matrix (ECM) breakdown and deposition. We have previously demonstrated increased mRNA expression for inhibitors of ECM breakdown without increased expression for mediators of ECM deposition in our animal model of BA by d 14. However, only a mild degree of hepatic fibrosis was seen at this time. We hypothesized that expression patterns for these proteins may change once more significant fibrosis had been established, and added resuscitation to the model to improve survival. Interestingly, we found that some mice spontaneously recovered at later time points with resuscitation, and thus compared expression for inhibitors of ECM breakdown and deposition in sick and recovered mice to determine the differences., Methods: Newborn Balb/c mice received an intraperitoneal injection 1.0 x 10(6) fluorescence forming units of rhesus rotavirus 24h after birth. Mice were monitored daily for weight gain, development of jaundice, acholic stools, and bilirubinuria. Fifty muL/g of 5% dextrose in normal saline were subcutaneously injected daily to each mouse starting on d 7 until sacrifice. Mice that survived past d 14 were sacrificed at d 21 after saline or RRV infection. Livers were then harvested post-injection d 21 for histologic and immunohistochemical analysis. RNA expression of known mediators of fibrosis was evaluated using quantitative real-time PCR. Protein expression was assessed using ELISA. Weights and normally distributed data were compared using Student's t test. Histologic findings were compared using Fisher's exact test. Comparisons of gene expression and skewed data were performed by the Mann-Whitney U test. Statistical significance was assigned to any P value less than 0.05., Results: Daily resuscitation resulted in a 35% (24/68) survival rate to d 21 in our model. Mice that recovered were significantly heavier than those that remained ill on d 14 (6.15 +/- 1.16 versus 4.94 +/- 0.82, P = 0.02) and 21 (7.31 +/- 1.41 versus 4.14 +/- 0.53, P < 0.001) despite the fact that there was no difference between the groups with respect to weight on d 7 (4.29 +/- 0.90 versus 3.89 +/- 0.81, P = 0.32). We found that all (10/10) animals that displayed clinical signs of biliary atresia on d 21 had moderate or severe histologic findings, while only one (1/9) of the recovered animals had liver abnormalities at sacrifice (P < 0.001 versus sick group). We also found that the sick mice had statistically significant median fold-increases of mRNA expression for TIMP-1 (31.9 versus 9.1, P = 0.041), TIMP-4 (88.1 versus 1.8, P = 0.022), and MMP-7 (51.8 versus 11.9, P = 0.006) compared with those that recovered. There was a trend toward decreased mRNA expression for PAI-1, which did not reach statistical significance (median 27.7 versus 2.19, P = 0.066). Increased protein expression for TIMP-1 and PAI-1 were also found in the sick group. The mRNA expression for the fibrillar collagens, fibronectin-1, connective tissue growth factor, snail-1, TIMP-2 and -3, and MMP-2 and MMP-9 was not different in the sick and recovered groups 21 d after RRV infection, and was not elevated from baseline gene expression., Conclusions: With resuscitation added to the animal model of BA, some mice spontaneously recover while others progress to more significant hepatic fibrosis. Mice with hepatic fibrosis have a continued increase in mRNA expression of TIMP-1, TIMP-4, and MMP-7, with a trend toward increased mRNA expression of PAI-1 on d 21. Protein levels for TIMP-1 and PAI-1 were also increased in the sick mice. Recovered mice display mild to no hepatic parenchymal disease and a normal pattern of mRNA expression for the mediators of fibrosis tested. No increase in mRNA expression for the mediators of ECM deposition was found in either group. These data further support the notion that inhibition of ECM breakdown alone is sufficient to induce hepatic fibrosis. Modulation of this process may be a putative target for preventing liver injury in patients with BA.

Background: Access to health care has been a source of controversy and public attention in health policy. The issues of access to and utilization of the healthcare system by infants and children is less well documented. Moreover, the impact on outcomes of race, ethnicity, and economic status in infants is vaguely addressed., Methods: We performed a retrospective analysis of children who had undergone pyloromyotomy from July 31, 1998 to July 31, 2008 at our public hospital and university teaching hospital. Data abstracted included gestational age at delivery, birth weight, gender, race, insurance status, age at presentation, symptom duration, preoperative ultrasound (US), operative date, laboratory evaluations, as well as preoperative, postoperative, and total length of stay (LOS)., Results: The mean total preoperative LOS was twice as long at our public hospital than our private hospital (1.78 d versus 0.85 d, P=0.003). Similarly, the mean total length of stay was 0.87 d longer at our public hospital (3.87 d versus 3 d), which trended toward significance (P=0.06). Significantly, 72% (27/33) patients at the private hospital had their US either as an out-patient or on the day of admission, while only 58% (28/48) had an US performed as expeditiously at the public hospital (P=0.03, chi(2) analysis)., Conclusions: Care at our public hospital leads to delayed diagnosis and treatment, resulting in longer preoperative and total LOS in infants with pyloric stenosis, most likely related to the timing of the preoperative US. Efforts should be made to encourage patients to use the outpatient clinic facilities for their ill infants, or for physicians at public hospitals to expedite the US process once the diagnosis of pyloric stenosis is entertained.

Background: The distribution of weight loss and its impact on metabolic health has not been documented for laparoscopic adjustable gastric banding (LAGB) in the adolescent population. We hypothesized that LAGB in obese adolescents would result in loss of android fat mass, resolution of comorbidities, and improvement in metabolic status., Study Design: Adolescents ages 14 to 17 who met criteria for bariatric surgery were enrolled in our FDA-approved LAGB trial. Demographic data, body mass index, body composition and bone density, laboratory evaluations, and comorbid conditions were assessed pre- and postoperatively., Results: Forty-five patients had complete 1-year followup and 41 patients had complete 2-year followup. Mean preoperative weight was 299 + or - 57 lb and body mass index was 48 + or - 6.4 kg/m(2). The percent excess weight losses at 6 months, 1 year, and 2 years were 31 + or - 16, 46 + or - 21, and 47 + or - 22, respectively. At 1-year followup, patients after LAGB had a significant decrease in their total and android fat mass. In addition, 47 of 85 identified comorbidities (55%) were completely resolved and 25 (29%) were improved in comparison with baseline. Improvements in alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, hemoglobin A1c, fasting insulin, triglycerides, and high density lipoprotein, were also seen., Conclusions: The percent excess weight loss after LAGB in morbidly obese adolescents is approximately 45% at 1- and 2-year followup, with the majority of weight loss consisting of android fat mass. Resolution or improvement of comorbidities is seen, and improved metabolic status, as demonstrated by liver function tests, lipid levels, and measures of glucose homeostasis, may be expected. These data support LAGB as an appropriate surgical option for morbidly obese adolescents.

Purpose: Some have suggested that the criteria for weight loss surgery in adolescents be stricter than those currently recommended for adults by the National Institutes of Health (NIH). The aim of the current study is to define the characteristics of adolescents who meet NIH consensus criteria for bariatric surgery in adults to determine their level of morbidity., Materials and Methods: Using the Medical Expenditure Panel Survey 2000-2004, children designated as meeting NIH criteria were 13 to 17 years of age with (1) a body mass index >or=40 or (2) a body mass index >35, and one or more comorbidity. We contrasted surgery candidates with noncandidates. We examined items that comprise a screener for identifying children with special health care needs. The Columbia Impairment Scale (CIS) was used to assess child functioning., Results: There were 134 children identified as candidates for bariatric surgery and 4736 noncandidates in the same age range. Candidates were more likely to have special health care needs (36% vs 23%) and more likely to have a CIS above 16 (34% vs 16%). Candidates for weight loss surgery were 2.36 times as likely to have a CIS score of 16 or higher and 1.87 times as likely to be identified as a child with special health care needs (P

The assault on the World Trade Center on September 11, 2001, has mandated that there be improved disaster preparedness for both children and adults in the immediate future. Fortunately, the events of September 11, 2001, spared 3,400 near miss children from substantial harm; however, NYC was not well prepared to handle significant numbers of pediatric patients had they been severely injured. Furthermore, there have been several medical sequelae of the attacks that have manifest long after the immediate postevent period. Both respiratory illness and mental health issues have been suffered by children because of the environmental toxins and the trauma of witnessing the event, respectively. The pediatric practitioners in the area did not feel well prepared to handle the increased demand for services. Also at the time, there was no pediatric-specific plan to either evacuate children in need of specialized care to centers with expertise in handling such patients or to mobilize pediatric practitioners (surgeons, critical care physicians, etc.) to the institutions where the masses of children would have initially been brought. Since then, there have been efforts to create educational materials to better prepare hospitals as well as proposals to create mobile pediatric disaster teams to deploy to hospitals in need of support. This review discusses these recognized and unrecognized issues in pediatric disaster preparedness to hopefully foster discussion for future strategies.

Introduction: Biliary atresia (BA) is a progressive obliteration of the extrahepatic bile ducts resulting in hepatic fibrosis. The underlying mechanisms have not been defined. We used an animal model of BA to evaluate mediators of extracellular matrix (ECM) processing to determine which factors may be involved., Methods: Newborn BALB/c mice received an intraperitoneal injection with rhesus rotavirus or saline within 24 h of birth. Livers were harvested on days 7 and 14 for histology and immunohistochemistry (IHC). RNA expression was determined using quantitative real-time PCR. Human liver from patients with BA and those having a resection for nonfibrosing diseases was also evaluated., Results: In experimental mice, mRNA expression for tissue inhibitor of metalloproteinase (TIMP)-1 and matrix metalloproteinase (MMP)-7 was increased 18-fold and 69-fold, respectively on day 7, with further increases on day 14. On day 14, mRNA expression for plasminogen activator inhibitor (PAI)-1 (38-fold), TIMP-4 (9.5-fold), and MMP-9 (5.5-fold) mRNA was also observed. Furthermore, integrin alpha(v) beta(6) mRNA expression was increased on days 7 (11-fold) and 14 (6-fold). Presence of integrin alpha(v) beta(6) protein was confirmed by IHC in both mouse and human specimens in the proliferating biliary epithelium., Conclusions: Our data suggest experimental BA is associated with increased mRNA expression of ECM degradation inhibitors, TIMP-1, PAI-1, and TIMP-4. MMP-7 and MMP-9 expression is also elevated in this model. Furthermore, increased gene expression of integrin alpha(v)beta(6) was demonstrated and IHC confirmed protein expression. Integrin alpha(v)beta(6) or the inhibitors of ECM breakdown may be attractive targets for future treatment strategies.

Background: Access to health care is a well-recognized issue in health policy, but use once patients have entered the health care system is uncommonly addressed., Methods: We performed a retrospective review of children between 2 and 17 years of age with pathologically confirmed appendicitis at our public city hospital and private university hospital and compared management and outcomes., Results: Among patients with acute appendicitis, the median length of stay was a day longer in the public hospital (2 days vs 1 day, P = <.001) despite a similar complication rate (12% vs 11%). More computed tomography (CT) scans were performed at the public hospital (36% vs 21%, P = .02) with a trend toward less use of ultrasound (US) (54% vs 65%, P = .13)., Conclusions: Children at the public city hospital have a longer length of stay and undergo more expensive imaging. These findings may provide areas for improvement to optimize the care of children with appendicitis at government-funded institutions.

Here we present a case of successful non-operative management of an iatrogenic recto-urethral fistula in a 13-year-old boy. The fistula was created when urethroscopic repair of a urethral stricture was attempted. Due to the anatomy of the lesion and previous urinary diversion, it was deemed possible to spare this patient diverting colostomy or surgical repair of the fistula. The result was successful closure of the fistula, which was confirmed on retrograde urethrogram. While we do not support the routine use of non-operative management for recto-urethral fistulas we have demonstrated that there are circumstances where it can be safely applied.

Tracheomalacia resulting from vascular compression of the trachea may require aortopexy for symptomatic relief. Several operative approaches have been described for infants and children. The authors describe the technique of aortopexy by means of a right-sided thoracoscopic method as the initial approach to relieve tracheal compression in 2 children. Intraoperative bronchoscopy is mandatory to assess the adequacy of aortopexy prior to the completion of suture placement. This procedure was very successful in relieving tracheal compression in a 17-month-old boy with an aberrant innominate artery take-off and in a 2-year and 7-month-old boy with a history of esophageal atresia/tracheoesophageal fistula repair and severe tracheomalacia. A right-sided thoracoscopic approach to aortopexy in infants with severe tracheomalacia may be successfully performed as the initial operative intervention in infants with vascular compression of the trachea.

Background: The Surgical Infection Society published their most recent recommendations for antimicrobial therapy in patients with intra-abdominal infections in 2002. These guidelines outlined several important considerations for the treatment of such infections, including which patients require antimicrobial agents, the appropriate duration of treatment, which antimicrobial regimens are appropriate, and the risk factors and indications for intensified regimens. However, the applicability of these recommendations to the pediatric population is not entirely clear., Methods: Systematic review of all literature regarding antimicrobial therapy in the most common intra-abdominal infection in children, appendicitis, with the goal of establishing guidelines for use., Results: Children with uncomplicated (acute or gangrenous), but not perforated, appendicitis can be treated with prophylactic antimicrobial agents for 24 h or less. Children with perforated appendicitis can be treated after appendectomy in the same manner as adults with established intra-abdominal infections; i.e., with therapeutic antibiotics until no clinical evidence of infection exists. This is true after both laparoscopic and open operations. Whereas "triple" antibiotic therapy has been the gold standard in pediatric patients, monotherapy with broad-spectrum agents is equally effective and possibly more cost-effective. The nonoperative management of perforated appendicitis with interval appendectomy represents a unique problem, and guidelines for therapy are less well established., Conclusions: The evidence supports using guidelines in the pediatric population similar to those suggested for the adult population for the management of acute appendicitis.

Background: Adolescent obesity continues to present one of the most difficult and important challenges for both the pediatric and adult medical communities. Evidence is mounting that bariatric surgery is the only reliable method for substantial and sustainable weight loss; however, the debate continues with regard to the optimal surgical procedure for both adolescents and adults. Although most US adult bariatric surgeons prefer the gastric bypass, our institution has demonstrated equivalent weight loss with significantly less morbidity using laparoscopic adjustable gastric banding (LAGB) in both adults and adolescents. This analysis is an update of our results in our first 73 patients, including resolution of comorbid conditions and compliance data., Methods: All adolescents aged 13 to 17 years who have undergone LAGB at our institution have been entered into our prospectively collected database since September 2001 and were reviewed. Data collected preoperatively included age, sex, race, body mass index (BMI), and presence of comorbid conditions. Postoperatively recorded data included length of stay, operative morbidity, need for reoperation, percentage of excess weight loss (%EWL), and BMI at 3-month intervals; status of any comorbid conditions, and number of postoperative visits and band adjustments., Results: Seventy-three adolescents aged 13 to 17 years (mean, 15.8 +/- 1.2 years) have undergone LAGB at our institution since September, 2001. Of these, 54 were female and 19 were male. The mean preoperative weight was 298 lb, with a BMI of 48 kg/m(2). The %EWL at 6 months, 1 year, and 2 years postoperatively was 35% +/- 16%, 57% +/- 23%, and 61% +/- 27%, respectively. One patient experienced a gastric perforation after a reoperation for band replacement because of a slip. One additional patient requested band removal because of restriction intolerance after a slip. A total of 6 patients developed band slippage, and 3 patients developed symptomatic hiatal hernias. Nutritional complications included asymptomatic iron deficiency in 13 patients, asymptomatic vitamin D deficiency in 4 patients, and mild subjective hair loss in 14 patients. In 21 patients who entered our Food and Drug Administration-approved study and had reached 1-year follow-up, there were 51 identified comorbid conditions. Of these, 35 (68.5%) were completely resolved, 9 (17.5%) were improved, 5 (10%) were unchanged, and 2 (4%) were aggravated after 1 year. Of 50 initial patients who underwent surgery more than 1 year ago, 2 patients lived a large distance from our institution, where band maintenance is being performed locally, and thus, the patients were excluded from the analysis. Two patients were lost to follow-up in the first year, and 3 patients were lost to follow-up in the second year, for an overall compliance rate of at least 89.5%. The mean number of office visits was 10 +/- 3 in the first year, and the mean number of adjustments was 6 +/- 2., Conclusions: Laparoscopic adjustable gastric banding continues to represent an attractive treatment strategy for morbidly obese pediatric patients with a %EWL of more than 55% at both 1- and 2-year follow-up, with minimal morbidity compared with the gastric bypass. Furthermore, the weight loss associated with LAGB provides excellent resolution or improvement of comorbid conditions. Although there is a necessary commitment by the patient that involves frequent office visits and band adjustments, adolescents are entirely capable of this commitment, and noncompliance should not be a reason to dissuade adolescents from having LAGB. It remains, in our opinion, the optimal surgical option for pediatric patients with morbid obesity.

Background: Acquired esophageal strictures in children are often the result of ingestion of caustic agents. We describe 2 children with severe esophageal strictures following lye ingestion, who successfully underwent esophagectomy and gastric pull-up utilizing combined thoracoscopic and laparoscopic techniques., Methods: This was a retrospective chart analysis of both patients. CASE 1: A 17-year-old female, who ingested a lye-containing substance, which lead to the need for gastrostomy and esophageal dilatations, developed an esophageal stricture. Thoracoscopic esophagectomy, laparoscopic gastric conduit creation, pyloroplasty, gastric pull-up, and esophagogastric anastomosis was performed one year later. She was tolerating a regular diet for almost 4 years following esophageal replacement when she developed a gastric ulcer with gastrobronchial fistula that required open repair via a right thoracotomy. She has since recovered and resumed her regular diet. CASE 2: A 13-month-old female who ingested a lye-based cleaner underwent tracheostomy and gastrostomy on the day of injury, and esophageal dilatations beginning 1 month later. Despite dilatations, she developed severe strictures for which at age 21 months she underwent thoracoscopic esophageal mobilization, laparoscopic creation of gastric conduit, pyloroplasty, and esophagogastric anastomosis. A right thoracotomy was necessary to negotiate the conduit safely up to the neck. She is tolerating feeds and has not developed any complications for nearly 3 years following esophageal replacement., Conclusions: Esophagectomy and gastric pull-up for esophageal lye injuries can be accomplished utilizing a combination of thoracoscopy and laparoscopy with excellent results. Long-term follow-up is necessary to manage potential complications in these patients.

Calcified catheter "cast" found on radiologic studies after central venous catheter removal is a rare complication that has been reported twice. Both cases were associated with thrombus. In this case report, we present a 15-year-old boy with acute lymphoblastic leukemia who demonstrated on CT scan a radiopacity in his left brachiocephalic vein after removal of an implanted venous access device. This was initially thought to be a retained catheter fragment. Diagnostic studies, including venogram, excluded the presence of a retained catheter fragment. Additional procedures to retrieve a nonexistent catheter fragment were thus avoided. Therefore, a catheter "cast" should be considered as part of the differential diagnosis when calcification is found on an imaging study after removal of an implantable venous access device to prevent an unwarranted surgical exploration.

Struma ovarii is rare ovarian tumor that is characterized by the presence of at least 50% thyroid tissue on histologic examination. This usually benign neoplasm is predominantly found in women between the ages of 40 and 60 years and infrequently in the pediatric age group. In the foregoing report, we present an unusual case of a large struma ovarii in a 16-year-old adolescent girl with abdominal pain and increasing abdominal girth. Removal of the mass was achieved via a laparoscopic approach. We conclude that the diagnosis of struma ovarii should be considered in adolescent girls presenting with large cystic ovarian masses and that a laparoscopic approach to management is the treatment of choice.

Background/purpose: Long-term follow-up of fundoplication in patients with familial dysautonomia (FD) has revealed a high rate of recurrent gastroesophageal reflux. This may be because of the unique characteristics of patients with FD which include autonomic denervation accompanied by cyclic vomiting and retching. We reviewed our results with adaptations to the Nissen fundoplication to determine which would be most effective in preventing the need for reoperation., Methods: We reviewed the records of 108 patient with FD who underwent fundoplication by a single pediatric surgeon from November 1978 to July 1, 2004. Patients were divided into 4 groups based on the operative technique: standard Nissen fundoplication, Nissen with a posterior gastropexy, Nissen with posterior gastropexy and a superior anchoring suture, and Nissen with a reinforced suture line in addition to the previous modifications. Demographic data and surgical outcomes were abstracted., Results: Patients who underwent a Nissen fundoplication with a reinforced suture line were significantly less likely to require a reoperation for recurrent reflux than any other patients (P = .05, Fisher's Exact test) despite the fact that they were younger than patients who underwent a standard Nissen alone., Conclusion: The addition of a reinforced suture line to the standard Nissen fundoplication decreases the failure rate for patients with gastroesophageal reflux and FD. A reinforced suture line may be an attractive modification for patients where the fundoplication may be under continued physical stress caused by autonomic perturbations, or other conditions such as uncontrolled seizures or progressive neurologic decline.

Background: Obesity in the adolescent population has reached epidemic proportions. Although diet and behavior modification can help a minority of teenagers, most of these patients go on to become obese adults. Recently, surgical intervention for morbid obesity has gained increasing support. To date, this has only included gastric bypass procedures. However, this procedure carries at least a 1% mortality rate even in the hands of the most experienced surgeons. Therefore, our center has been using laparoscopic adjustable gastric banding (LAGB) to treat adolescents with morbid obesity. This analysis is a report of our short-term results in our first 53 patients., Methods: All adolescents aged 13 to 17 years who had undergone LAGB at our institution and had been entered into our prospectively collected database since 2001 were reviewed. Data collected preoperatively included age, sex, race, and body mass index (BMI). Postoperatively recorded data included length of stay, operative morbidity, need for reoperation, as well as percentage of excess weight loss (%EWL) and BMI at 3-month intervals., Results: Fifty-three teenagers aged 13 to 17 years (mean, 15.9 years) underwent LAGB at our institution since September 2001. Of these, 41 were female and 12 were male. The mean preoperative weight was 297 +/- 53 lb and the mean initial BMI was 47.6 +/- 6.7 kg/m2. The %EWL was 37.5 +/- 17.0 at 6 months, 62.7 +/- 27.6 at 1 year, and 48.5 +/- 15.6 at 18 months of follow-up. There were no intraoperative complications. Two patients had band slips that required laparoscopic repositioning, and 2 patients developed a symptomatic hiatal hernia that required laparoscopic repair. All of these procedures were performed as outpatient procedures. A fifth patient developed a wound infection requiring incision and drainage. Other complications included mild hair loss in 5 patients, iron deficiency in 4 patients, nephrolithiasis and cholelithiasis in 1 patient, and gastroesophageal reflux in 1 patient., Conclusions: Laparoscopic adjustable gastric banding is not only a safe operation for morbidly obese pediatric patients, but also represents an effective treatment strategy with a %EWL of approximately 50% at both 1 year and 18 months of follow-up. Because of the minimal morbidity and complete absence of mortality of the LAGB, it is the optimal surgical option for pediatric patients with morbid obesity.

Children with acquired immunodeficiency syndrome (AIDS) are at an increased risk for lymphoproliferative and neoplastic disorders. Included among these are smooth muscle neoplasms such as leiomyomas and leiomyosarcomas. There have been at least 15 reported cases of smooth muscle tumors in the approximately 8,000 children with AIDS, however the incidence in immunocompetent children is only two per ten million. The lesions in children with human immunodeficiency virus infection are usually found in the lung, liver, and gastrointestinal tract. Here, we present an unusual case of a 12-year-old African American girl with vertically acquired AIDS who presented to the pediatric emergency department with severe diffuse abdominal pain. She was ultimately found to have an appendiceal leiomyoma on abdominal exploration, the first reported case. Our report suggests that smooth muscle tumors of the appendix be included in the differential diagnosis of abdominal masses in children with AIDS.

Uterus didelphys is a rare congenital anomaly with a well-documented association with obstructed hemivagina and ipsilateral renal agenesis. Treatment of this anomaly includes drainage of hematocolopos and excision of the vaginal septum, which has traditionally used a scalpel or scissors, often with hymenotomy. Recently, a less invasive approach using hysteroscopic resection has been reported, allowing improved visualization with preservation of the hymenal ring. In this article, we present an alternative minimally invasive approach using a combination of laparoscopy and vaginoscopy in the case of a 10-year-old girl. This approach allows for treatment in cases wherein vaginoscopy provides inadequate visualization with the advantage of enabling full evaluation for associated complications affecting future fertility including endometriosis, pelvic infection, and pelvic adhesions.

Persistent interstitial pulmonary emphysema (PIPE) is a syndrome characterized by air-leakage in the perivascular tissues of the lung, primarily affecting mechanically ventilated neonates. Reports in the literature of infants developing PIPE with no history of respiratory distress syndrome (RDS) or mechanical ventilation are scarce. Here, we present a case of a 3-month-old former full term male infant with no history of RDS or mechanical ventilation who presented with focal cystic lung disease associated with spontaneous tension pneumothorax. He was ultimately found to have PIPE based on pathologic evaluation of the resected cystic region. We believe that focal PIPE should be included in the differential diagnosis of cystic lung disease in a full term, unventilated infant, even when spontaneous pneumothorax is the presenting entity.

Purpose: There is persistent controversy regarding the optimal surgical therapy for children with appendicitis. We have recently adopted laparoscopic appendectomy in lieu of the open technique for children with perforated appendicitis. We hypothesized that laparoscopic appendectomy would be as effective as open appendectomy in preventing postoperative complications., Materials and Methods: We reviewed the medical records of children admitted to our hospital over a 5-year period with the diagnosis of perforated appendicitis. Patients were divided into two groups based on the operative approach: laparoscopic vs. open appendectomy. Demographic data, duration of presenting symptoms, initial white blood cell (WBC) count, length of stay, and complications were abstracted. Data were compared using appropriate statistical analyses., Results: There was no difference between the laparoscopic (n = 43) and open (n = 77) groups with respect to gender, duration of presenting symptoms, initial WBC, or length of stay. However, patients in the laparoscopic group had a significantly lower complication rate than those in the open group (6/43 vs. 23/77, P = 0.05). Infectious complications were no different between groups. Patients in the laparoscopic group tended to be older than patients in the open group (10.6 +/- 3.3 years vs. 8.5 +/- 4.1 years, P = 0.003)., Conclusion: Laparoscopic appendectomy for children with perforated appendicitis has the same infectious complication rate and a lower overall complication rate than open appendectomy. A prospective study with standardized postoperative care would be needed to determine whether laparoscopic appendectomy for children with perforated appendicitis is the treatment of choice, but until then it remains an attractive alternative.

The ability to biopsy indeterminate pulmonary lesions in children has evolved with advances in minimal access surgery. Recent advances in preoperative localization including image-guided dye injection or wire implantation have expanded the types of lesions that are accessible via minimal access surgery. We present a case of a 13-year-old boy who underwent preoperative localization using both methylene blue dye and microcoil labeling, and a subsequent thoracoscopic pulmonary wedge resection under the same anesthesia. The combined use of both dye and microcoil localization provides the advantage of superior intraoperative visualization of the lesion and the ability to use fluoroscopy to confirm the presence of the nodule in the surgical specimen. We recommend this technique for the biopsy of indeterminate pulmonary lesions that would not otherwise be accessible via a minimally invasive approach.

Background: Laparoscopic splenectomy is being performed more commonly in children, although its advantages are not clear. We sought to determine whether laparoscopic splenectomy was superior to open splenectomy., Methods: The records of all pediatric patients undergoing splenectomy without significant comorbidities over a 12-year period were examined. The patients were divided into those undergoing laparoscopic splenectomy and those undergoing open splenectomy. Demographics, operative time, estimated blood loss, spleen size, length of stay, and total charges were compared between the groups., Results: Eighty-one (58%) children underwent laparoscopic splenectomy, and 59 (42%) children underwent open splenectomy. The groups were similar in age and sex; hereditary spherocytosis was more common in the LS group. Operating time was longer in the laparoscopic splenectomy group (231 +/- 10 min vs 138 +/- 9 min; P<0.001), but blood loss and complication rates were similar. Twelve (15%) conversions were necessary primarily due to spleen size. Although children undergoing LS had a shorter length of stay (2.4 +/- 0.1 vs 4.1 +/- 0.3 days; P<0.001), they incurred higher charges (dollars 21199 +/- 664 vs dollars 15723 +/- 1737; P<0.002)., Conclusion: Laparoscopic splenectomy is a safe procedure in children, resulting in shorter hospital stay, which may translate into earlier return to activity and a smaller burden on the child's caretakers.

Background: Although injury prevention strategies for bicyclists have focused on legislation requiring helmet use to prevent head trauma, direct impact handlebar injuries account for a significant proportion of bicycle-related injuries. Little attention, however, has been paid to strategies that prevent direct impact handlebar injuries. We reviewed our experience with bicycle-related injuries and compared outcome for children who flipped over the handlebars to those for children who sustained direct impact from the handlebars., Methods: We queried our prospective trauma database for all bicycle injuries from 1998 to 2003. All patients with the descriptor "handlebar" in the subtext were selected. Patients were divided into two groups: those who flipped over the handlebars (n = 160) and those who sustained direct impact from the handlebars (n = 61). We examined age, gender, helmet use, injury severity score (ISS), Glasgow Coma Score (GCS), length of stay (LOS) and the need for operation. The Student's t test was used to compare continuous variables when the data were normally distributed and the Mann-Whitney was used when the data were skewed. Chi-square analysis or Fisher's exact test was used to compare categorical data., Results: There was no difference between the two groups with respect to age, gender, helmet use, ISS, and GCS. However, children who suffered from handlebar injuries were more likely to require operative intervention (19/61 versus 28/160, p = 0.04) and had a significantly longer LOS (3 days versus 1 day, p < 0.001). Children who sustained direct impact from the handlebars and required operative intervention were statistically more likely to suffer from abdominal or soft tissue injuries, while those who flipped over the handlebars were statistically more likely to suffer from facial or skeletal injuries., Conclusions: Children who suffer from direct impact of the handlebars are more likely to require operative intervention and have a longer LOS than those who flip over the handlebars. While helmet utilization by bicyclists may have reduced the number of serious head injuries, direct impact from the handlebars remains a major source of bicycle-related morbidity since nearly one third of these patients required surgery. Future injury prevention strategies for bicyclists should be aimed at reducing the incidence of direct impact handlebar-related injuries.

Background: Initial non-operative therapy for children with perforated appendicitis has become increasingly popular with the advent of powerful broad-spectrum antibiotics. However, there is no consensus regarding which patients may be managed effectively with this strategy. We reviewed all children with perforated appendicitis who were treated initially with non-operative therapy to determine those characteristics that may predict a successful outcome., Methods: We reviewed the medical records of children admitted to our hospital between January 1, 2000 and May 1, 2003 with the diagnosis of perforated appendicitis. Only those who were treated initially with a single broad-spectrum antibiotic (piperacillin-tazobactam), with the intention of performing an interval appendectomy, were included in this study. Patients were divided into two groups based on whether they were managed successfully with non-operative therapy: Responders and non-responders. Non-responders were defined as patients who either did not improve with antibiotic therapy or who required appendectomy prior to their electively scheduled time (six weeks). Demographic data, duration and type of presenting symptoms, initial white blood cell count (WBC), percent bands, percent neutrophils (PMNs), computed tomography (CT) interpretation, and interventions/operations were abstracted. Categorical data were compared using Chi-square analysis or the Fisher exact test; continuous variables were compared using the Student t-test and the Mann-Whitney U-test., Results: Overall, 26% (19/73) of patients treated initially non-operatively required appendectomy prior to the electively scheduled date. There was no difference between responders (n = 54) and non-responders (n = 19) with respect to age, gender, initial WBC, percent bands, percent PMNs, or duration and type of presenting symptoms. However, responders were more likely to have a phlegmon on CT scan compared to non-responders (11/54 vs. 0/19, p = 0.03). Non-responders were twice as likely to undergo drainage of an abscess by interventional radiology (10/19 vs. 13/54, p = 0.02) compared to responders. Among all patients who required percutaneous drainage, the failure rate of non-operative management was 43% (10/23)., Conclusions: Children with perforated appendicitis can be managed effectively with nonoperative therapy, even in the presence of intra-abdominal abscesses. However, the need for abscess drainage increases the failure rate, perhaps due to inadequate source control. Those patients with a phlegmon on CT scan as opposed to an abscess, are most likely to respond to non-operative management. Initial non-operative therapy of perforated appendicitis in children is appropriate under certain clinical circumstances, especially when the body itself or interventional radiology can achieve adequate source control.

Background: Although the presence of a contrast blush (CB) on computed tomographic (CT) scan is associated with an increased failure rate of nonoperative management in adults with blunt splenic injury, little information is available for the pediatric population, where nonoperative management is the standard of care. Our aim was to determine whether the finding of CB on CT scan could predict failure of nonoperative therapy in children with blunt splenic injury., Methods: A retrospective analysis of 343 patients admitted with blunt splenic injury to our Level I pediatric trauma center over a 7-year period was performed. All CT scans were reviewed by a radiologist who was blinded to the patient outcome. We excluded 127 patients who either underwent immediate laparotomy without a CT scan or whose CT scans were unavailable at the time of this review. We divided the patients into two groups on the basis of the presence or absence of CB on the updated reading of the CT scan. Demographic variables analyzed included age, sex, mechanism of injury, Injury Severity Score, Glasgow Coma Scale score, initial hemoglobin and hematocrit, and emergency department pulse rate and systolic blood pressure. Outcome measures compared include length of stay, length of intensive care unit stay, the need for splenic intervention, and mortality. Continuous variables were compared using Student's t test for normally distributed data and the Mann-Whitney test for skewed data. Categorical data were compared using chi2 analysis or Fisher's exact test. Statistical significance was assigned to values of p < 0.05., Results: Among the study population (N = 216), 27 patients (12.5%) had CB on CT scan. Patients with CB had significantly lower hematocrit (p = 0.0004) and required operative intervention more frequently than those without CB (22% vs. 4%;p = 0.0008). Among patients with CB, mean pulse rate at presentation was higher in those that required splenic intervention (SI) (129 +/- 20.1) compared with those who underwent successful nonoperative therapy (100.4 +/- 23.1; p = 0.01). Only grade V injuries correlated with the need for laparotomy., Conclusion: Children with blunt splenic injury who have CB on CT scan are more likely to require SI than those without CB. However, because the majority of patients with CB did not require SI, in the absence of hemodynamic instability, this finding may be insufficient to determine the need for SI. CB is a specific marker of active bleeding that may predict the need for early splenic intervention in a specific subset of patients at presentation.

Background: Children with perforated appendicitis often have a prolonged hospital course complicated by surgical site or intra-abdominal infections. Treatment with multiple intravenous (IV) antibiotics after appendectomy has been the standard of care for these patients. We have recently adopted a protocol using piperacillin-tazobactam (PT) as a single agent in lieu of the standard multi-drug regimen (MD). We hypothesized that PT would be as effective as MD in reducing postoperative complications and would result in decreased resource utilization., Methods: We reviewed the medical records of all children admitted to our hospital between January 1, 1998 and December 31, 2001 with the diagnosis of perforated appendicitis. Patients who underwent operation within the first 24 h of admission were divided into two groups based on their antibiotic regimen: PT versus MD. Demographic data, duration of presenting symptoms, initial WBC, length of stay, and infectious complications were abstracted. Categorical data were compared using Chi square analysis; continuous variables were compared using Student's t-test when the data were normally distributed and the Mann-Whitney U test when the data were skewed., Results: There was no difference between the PT (n = 51) and MD (n = 43) groups with respect to age, duration of presenting symptoms, initial WBC, or length of hospital stay. However, patients in the MD group had a significantly higher overall complication rate than those in the PT group (14/43 vs. 4/51, p = 0.002). Antibiotic-related complications including surgical site infections, venous catheter-related infections, intra-abdominal abscesses, and drug reactions were also higher in the MD group (10/43 vs. 4/51, p = 0.04). The outpatient charges for each patient based on an average of seven days of home antibiotics were $2,460 for the PT group and $4,349 for the MD group., Conclusions: Children with perforated appendicitis can be managed effectively with a single broad-spectrum antibiotic after appendectomy. Monotherapy is not only more efficacious than multi-drug therapy, but may be more cost effective. The use of monotherapy for children with perforated appendicitis after adequate source control should be considered the treatment of choice.

Hirschsprung's disease is characterized by aganglionosis of the distal colon and hypertonicity of the anal sphincter. Endothelin receptor type B mutant (piebald) mice phenotypically resemble infants with Hirschsprung's disease in that these mice are susceptible to developing toxic megacolon because of the absence of ganglion cells in their distal colon. Therefore, we hypothesized that newborn piebald mice would have a higher resting anal sphincter pressure than would newborn wild-type mice. To test this hypothesis, we developed a reliable and reproducible technique for measuring the resting anal sphincter pressure in mice. Heterozygote breeding pairs of endothelin receptor type B mutant mice were purchased and bred in our animal facility. Pregnant, time-dated C57BL/6J mice provided control newborn mice. One-day-old newborn mice were evaluated for resting anal sphincter pressure. Under the operating microscope, a 24-gauge open-tip epidural catheter was placed into the anus until a deflection (approximately 3 to 5 mm) was noticed on a polygraph pressure monitor. Three consecutive measurements were obtained for each mouse. Mean values for each group were determined and compared using Student's t test. The resting anal sphincter pressure (mean +/- standard deviation) in newborn C57BL/6J mice was 13.3 +/- 2.6 mmHg, whereas that in piebald mice 22.7 +/- 2.5 mmHg (P < 0.0001). Therefore, because of their increased resting anal sphincter pressure, piebald mice may provide a useful animal model for the study of Hirschsprung's disease.

Patients with Crohn's disease are at risk for developing both internal and external fistulae. These can be asymptomatic incidental radiologic findings or causes of incontinence, chronic pain, abscesses, and sepsis. They can have a devastating impact on quality of life. Careful prospective studies of therapy are few in adult medicine and entirely lacking in the pediatric age group. Assessment and management require a coordinated effort between gastroenterologist, radiologist, and surgeon. Principles of management include surgical drainage of infection combined with medical therapy. Only infliximab has been studied in prospective, double-blinded fashion and clearly shown to be of use in the short term. There is good evidence that metronidazole may be useful acutely and that 6-mercaptopurine azathioprine may help to maintain closure. Diverting ostomies are of very limited value and corticosteroids seem to make matters worse. There are many other therapies that have been reported to be helpful in small, uncontrolled studies.

Since the first description by Frantz in 1959 of a papillary cystic tumor of the pancreas, solid pseudopapillary tumors have been increasing in incidence. However, management of these lesions remains controversial. Patients under the age of 20 years more often undergo local excision than do their older counterparts, resulting in increased recurrence rates. The cause of this discrepancy is not clear but may be related to an inability to make a definitive preoperative diagnosis. The authors report a case of a solid pseudopapillary tumor of the pancreas in a 13-year-old girl in which the diagnosis was established preoperatively by endoscopic ultrasound scan with fine-needle aspiration (EUS-FNA). EUS-FNA represents a diagnostic technique commonly used in adults that may be useful in identifying the rare pediatric patient with pancreatic malignancy., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Bacterial translocation (BT) may be a normal physiologic process that is important for mucosal antigen sampling in the gut. However, physiologic insults such as endotoxemia, hemorrhagic shock, or necrotizing enterocolitis (NEC) may lead to pathologic BT and thus contribute to the pathogenesis of nosocomial infection. The mechanism may involve accelerated enterocyte apoptosis at the intestinal villus apex resulting, at least transiently, in a "bare area" at the villus tip where bacteria can attach and traverse the epithelium. Evidence suggests that sustained upregulation of the inducible isoform of nitric oxide synthase (NOS-2) co-localizes with enterocyte apoptosis and immunoreactivity to 3-nitrotyrosine, the footprint of peroxynitrite (ONOO-), a potent oxidant formed by the reaction of nitric oxide (NO) with superoxide. We propose that the bare area at the villus apex is caused by apoptosis of enterocytes that have migrated from the base of the crypts to the villus apex and are shed into the intestinal lumen. These bare areas, and thus the degree of BT, may be the result of an imbalance between enterocyte proliferation and apoptosis. We postulate that normal enterocyte apoptosis is mediated by the caspase cascade, whereas enterocyte proliferation and differentiation in the crypt may be regulated by tyrosine kinase-dependent signaling pathways. Both of these cellular pathways may be influenced by overproduction of NO and its metabolite ONOO-. Therefore, sustained NO production and ONOO- formation occurring in inflammatory states may differentially accelerate apoptosis in the villus apex and/or inhibit proliferation at the base of the crypts resulting in expanded extrusion zones at the villus tip and accelerated BT.

Background: Sustained overproduction of nitric oxide and peroxynitrite (ONOO(-)) in conditions such as necrotizing enterocolitis and inflammatory bowel disease may promote gut barrier failure by inducing enterocyte apoptosis. NF-kappaB is upregulated in the gut during inflammation and, in addition to its proinflammatory effects, may upregulate protective or antiapoptotic factors such as inhibitor of apoptosis proteins (IAPs). We have previously demonstrated that NF-kappaB inhibition increases cytokine-induced enterocyte apoptosis; however, the effect of NF-kappaB on ONOO(-)-induced enterocyte apoptosis is unknown., Materials and Methods: Rat intestinal epithelial cells (IEC-6) were transfected with the adenoviral vector AdIkappaB or AdlacZ. AdIkappaB contains a mutated form of IkappaB which functions as a superrepressor of NF-kappaB. Cells were then treated with 50 microM ONOO(-) or decomposed ONOO(-). Apoptosis was then determined by flow cytometry with annexin V-FITC and propidium iodide staining. Caspase activation and IAP, Bcl-2, Bad, and Bax expression were examined using Western blot analysis, and NF-kappaB activation was determined via electrophoretic mobility shift assay (EMSA)., Results: Inhibition of NF-kappaB with AdIkappaB significantly enhanced ONOO(-)-induced apoptosis in IEC-6 cells. ONOO(-) treatment did not activate NF-kappaB in IEC-6 cells as determined by EMSA. There was no difference in IAP, Bcl-2, Bad, and Bax expression between nontransfected, AdlacZ-transfected, and AdIkappaB-transfected cells. Baseline procaspase 3 activation was increased in AdIkappaB-transfected cells., Conclusions: NF-kappaB inhibition enhances ONOO(-)-induced enterocyte apoptosis, suggesting that NF-kappaB upregulates a protective factor. This protective factor does not appear to be an IAP or Bcl-2 family member and may be expressed constitutively, since ONOO(-) did not activate NF-kappaB over baseline levels of activation.

Aminoguanidine (AG), a nitric oxide synthase (NOS) inhibitor, has been widely used to study the role of inducible NOS (iNOS) in host defense against infections caused by various pathogens including Salmonella typhimurium. iNOS has been reported to play an important role in host defense against S. typhimurium infection both in vitro and in vivo. In this report we show those AG treatment lead to weight loss in both wild-type and iNOS knockout mice, and rendered them more susceptible to Salmonella infection. These results suggest that AG may have side effects other than the inhibition of iNOS, and that data obtained from studies using AG should be interpreted with caution.

Background/purpose: The authors have shown previously that surgical specimens from infants with acute necrotizing enterocolitis (NEC) show upregulation of inducible nitric oxide (NO) synthase (iNOS) and interferon-gamma mRNA. However, the contribution of other inflammatory cytokines such as interleukin-8 (IL-8), IL-11, and IL-12 has not been defined. Likewise, the role of GTP-cyclohydrolase, the rate-limiting enzyme in tetrahydrobiopterin synthesis, and thus NO production by iNOS is unclear. In this study, the authors sought to further define the pattern of cytokine expression seen in infants with acute NEC., Methods: The authors measured intestinal cytokine mRNA expression by semiquantitative reverse transcriptase polymerase chain reaction in 21 infants with histologically confirmed NEC, 18 with other inflammatory conditions, and in 9 patients without intestinal inflammation. Guanosine triphosphate-cyclohydrolase (GTP-CH) activity was measured by specific enzyme assay. Univariate exact logistic regression analysis was performed to identify predictors of outcome., Results: IL-8 and IL-11 mRNA were upregulated in patients with acute NEC compared with those with other inflammatory conditions or those without disease; these levels returned to baseline at the time of stoma closure. Increased IL-11 mRNA decreased the likelihood of pan-necrosis (odds ratio, 0.93; P =.002). Increased IL-12 levels (but not IL-8) seemed to protect against pan-necrosis (odds ratio, 0.70; P =.06)., Conclusions: Local upregulation of IL-11 may represent an adaptive response designed to limit the extent of intestinal damage in NEC. Decreased IL-12 levels may contribute to the pathogenesis of NEC by allowing bacteria to escape host defenses., (Copyright 2001 by W.B. Saunders Company.)

Background/purpose: Injuries that occur around the driveway are not typically regarded as reportable to the police and thus are often underrecognized. The aim of this study was to characterize the pattern and consequences of motor vehicle collisions that occur in the driveway., Methods: Over the past 13 years, 64 patients admitted to the Children's Hospital of Pittsburgh sustained motor vehicle-related injuries in a driveway. These injuries resulted from a vehicle driven by an adult driver striking a child (group 1) or a child shifting an idle vehicle out of gear (group 2). We compared demographic variables and outcome measures between the 2 groups., Results: There was no difference in gender, injury pattern, Injury Severity Score, length of stay, or operations performed between the groups. Patients in group 1 were younger, smaller, had a lower Glasgow Coma Scale, and had poorer outcomes. The majority of collisions (~65%) in group 1 resulted from a truck or sport-utility vehicle going in reverse., Conclusions: Younger children are more severely injured in driveway-related crashes, which are most likely to be caused by a truck or sport-utility vehicle going in reverse. These vehicles should be equipped with additional safety features such as extended mirrors to visualize small children.

Sustained upregulation of inducible nitric oxide (NO) synthase in the liver after endotoxin [lipopolysaccharide (LPS)] challenge may result in hepatocellular injury. We hypothesized that administration of a NO scavenger, NOX, may attenuate LPS-induced hepatocellular injury. Sprague-Dawley rats received NOX or saline via subcutaneous osmotic pumps, followed 18 h later by LPS challenge. Hepatocellular injury was assessed using biochemical assays, light, and transmission electron microscopy (TEM). Interleukin (IL)-6 mRNA was measured by RT-PCR. Tumor necrosis factor (TNF)-alpha protein expression was determined by immunohistochemistry. NOX significantly reduced serum levels of ornithine carbamoyltransferase and aspartate aminotransferase. TNF-alpha and IL-6 expression were increased in the livers of saline-treated but not NOX-treated rats. Although there was no difference between groups by light microscopy, TEM revealed obliteration of the space of Disse in saline-treated but not in NOX-treated animals. Electron paramagnetic resonance showed the characteristic mononitrosyl complex in NOX-treated rats. We conclude that NOX reduces hepatocellular injury after endotoxemia. NOX may be useful in the management of hepatic dysfunction secondary to sepsis or other diseases associated with excessive NO production.

Background: Necrotizing enterocolitis (NEC) is the most frequent and lethal disease that affects the gastrointestinal tract of the premature infant. Controversy persists as to the most appropriate management once the diagnosis is confirmed., Methods: Review of the pertinent medical literature., Results: The incidence of NEC is increasing, but the survival rate is not. Initial management of NEC consists of bowel rest, orogastric decompression, intravenous hydration, and broad-spectrum antibiotics; surgical intervention is typically reserved for infants with advanced disease or evidence of intestinal perforation. There is no consensus in the literature regarding the optimal treatment strategy for patients who require surgical intervention. There exists a lack of randomized trials comparing definitive intestinal resection with or without primary anastomosis, intestinal diversion with limited resection, or peritoneal drainage without resection., Conclusion: An individualized approach must be taken to achieve optimum survival for patients with NEC. Isolated perforation, in our opinion, is best managed with resection and enterostomy, whereas pan-intestinal involvement is best managed with proximal diversion alone.