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Introduction : Umbilical access in laparoscopic surgery has been cited as a factor for increased complications in low-birth-weight infants and those less than three months old. In a previous series, 10.6% of pediatric surgeons reported complications in this population associated with umbilical access, citing carbon dioxide (CO2) embolism as the most common complication. To further examine the safety of this technique, we report our outcomes with blunt transumbilical laparoscopic access at our institution over four years. Methods : A retrospective review was performed of patients less than three months of age who underwent laparoscopic pyloromyotomy or inguinal hernia repair from 2016-2019. Operative reports, anesthesia records, and postoperative documentation were reviewed for complications related to umbilical access. Complications included bowel injury, vascular injury, umbilical vein cannulation, CO2 embolism, umbilical surgical site infection (SSI), umbilical hernia requiring repair, and death. Results : Of 365 patients, 246 underwent laparoscopic pyloromyotomy, and 119 underwent laparoscopic inguinal hernia repairs. Median age at operation was 5.9 weeks [4.3,8.8], and median weight was 3.9 kg [3.4,4.6]. Nine complications (2.5%) occurred: 5 umbilical SSIs (1.4%), 1 bowel injury upon entry requiring laparoscopic repair (0.2%), 1 incisional hernia repair 22 days postoperatively (0.2%), and 2 cases of hypotension and bradycardia upon insufflation that resolved with desufflation (0.5%). There were no intraoperative mortalities or signs/symptoms of CO2 embolism. Conclusion : In this series, umbilical access for laparoscopic surgery in neonates less than three months of age was safe, with minimal complications. Although concern for umbilical vessel injury, cannulation, and CO2 embolism exists, these complications are not exclusively associated with umbilical access technique.

Introduction Botulinum toxin (BT) injections may play a role in preventing Hirschsprung associated enterocolitis (HAEC) episodes related to internal anal sphincter (IAS dysfunction). Our aim was to determine the association of outpatient BT injections for early obstructive symptoms on the development of HAEC. Methods A retrospective review of children who underwent definitive surgery for Hirschsprung disease (HSCR) from July 2010 – July 2020 was performed. The timing from pull-through to first HAEC episode and to first BT injection was recorded. Primary analysis focused on the rate of HAEC episodes and timing between episodes in patients who did and did not receive BT injections. Results Eighty patients were included. Sixty patients (75%) were male, 15 (19%) were diagnosed with trisomy 21, and 58 (72.5%) had short-segment disease. The median time to pull-through was 150 days (IQR 16, 132). Eight patients (10%) had neither an episode of HAEC or BT injections and were not included in further analysis. Forty-six patients (64%) experienced at least one episode of HAEC, while 64 patients (89%) had at least one outpatient BT injection. Compared to patients who never received BT injections (n = 9) and those who developed HAEC prior to BT injections (n = 35), significantly fewer patients who received BT injections first (n = 28) developed enterocolitis (P Conclusion Outpatient BT is associated with decreased episodes of HAEC and increased interval between HAEC episodes requiring inpatient treatment. Scheduling outpatient BT injections to manage obstructive symptoms may be beneficial after pull-through for HSCR.

Purpose COVID-19 has prompted significant policy change, with critical attention to the conservation of personal protective equipment (PPE). An extended surgical mask use policy was implemented at our institution, allowing use of one disposable mask per each individual, per day, for all the cases. We investigate the clinical impact of this policy change and its effect on the rate of 30-day surgical site infection (SSI). Methods A single-institution retrospective review was performed for all the elective pediatric general surgery cases performed pre-COVID from August 2019 to October 2019 and under the extended mask use policy from August 2020 to October 2020. Procedure type, SSI within 30 days, and postoperative interventions were recorded. Results Four hundred and eighty-eight cases were reviewed: 240 in the pre-COVID-19 cohort and 248 in the extended surgical mask use cohort. Three SSIs were identified in the 2019 cohort, and two in the 2020 cohort. All postoperative infections were superficial and resolved within 1 month of diagnosis with oral antibiotics. There were no deep space infections, readmissions, or infections requiring re-operation. Conclusion Extended surgical mask use was not associated with increased SSI in this series of pediatric general surgery cases and may be considered an effective and safe strategy for resource conservation with minimal clinical impact.

Introduction There are many described technique to performing laparoscopic inguinal hernia repair in children. We describe our outcomes using a percutaneous internal ring suturing technique. Methods A retrospective review of patients under 18 years old who underwent repair between January 2014 - March 2019 was performed. A percutaneous internal ring suturing technique, involving hydro-dissection of the peritoneum, percutaneous suture passage, and cauterization of the peritoneum in the sac prior to high ligation, was used. p Results 791 patients were included. The median age at operation was 1.9 years (IQR 0.37, 5.82). The median operative time for a unilateral repair was 21 min (IQR 16, 28), while the median time for a bilateral repair was 30.5 min (IQR 23, 41). In total, 3 patients required conversion to an open procedure (0.4%), 4 (0.6%) experienced post-operative bleeding, 9 (1.2%) developed a wound infection, and iatrogenic ascent of testis occurred in 10 (1.3%) patients. Twenty patients (2.5%) developed a recurrent hernia. All but two were re-repaired laparoscopically. Conclusions The use of percutaneous internal ring suturing for laparoscopic repair of inguinal hernias in the pediatric population is safe and effective with a low rate of complications and recurrence.

Background The use of laparoscopy in the repair of duodenal atresia has been increasing. However, there is no consensus regarding which surgical approach has better outcomes. We aimed to compare the different surgical approaches and types of anastomoses for duodenal atresia repair. Methods Patients who underwent duodenal atresia repair at a single pediatric center were identified between January 2006 and June 2022. Those with concomitant gastrointestinal anomalies or who required other simultaneous operations were excluded. The primary outcome was rate of complications, defined as rate of leak, stricture, and re-operation by surgical approach and technique of anastomosis. Results A total of 78 patients were included. The majority were female (51.3%, n = 40), with a median age of 4 days (IQR 3.0,8.0) and a median weight of 2.7 kg (IQR 2.2,3.3) at repair. The re-operation rate was 7.7% (n = 6), of which two were anastomotic leaks, and four were anastomotic strictures. The leak rate was 5.6% (n = 1/18) for the open handsewn and 4.8% (n = 1/21) for the laparoscopic handsewn technique. The stricture rate was 12.5% (n = 1/8) for the laparoscopic-assisted handsewn, 9.1% (n = 2/22) for the laparoscopic U-clip, 4.8% (n = 1/21) for the laparoscopic handsewn, and none with laparoscopic stapled and laparoscopic converted to open handsewn techniques. No differences were found in complication rate when controlling for surgical approach. Conclusion The method of surgical approach did not affect the outcomes or complications in the repair of duodenal atresia.

Background Initial treatment of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Our aim was to describe the protocol and subsequent outcomes. Methods We conducted a single-center retrospective review of patients diagnosed with HPS from 2016 to 2023. All patients were given ad libitum feeds postoperatively and discharged home after tolerating three consecutive feeds. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the number of preoperative labs drawn, time from arrival to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate. Results The study included 333 patients. A total of 142 patients (42.6%) had electrolytic disturbances that required fluid boluses in addition to 1.5x maintenance fluids. The median number of lab draws was 1 (IQR 1,2), with a median time from arrival to surgery of 19.5 hours (IQR 15.3,24.9). The median time from surgery to first and full feed was 1.9 hours (IQR 1.2,2.7) and 11.2 hours (IQR 6.4,18.3), respectively. Patients had a median postoperative LOS of 21.8 hours (IQR 9.7,28.9). Re-admission rate within the first 30 postoperative days was 3.6% ( n = 12) with 2.7% of re-admissions occurring within 72 hours of discharge. One patient required re-operation due to an incomplete pyloromyotomy. Discussion This protocol is a valuable tool for perioperative and postoperative management of patients with HPS while minimizing uncomfortable intervention.

Patients with Hirschsprung's disease (HSCR) remain at risk of developing Hirschsprung-associated enterocolitis (HAEC) after surgical intervention. As inpatient management remains variable, our institution implemented an algorithm directed at standardizing treatment practices. This study aimed to compare the outcomes of patients pre- and post-algorithm. A retrospective review of patients admitted for HAEC was performed; January 2017–June 2018 encompassed the pre-implementation period, and October 2018–October 2019 was the post-implementation period. Demographics and outcomes were compared between the two groups. Sixty-two episodes of HAEC occurred in 27 patients during the entire study period. Sixteen patients (59%) had more than one episode. The most common levels of the transition zone were the rectosigmoid (50%) and descending colon (27%). Following algorithm implementation, the median length of stay (2 vs. 7 days, p

Background Operative approaches for superior mesenteric artery syndrome (SMAS) vary from Roux-en-Y duodenojejunostomy to the more conservative division of the ligament of Treitz with inferior duodenal derotation known as the Strong procedure. We sought to examine outcomes following a modified version of Strong procedure where the duodenum is lowered as opposed to derotated for the management of SMAS. Materials and methods We conducted a retrospective chart review of children who underwent surgical management of SMAS between January 2008 and December 2017. An online survey regarding symptom resolution, feeding practices, and the need for additional procedures was distributed. Data are reported as medians with interquartile range (IQR) and proportions as percentages. Results Seven patients with a median age of 15 y (IQR 8, 16) and median body mass index of 16.9 (IQR, 12.6, 22.1) were included. Presenting symptoms included pain (71%), nausea (57%), and vomiting (43%). Six patients initially underwent duodenal lowering, whereas one patient underwent duodenoduodenostomy. One patient underwent adhesiolysis for bowel obstruction in the early postoperative period. All patients had symptom resolution at a postoperative follow-up of 22 d (IQR, 15, 45). Two patients had symptom recurrence, and one patient required reoperation. Six patients completed the survey at a median of 2.3 y (IQR, 1.7, 3.2) postoperatively, of which four underwent duodenal lowering. Of these, 75% (n = 3) were asymptomatic. One patient with recurrence reported occasional nausea and emesis but has not required additional surgery. Conclusions Release of the ligament of Treitz with duodenal lowering results in resolution of symptoms in 75% of patients. This operative approach may be considered before performing more complex operations for SMAS.

We report the findings of a three-year prospective observational study elucidating long-term symptoms and complications of patients who underwent minimally invasive pectus excavatum repair with intercostal nerve cryoablation with specific attention to postoperative pain control associated with the cryoablation technique.Surveys were administered to patients who underwent bar placement for pectus excavatum with intercostal nerve cryoablation from 2017 to 2021 regarding pain scores, pain medication usage, and limitations to activity beginning on the day of surgery, on the day of discharge, and at two-week and three-month follow-up.Of 110 patients, forty-eight (44%) completed the discharge survey; sharp pain and pressure on the first postoperative night were the most described pain characteristics, most frequently in the middle of the chest. On follow-up, 55% of patients reported tolerable residual pain at two weeks and 41% at three months, with 25% requiring intermittent pain medication at three months. There were three readmissions for inadequate pain control and 110 calls to the surgery clinic by three-month follow-up, most commonly for persistent pain and frequent popping sensation with movement.Although cryoablation is an excellent pain control modality, these data suggest that patients underreport functional symptoms and experience more frequent discomfort and alteration of daily living activities.

Objectives With the rise of antibiotic resistance, the use of prophylactic preoperative antibiotics (PPA) has been questioned in cases with low rates of surgical site infection (SSI). We report PPA usage and SSI rates after elective laparoscopic cholecystectomy at our institution. Materials and Methods A retrospective review of children younger than 18 years who underwent elective outpatient laparoscopic cholecystectomy between July 2010 and August 2020 was performed. Demographic, preoperative work-up, antibiotic use, intraoperative characteristics, and SSI data were collected via chart review. SSI was defined as clinical signs of infection that required antibiotics within 30 days of surgery. Results A total of 502 patients met the inclusion criteria; 50% were preoperatively diagnosed with symptomatic cholelithiasis, 47% with biliary dyskinesia, 2% with hyperkinetic gallbladder, and 1% with gallbladder polyp(s). The majority were female (78%) and Caucasian (80%). In total, 60% (n = 301) of patients received PPA, while 40% (n = 201) did not; 1.3% (n = 4) of those who received PPA developed SSI, compared with 5.5% (n = 11) of those who did not receive PPA (p = 0.01). Though PPA use was associated with a 77% reduction in the risk of SSI in multivariate analysis (p = 0.01), all SSIs were superficial. One child required readmission for intravenous antibiotics, while the remainder were treated with outpatient antibiotics. Gender, age, body mass index, ethnicity, and preoperative diagnosis did not influence the likelihood of receiving PPA. Conclusion Given the relatively low morbidity of the superficial SSI, conservative use of PPA is advised to avoid contributing to antibiotic resistance.

We previously developed an institutional, evidence-based fluid resuscitation protocol for neonates with infantile hypertrophic pyloric stenosis (HPS) based on the severity of electrolyte derangement on presentation. We aim to evaluate this protocol to determine its efficacy in reducing the number of preoperative lab draws, time to electrolyte correction, and overall length of stay.A single center, retrospective review of 319 infants with HPS presenting with electrolyte derangement from 2008 to 2020 was performed; 202 patients managed pre-protocol (2008-2014) and 117 patients managed per our institutional fluid resuscitation algorithm (2016-2020). The number of preoperative lab draws, time to electrolyte correction, and length of stay before and after protocol implementation was recorded.Use of a fluid resuscitation algorithm decreased the number of infants who required four or more preoperative lab draws (20% vs. 6%) (p .01), decreased median time to electrolyte correction between the pre and post protocol cohorts (15.1 h [10.6, 22.3] vs. 11.9 h [8.5, 17.9]) (p .01), and decreased total length of hospital stay (49.0 h [40.3, 70.7] vs. 45.7 h [34.3, 65.9]) (p .05).Implementation of a fluid resuscitation algorithm for patients presenting with hypertrophic pyloric stenosis decreases the frequency of preoperative lab draws, time to electrolyte correction, and total length of hospital stay. Use of a fluid resuscitation protocol may decrease discomfort through fewer preoperative lab draws and shorter length of stay while setting clear expectations and planned intervention for parents.III - Retrospective comparative study.

Osteogenesis imperfecta (OI) is a genetic disorder of collagen resulting in a “fragile” skeleton with increased fracture risk and other complications, dependent on the specific variant. Pectus deformities of the chest wall, while not common, can be associated with OI. The use of a pectus carinatum brace in a patient with OI poses unknown risks for fractures and adverse treatment outcomes. We successfully applied external compression bracing using the dynamic compression system to one such patient. This case illustrates the ability to treat an OI patient with pectus carinatum using a nonsurgical brace, without complications, resulting in an excellent cosmetic result.

Introduction: Longstanding gastrostomy sites are prone to leakage and excoriation secondary to protrusion of gastric mucosa into the tract, dilation of the site over time, and development of refractory granulation tissue. Surgical revision with creation of a new gastric and skin exit site can be difficult. We describe a technique to re-site a gastrostomy tube (GT) utilizing the existing GT site. Materials and methods: For one patient with gastrostomy site refractory complications, we re-sited the GT using the existing site. A clamp was placed through the old GT site and was palpated through the abdominal wall. An incision over the tip was made and a silk tie was passed from this new site, exiting through the old site. A One-step™ device was then pulled from the old site out through the new site, and closure of the old gastrostomy was performed. Results: The procedure took approximately 40 min to complete. Oral and GT intake was started within 3 hours. There were no intra- or post-operative complications. The patient was discharged home the same day. Conclusion: This simple technique allows for revision of a gastrostomy tube without the use of laparoscopy and permits a cosmetically pleasing incision. Keywords: Gastrostomy tube, Gastrostomy site revision, Revision

Esophageal diverticula in the pediatric population are rare. The etiologies and presentations can vary widely which can make it difficult to diagnose without imaging or direct visualization. We are reporting a case of a 14-year-old male with history of asthma, anorexia, weight loss, and chest discomfort. CXR findings of mediastinal widening prompted a more extensive evaluation. He was found to have two esophageal diverticula, phlegmonous changes, and osteomyelitis of the T5 and T6 vertebra. He was initially treated with IV antibiotic therapy, bypassing the affected area with nasogastric enteric tube feedings, and a cervical thoracic orthosis brace for spine stability. He regained his lost weight and became asymptomatic, returning to a regular diet. The family has declined to pursue surgical intervention at present.

Penile adhesions are the most common complication after circumcision, although strategies to decrease them are poorly studied. We conducted a prospective, randomized trial comparing the use of 2-octyl cyanoacrylate (glue) skin adhesive to hydrophobic ointment after circumcision.Patients7years old undergoing circumcision were randomized to glue around the sutures and corona of the penis or antibiotic ointment. The primary outcome variable was postoperative penile adhesions. Utilizing a power of 0.8 and an alpha of 0.05, 168 patients were calculated for each arm. Because of high attrition, we planned to include up to 500 patients. Presence/absence of adhesions was evaluated 2-4weeks postop. Parents subjectively scored happiness, comfort, distress, and concern on a Likert scale 1-5.From 11/2012 through 7/2016, 409 patients were enrolled. Adhesion data were available on 243 patients. There was no difference between glue (16.8%) and those with antibiotic ointment (15.2%) (p=0.88) or in parental satisfaction across all areas measured. 165 patients were lost to follow-up, evenly distributed between the two groups (38% vs. 42%, p=0.49).The placement of 2-octyl cyanoacrylate skin adhesive does not decrease the rate of postoperative penile adhesions after circumcision. Parent satisfaction outcomes are similar.Treatment study.Level II.

The diagnosis and exclusion of appendicitis continues to be 1 of the primary concerns of providers who care for children with abdominal pain. Jennings et al,1 from the Seattle Children’s Hospital, adopted a statistical model to analyze the most cost-effective approach to a common and age-old problem: the diagnosis of pediatric appendicitis. Specifically, 10 imaging strategies were modeled, using differing previous probabilities (a la Bayes’ theorem) of appendicitis.2 A “Goldilocks” prevalence of the disease (neither too little nor too much) was reasonably assumed: 16% to 67% in this case. The most cost-effective (cost per quality-adjusted life-years gained) approach was then an initial ultrasound followed by a computed tomographic scan only if the appendix was not visualized and secondary signs of appendicitis (periappendiceal fluid collections, free fluid, hyperemia, fat stranding, bowel wall edema, or … Address correspondence to Rebecca M. Rentea, MD, Department of Pediatric Surgery, Children’s Mercy Hospital Kansas City, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: rrentea{at}cmh.edu

Purpose Needs assessment is a critical component of educational program design. Follow-up is important for improvement. Two electronic educational programs, Exam-based Pediatric surgery Educational Reference Tool (ExPERT) and Pediatric Surgery Not a Textbook (NaT), offered by the American Pediatric Surgical Association (APSA) have been functional for over three years, allowing for follow-up assessment. Methods A 22-question survey was distributed via email to APSA members. Questions included practice demographics, learning preferences and APSA material use. Mann–Whitney analysis was performed (p Results 294 members responded. 43% were in academic practice with a pediatric surgery fellowship. Top preferences for obtaining/maintaining medical knowledge were national meetings (27%), ExPERT (24%), and the NaT (20%). Comparatively, in a 2014 assessment, electronic programs were less desired (16%). Cost was cited by > 1/3 for not subscribing to ExPERT or NaT. Question discussions were often read regardless of response. > 86% would subscribe to APSA resources if there were no CME requirement. The most frequently cited knowledge gap was fetal therapy (30%). Conclusions This is the first publication documenting increased acceptance of electronic educational platforms for pediatric surgeons. Well-utilized and valued, the data justify and encourage continued development of electronic educational resources. Room for improvement exists in affordability, knowledge gaps, and individualizing curriculum development. Level of evidence IV

Introduction: Children with pectus carinatum (PC) are particularly vulnerable to psychosocial effects of poor body image, even though they may not experience physical symptoms. Nonoperativ...

Pain following bar placement for pectus excavatum is the dominant factor post-operatively and determines length of stay (LOS). We recently adopted intercostal cryoablation as our preferred method of pain control following minimally invasive pectus excavatum repair. We compared the outcomes of cryoablation to results of a recently concluded trial of epidural (EPI) and patient-controlled analgesia (PCA) protocols.We conducted a prospective observational study of patients undergoing bar placement for pectus excavatum using intercostal cryoablation. Results are reported and compared with those of a randomized trial comparing EPI with PCA. Comparisons of medians were performed using Kruskal-Wallis H tests with alpha 0.05.Thirty-five patients were treated with cryoablation compared to 32 epidural and 33 PCA patients from the trial. Cryoablation was associated with longer operating time (101 min, versus 58 and 57 min for epidural and PCA groups, p 0.01), resulted in less time to pain control with oral medication (21 h, versus 72 and 67 h, p 0.01), and decreased LOS (1 day, versus 4.3 and 4.2 days, p 0.01).Intercostal cryoablation during minimally invasive pectus excavatum repair reduces LOS and perioperative opioid consumption compared with both EPI and PCA.II.

Background Laparoscopic gastrostomy is a common procedure in children. We developed a same-day discharge (SDD) protocol for laparoscopic button gastrostomy. Methods We performed a prospective observational study of children undergoing laparoscopic button gastrostomy and were eligible for SDD from August 2017–September 2019. Patients were eligible if: 1) the family was comfortable with eliminating overnight admission and were suitable candidates for outpatient surgery (absence of major co-morbidities), 2) they were not undergoing additional procedures requiring admission, and 3) they received pre-operative education. Results Sixty-two patients who underwent laparoscopic button gastrostomy were eligible for SDD. The median age was 2.1 years [IQR 0.9–4.1], and the median weight was 10.5 kg [IQR 7.6–15.5]. Forty-one (66%) were previously nasogastric fed. The median operative time was 22 min [IQR 16–29]. The median time to initiation of feeds was 4.4 h [IQR 3.4–5.5]. Fifty-one (82%) were discharged the same day with a median length of stay of 9 h [IQR 7–10]. Eleven were admitted, most commonly for further teaching. Eleven SDD patients were seen in the emergency room Conclusion Same-day discharge following laparoscopic gastrostomy is safe and feasible for select pediatric patients who undergo pre-operative education. The SDD pathway results in a low admission rate and relatively low ER visits. Type of study Prospective Observational Study. Level of Evidence Level II.

Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains one of the most common operations performed in children. The advent of data-driven medicine has led to questions about every aspect of the operation-whether appendectomy is even necessary, when it should be performed (timing), how the procedure is done (laparoscopic variants versus open and irrigation versus no irrigation), length of hospital stay, and antibiotic duration. The goal of this analysis is to review the current status of, and available data regarding, the surgical management of appendicitis in children.

Literature reports worse outcomes for operations performed during off-hours. As this has not been studied in pediatric extracorporeal life support (ECLS), we compared complications based on the timing of cannulation..This is a retrospective review of 176 pediatric ECLS patients between 2004 and 2015. Patients cannulated during daytime hours (7:00 A.M. to 7:00 P.M., M-F) were compared to off-hours (nighttime or weekend) using t-test and Chi-square.The most common indications for ECLS were congenital diaphragmatic hernia (33 %) and persistent pulmonary hypertension (23 %). When comparing regular hours (40 %) to off-hours cannulation (60 %), there were no significant differences in central nervous system complications, hemorrhage (extra-cranial), cannula repositioning, conversion from venovenous to venoarterial, mortality on ECLS, or survival-to-discharge. The overall complication rate was slightly lower in the off-hours group (45.7 % versus 61.9 %, P = 0.034).Outcomes were not significantly worse for patients undergoing ELCS cannulation during off-hours compared to normal weekday working hours.

Importance Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction. Objective To review the current spectrum, potential strategies, and implementation process of telemedicine in pediatric surgery. Design Review and opinion design. Setting n/a. Participants n/a. Main outcomes and measures n/a. Results n/a. Conclusions and relevance Telemedicine is an emerging approach with the potential to facilitate efficient, cost-effective delivery of pediatric surgical services. Brief Abstract Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction. The objectives of this review are to explore common terms in telemedicine, provide an overview of current legislative and billing guidelines, review the current state of telemedicine in surgery and pediatric surgery, and provide basic themes for successful implementation of a pediatric surgical telemedicine program. Type of Study Review. Level of Evidence Level V.

Intraabdominal testes that lack sufficient vessel length to perform an orchiopexy require division of the testicular vessels. Historically, the vessels are divided at the initial operation, and the orchiopexy is then performed as a two-stage procedure with the assumption for the development of neovascularization along the vas deferens during the interim. Recent reports suggest the orchiopexy may be performed primarily at the time of vessel division. However, these strategies have not been prospectively compared. Therefore, we conducted a randomized pilot trial to examine the role for a larger comparative study.After Internal Review Board approval, all patients undergoing laparoscopic orchiopexy for a nonpalpable testis were considered for enrollment. This study was designed as a pilot study to evaluate testicular survival at 6 months of follow-up. After consent was obtained, computer randomization was used to determine a primary or two-stage orchiopexy. All procedures were performed by five surgeons, and allotment had no affect on surgeon selection.Between October 2007 and September 2013, 112 patients were enrolled in the study. Twenty-seven patients (14 primary and 13 two-stage) met criteria for randomization based on inability to bring the testis to the contralateral internal ring. There was no difference in the approach among surgeons. Mean operative time and cost significantly favored the primary approach, and testicular survival rates were the same.Based on the data in our pilot study, approximately 70% of patients with a nonpalpable testis will not require vascular division. This study suggests that when vascular division is required, the primary orchiopexy may be equivalent to the traditional two-stage procedure with regard to testicular survival and superior to the two stage in total operative time and charges. These data provide evidence for sufficient equipoise to proceed with the development of a large multi-institutional trial comparing these two approaches.

Background We conducted a randomized trial comparing 1 and 2-stage laparoscopic orchiopexy for intra-abdominal testes. During recruitment, it became apparent that most patients with non-palpable testes do not require vascular division. In this report, we outline the location and quality of testes found during operative exploration in patients who consented for the study but were not randomized. Methods Analysis was performed on 80 patients undergoing operative exploration for non-palpable testes between 2007 and 2014. The location and pathology of undescended testes were analyzed. Results There were 87 preoperative non-palpable testes in 80 patients that were consented but not randomized to 1 or 2 stage orchiopexy with vascular division. Forty (46%) of nonrandomized testes were atrophic or absent, and 47 (54%) were normal in appearance. Sixty eight testes were evaluated via laparoscopy. The most common location for normal (81%) and absent/atrophic (70%) testes was the inguinal canal. Atrophic testes were more often left sided (72.5%) with normal testes equally divided. Patients with atrophic or absent testicles were more likely to have a closed internal ring (p Conclusion This study demonstrates the majority of patients undergoing operative exploration for non-palpable testes will not require vascular division, and instead would be either atrophic or able to undergo traditional orchiopexy. Level of Evidence: III

Objective Bracing for pectus carinatum (PC) has emerged as an alternative to surgical correction. However, predictive factors for bracing remain poorly understood, as much of the data have been reported from small series. Materials and Methods We reviewed a prospective dataset in patients with PC who underwent dynamic compression bracing (DCB) from July 2011 to July 2016. Bracing was initiated in patients > 10 years of age with a significant PC and desire for bracing. Data were analyzed for those observed two or more times after the brace was fitted to the patient. Results A total of 503 patients were evaluated for PC and 340 (68%) underwent DCB. Eighty-five percent were males with an average age of 14 ± 2 years. There was a positive correlation of age with pressure of initial correction (PIC, r = 0.2). One patient underwent operative correction as the initial therapy. Two hundred seventeen patients had two or more visits after the patient was fitted for the brace. The mean PIC in this cohort was 4 psi (range: 1.5–7.8), and the median duration of bracing in this group was 16 months (IQR: 7–23 months). One hundred three patients (47%) achieved complete correction after an average bracing time of 7.5 months and were then placed in the retainer mode. Thirty patients successfully completed bracing therapy and required an average of 23 months of therapy (2 months–4 years). No patient recurred after bracing was completed, but one failed bracing and required operative correction. Complications included mechanical problems (8%), skin complications (10%), complaints of tightness (3%), and pain (2%). Conclusion DCB has both early and lasting effects in the correction of PC with minimal complications. Predictive factors for successful resolution of the PC include increased duration of DCB and lower initial PIC.

* Abbreviations: ED — : emergency department NOM — : nonoperative management The current standard of care for children with acute uncomplicated appendicitis is a 30-minute, minimally invasive operation that is frequently done on an outpatient basis. The risk of operative complications is small and it is unlikely that patients will develop long-term problems related to appendicitis. Therefore, the alternative approach, nonoperative management (NOM) of appendicitis faces an uphill battle to establish noninferiority when compared to surgical management. In this timely study, Bachur et al1 reviewed data from the Pediatric Health Information System database over nearly 7 years, identifying 4190 children who met the following criteria for NOM: an emergency department (ED) visit with the diagnostic code for uncomplicated acute appendicitis, treatment with antibiotics, no procedure codes for appendectomy during the index visit, and no history of a previous appendectomy or appendicitis in the past year. The comparison group of 61 522 children had a diagnostic code for uncomplicated acute appendicitis … Address correspondence to Charles L. Snyder, MD, Department of Surgery, Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: csnyder{at}cmh.edu

Emergency department (ED) visits and hospital readmissions are common after gastrostomy tube (GT) placement in children. We sought to characterize interhospital variation in revisit rates and explore the association between this outcome and hospital-specific GT case volume.We conducted a retrospective cohort study from 38 hospitals using the Pediatric Health Information System database. Patients younger than 18 years who had a GT placed in 2010 to 2012 were assessed for a GT-related (mechanical or infectious) ED visit or inpatient readmission at 30 and 90 days after discharge from GT placement. Risk-adjusted rates were calculated using generalized linear mixed-effects models accounting for hospital clustering and relevant demographic and clinical attributes, then compared across hospitals.A total of 15,642 patients were included. A median of 468 GTs were placed in all the 38 hospitals during 3 years (range: 83-891), with a median of 11.4 GT placed per 1000 discharges (range: 2.4-16.7). Median ED visit for each hospital at 30 days after discharge was 8.2% (range: 3.7%-17.2%) and 14.8% at 90 days (range: 6.3%-26.1%). Median inpatient readmissions for each hospital at 30 days after discharge was 3.5% (range: 0.5%-10.5%) and 5.9% at 90 days (range: 1.0%-18.5%). Hospital-specific GT placement per 1000 discharges (rate of GT placement) was inversely correlated with ED visit rates at 30 (P = 0.007) and 90 days (P = 0.020). The adjusted 30- and 90-day readmission rate and the adjusted 30- and 90-day ED return rates decreased with increasing GT insertion rate (P 0.001).Higher hospital GT insertion rates are associated with lower ED revisit rates but not inpatient readmissions.

Purpose Pathologic evaluation of the appendix after appendectomy is routine and can identify unexpected findings. We evaluated our experience in children undergoing appendectomy to review the clinical course of patients with unexpected appendiceal pathology. Methods After IRB approval, a retrospective review was conducted on patients who underwent appendectomy from January 1, 1995 to March 1, 2011. Patient demographics, diagnosis, pathological findings, disease outcomes, and treatment were collected only on patients with abnormal pathology. Results 3602 patients underwent appendectomy . 113 patients had normal appendices, and 86 patients had unexpected findings, including carcinoid tumor (n=9), pinworm (n=34), granuloma (n=14), eosinophilic infiltrates (n=18), and other (n=11). All cases of carcinoid tumor were completely resected, with no recurrence or need for reoperation. Of the 34 patients with pinworm infestation, 41.2% underwent antimicrobial therapy, and none had post-operative symptoms. One patient (7%) with an appendiceal granuloma developed Crohn's disease. Three patients (16.7%) with eosinophilia developed symptomatic intestinal eosinophilia. Conclusions Pediatric appendiceal carcinoid is an incidental finding; in this series, none required further intervention. Appendiceal granulomas are not commonly associated with developing Crohn's disease in the short term. Routine antibiotics for the treatment of pinworms are adequate. Patients with appendiceal eosinophilia may develop symptomatic intestinal eosinophilia.

Background We conducted a prospective, randomized trial comparing protocol to ad libitum (ad lib) feeding after laparoscopic pyloromyotomy. Methods Infants undergoing laparoscopic pyloromyotomy were randomized to protocol versus ad lib feeding strategies. The protocol started with Pedialyte® two hours post-operative. This was repeated by another round of Pedialyte®, then two rounds of half-strength formula or breast milk, followed by two rounds of full strength formula or breast milk, followed by the home feeding regimen, at which time the patient was discharged if feeding well. The ad lib group was allowed formula or breast milk two hours after the operation and considered for discharge after tolerating three consecutive feeds. The primary outcome variable was the length of postoperative hospitalization. Results One hundred fifty infants were enrolled between January 2010 and December 2011. There were no differences in patient characteristics at presentation. While the ad lib group reached goal feeds sooner than the protocol group, this did not translate into a difference in duration of postoperative hospitalization. There were more patients with emesis in the ad lib group after goal feeding was reached, but no difference in readmissions. Conclusion Ad lib feeding allows patients to reach goal feeds more rapidly than protocol feeding following laparoscopic pyloromyotomy. However, this goal is usually reached beyond discharge hours, resulting in a similar duration of hospitalization.

Purpose Controversy exists regarding differences in mortality between isolated ileal perforation (IIP) and necrotizing enterocolitis (NEC). We sought to identify risk factors and determine mortality rates for these two entities. Methods A retrospective review was conducted on all patients with NEC or IIP undergoing surgical management at our institution from May 1971 to December 2011. Demographics, birth history, management strategies, and mortality were recorded. Chi-square and unpaired t-test were used where appropriate. Results During the study period, 236 patients underwent operative management with 17.8% of those being for IIP. Patients with IIP had a lower estimated gestational age (27.8 ± 3.0 vs. 29.5 ± 4.2 weeks, p = 0.014), were more likely to be of multiple gestation (33.3 vs. 16.5%, p = 0.022), and were younger at diagnosis (8.7 ± 8.1 vs. 14.3 ± 11.1 days, p = 0.003) compared with those undergoing operation for NEC. Mortality was threefold lower with IIP (9.5 vs. 36.1%, p Conclusions IIP carries a unique set of risk factors and has a significantly lower mortality rate when compared with NEC.

Background Laparoscopy through a single umbilical incision is an emerging technique supported by case series, but prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing single site umbilical laparoscopic cholecystectomy to 4-port laparoscopic cholecystectomy. Methods After IRB approval, patients were randomized to laparoscopic cholecystectomy via a single umbilical incision or standard 4-port access. The primary outcome variable was operative time. Utilizing a power of 0.8 and an alpha of 0.05, 30 patients were calculated for each arm. Patients with complicated disease or weight over 100kg were excluded. Post-operative management was controlled. Surgeons subjectively scored degree of technical difficulty from 1=easy to 5=difficult. Results From 8/2009 through 7/2011, 60 patients were enrolled. There were no differences in patient characteristics. Operative time and degree of difficulty were greater with the single site approach. There were more doses of analgesics used and greater hospital charges in the single site group that trended toward significance. Conclusion Single site laparoscopic cholecystectomy produces longer operative times with a greater degree of difficulty as assessed by the surgeon. There was a trend toward more doses of post-operative analgesics and greater hospital charges with the single site approach.

Appendicitis is one of the most common surgical conditions in children. Laparoscopy has become the standard approach to appendectomy over the past decade. Some critics cite a lack of evidence documenting clear advantages to laparoscopy. To define the pattern of approach compared to outcomes in the United States, we analyzed the Pediatric Health Information System (PHIS) database to document the impact on outcomes with the rise in laparoscopy.After IRB approval, we queried the PHIS database for all patients over 12 years. The percentages of cases performed open (OA) and laparoscopically (LA) were established for each year. Annual complication percentages were identified for wound infection, intra-abdominal abscess, subsequent laparotomy, and obstruction. For each complication, trend comparisons between LA and OA were made with generalized linear models.There were 111,194 appendectomies with a positive trend in percentage of laparoscopy from 1999 (22.2%) to 2010 (90.8%), P0.0001. Over 12 years, there were significant differential trends between LA and OA in rates of wound infection, abscesses, bowel obstructions, and laparotomies within 30 days (P0.0001 for each). There was no trend in wound infection rates within OA over time (P=0.31), while there was a decrease in infection rates within LA over time (P0.0001).On the basis of a national database analysis, laparoscopy has increased for appendectomy in children over the past 12 years and is associated with a significant decrease in post-operative complications.

Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.

Pleural space disease in children is usually the result of abnormal accumulation of material within the space between the visceral and parietal pleura, rather than intrinsic problems with the pleura itself. Adults secrete and reabsorb about 2.5 L of pleural fluid each day. The goals of treating pleural space disease are to remove abnormal material, re-expand the lung, re-approximate the pleura, and treat the underlying cause. As in many other aspects of pediatric surgery, the pendulum has swung toward generally less invasive approaches: small pigtail catheters for almost all pleural collections, chemical (fibrinolytic) debridement of more solid material, and VATS procedures rather than open thoracotomy. Similarly, there has been a strong trend toward evidence-based treatment of pleural disease in children; empyema is an excellent model of careful, reproducible, randomized studies affecting a significant change in the care of children.

Purpose Several surgeons have documented outcomes following the Nuss operation. Most reports have described the use of thoracoscopy to avoid cardiac injury. Since 1999, our group has utilized a subxiphoid incision, allowing insertion of the surgeon's finger into the substernal space to help guide the bar across the mediastinum. Our initial experience has been reported and we are now reporting our entire experience to date. Methods A retrospective review was conducted on all patients who underwent pectus excavatum repair using a subxiphoid incision from December, 1999 to September, 2015. Results During the study period, 554 repairs were performed. A total of 80% of the patients were male. The mean age was 14.3 years ± 3.1, the mean operating time was 52 minutes ± 17.4, the mean length of stay was 4.2 days ± 1.1, and the mean time to bar removal was 2.7 years ± 0.7. A total of 20 patients (3.6%) received two bars. No patients sustained cardiac injury or evidence of pericarditis. Postoperatively, 22 patients (4%) developed an infection, either cellulitis or a local abscess requiring incision and drainage and/or antibiotics. In four of these 22 patients, the wound infection developed after the bar had been removed. Only one patient required bar removal before 2 years due to an infection. A total of 12 patients required either repositioning of the bar due to rotation (4) or removal of a stabilizer due to chronic discomfort (8), 2 required early bar removal for chronic pain, and 1 patient developed a tension pneumothorax in the operating room. A recurrence has developed in two patients but neither patient has desired correction. Conclusion In this relatively large series of patients, the addition of a subxiphoid incision to the technique has allowed for safe passage of the bar across the mediastinum to avoid cardiac injury during the Nuss operation.

In 2011, we established a dedicated center for patients with chest wall deformities. Here, we evaluate the center’s effect on patient volume and management. A retrospective review of 699 patients with chest wall anomalies was performed. Patients were compared, based on the date of initial consultation, before the pectus center opened (July 2009–June 2011, Group 1) versus after (July 2011–June 2013, Group 2). Analysis was performed utilizing Chi-square and Mann–Whitney U tests. 320 patients were in Group 1 and 379 in Group 2, an 18.4 % increase in patient volume. Excavatum patients increased from 172 (Group 1) to 189 (Group 2). Carinatum patients increased from 125 (Group 1) to 165 (Group 2). Patients undergoing operative repair of carinatum/mixed defects dropped significantly from 15 % (Group 1) to 1 % (Group 2) (p