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Electronic cigarettes (e-cigarettes) are handheld, battery-powered vaporizing devices. It is estimated that more than 25% of youth have used these devices recreationally. While vaping-associated lung injury is an increasingly recognized risk, little is known about the risk of traumatic injuries associated with e-cigarette malfunction.A multi-institutional retrospective study was performed by querying the electronic health records at nine children's hospitals. Patients who sustained traumatic injuries while vaping from January 2016 through December 2019 were identified. Patient demographics, injury characteristics, and the details of trauma management were reviewed.15 children sustained traumatic injuries due to e-cigarette explosion. The median age was 17 y (range 13-18). The median injury severity score was 2 (range 1-5). Three patients reported that their injury coincided with their first vaping experience. Ten patients required hospital admission, three of whom required intensive care unit admission. Admitted patients had a median length of stay of 3 d (range 1-6). The injuries sustained were: facial burns (6), loss of multiple teeth (5), thigh and groin burns (5), hand burns (4), ocular burns (4), a radial nerve injury, a facial laceration, and a mandible fracture. Six children required operative intervention, one of whom required multiple operations for a severe hand injury.In addition to vaping-associated lung injury, vaping-associated traumatic injuries are an emerging and worrisome injury pattern sustained by adolescents in the United States. This report highlights another means by which e-cigarettes pose an increasing risk to a vulnerable youth population.

Background Pediatric surgeons are often asked to treat clinical problems for which little high-quality data exist. For adults with adhesive small bowel obstruction (ASBO), water soluble contrast-based protocols are used to guide management. Little is known about their utility in children. We aimed to better understand key factors in clinical decision-making processes and integration of adult based data in pediatric surgeon's approach to ASBO. Methods We administered a web-based survey to practicing pediatric surgeons at institutions comprising the Western Pediatric Surgery Research Consortium. Results The response rate was 69% (78/113). Over half of respondents reported using contrast protocols to guide ASBO management either routinely or occasionally (n = 47, 60%). Common themes regarding the incorporation of adult-based data into clinical practice included the need to adapt protocols for pediatric patients, the dearth of pediatric specific data, and the quality of the published adult evidence. Conclusions Our findings demonstrate that pediatric surgeons use contrast-based protocols for the management of ASBO despite the paucity of pediatric specific data. Furthermore, our survey data help us understand how pediatric surgeons incorporate adult based evidence into their practice.

Background: Appendicitis is the most common operative emergency in children. As a result of accumulating evidence from randomized trials, observational studies, database work, and meta-analyses, the management of appendicitis in children has been shifting the past 15 years with many new debates emerging. In this article, we review our current management schemes. Methods: We reviewed the current and critical literature relevant to the rationale for our current management. Results: Clinical pathways appear to reduce variation and cost while improving the ability to diagnose and treat the disease. Minimally invasive approaches can be used to treat all forms of appendicitis. Conclusions: The future role of non-operative management deserves ongoing exploration. Refining diagnostic treatment algorithms and enhancing antibiotic stewardship are important moving forward.

Current studies show cryoablation decreases opioid requirements and lengths of stay (LOS) in patients undergoing the Nuss procedure for pectus excavatum. This study evaluated the relationship between cryoablation and clinical outcomes for the Nuss procedure.A retrospective single-center chart review was performed on patients undergoing the Nuss procedure with intercostal cryoablation from December 2017-August 2021. Demographics, hospital course, and postoperative complications were abstracted. To evaluate the evolution of outcomes over time, the earliest quarter (Q1) of cryoablation patients was compared to the last quarter (Q4).Over 45 months, 350 Nuss procedures with cryoablation were performed. The mean age at operation was 15.7 ± 2.3 years with an average Haller Index of 5.4 ± 4.2. The mean operative time was 136 ± 40.5 minutes. On average, patients used 2.8 ± 2.5 OME/kg of opioid in hospital with a LOS of 2.7 ± 1.1 days. The Q4 patients were discharged 1.3 days earlier (p0.05) than Q1 patients, with 80% of Q4 discharged by postoperative day #2 vs. 23% in Q1 (p0.05). Q4 patients received 74% (p0.05) less opioid in hospital and 21% (p0.05) less on discharge. Within 90 days postoperatively, complication rates (chest tube placement, wound infection, readmission, neuropathic pain) were similar. Only two patients (0.6%) required reoperation for bar migration/slippage.With increased experience, cryoablation for the Nuss procedure decreased opioid use by 74% and was associated with 80% of patients achieving early discharge. Major complication rates were not increased. Cryoablation can be successfully implemented as an effective method of postoperative analgesia.Level III.

No prior studies have examined the outcomes of early vasopressor use in children sustaining blunt liver or spleen injury (BLSI).A planned secondary analysis of vasopressor use from a 10-center, prospective study of 1004 children with BLSI. Inverse probability of treatment weighting (IPTW) was used to compare patients given vasopressors48 h after injury to controls based on pretreatment factors. A logistic regression was utilized to assess survival associated with vasopressor initiation factors on mortality and nonoperative management (NOM) failure.Of 1004 patients with BLSI, 128 patients were hypotensive in the Pediatric Trauma Center Emergency Department (ED); 65 total patients received vasopressors. Hypotension treated with vasopressors was associated with a sevenfold increase in mortality (AOR = 7.6 [p 0.01]). When excluding patients first given vasopressors for cardiac arrest, the risk of mortality increased to 11-fold (AOR = 11.4 [p = 0.01]). All deaths in patients receiving vasopressors occurred when started within the first 12 h after injury. Vasopressor administration at any time was not associated with NOM failure.After propensity matching, early vasopressor use for hypotension in the ED was associated with an increased risk of death, but did not increase the risk of failure of NOM.Level III prognostic and epidemiological, prospective.

Objectives In previous studies, SIPA was shown to be better than the SI in identifying children who have an elevated ISS, required transfusion, or were at a high risk of death. No comparison has been made to the consensus-based criteria that identify patients requiring the highest-level trauma activation. The objective of this study was to determine if the SIPA was more accurate than the SI in identifying children with increased need for trauma team activation as defined by the criterion standard definition, and secondly the sensitivity and specificity of the SI and SIPA. Methods Retrospective review of prospectively collected trauma based data. Children aged 1–17 years admitted to a pediatric level 1 trauma center between 1/1/16 and 12/31/17 and met the prehospital criteria for level 1 or 2 trauma activation were included. We evaluated the ability of SI > 0.9 at ED presentation and elevated SIPA to predict need for trauma activation based on consensus criteria. SIPA cutoffs were > 1.22 (age 4–6), > 1.0 (age 7–12), and > 0.9 (age 13–17). Results Among 3378 children, 1486 (44%) had an elevated SI and 590 (18%) had an elevated SIPA. There were 160 (5%) patients who met at least one consensus criterion. Broadly, sensitivity and specificity analyses reveal poor sensitivity for both SI and SIPA (59.4% versus 43.1% respectively) measures but a moderate specificity for SIPA (83.8%). Both SI and SIPA have a poor PPV (6.4% versus 11.7%) but high NPV (96.6% versus 96.7%). Overall, SIPA has higher accuracy than SI in predicting consensus criteria 82% versus 57%). Conclusion SIPA is more accurate than the SI in identifying children who meet a consensus criterion defining the need for highest-level trauma activation. The low PPV and sensitivity suggest that SIPA alone, while somewhat less likely to lead to overtriage than SI is not ideal for ruling in the need for level one resources as defined by the consensus criteria. Prognosis study, retrospective. Level of Evidence Level II.

Purpose Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery. Methods A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children’s hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion. Results Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P = 0.028]. Conclusion Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS. Type of study Prospective pilot study Level of evidence Level III.

PURPOSE The purpose of this study was to investigate factors impacting transplant-free survival among infants with biliary atresia. METHODS A multi-institutional, retrospective cohort study was performed at nine tertiary-level children's hospitals in the United States. Infants who underwent Kasai portoenterostomy (KP) from January 2009 to May 2017 were identified. Clinical characteristics included age at time of KP, steroid use, surgical approach, liver pathology, and surgeon experience. Likelihood of transplant-free survival (TFS) was evaluated using logistic regression, adjusting for patient and surgeon-level factors. Secondary outcomes at 1 year included readmission, cholangitis, reoperation, mortality, and biliary clearance. RESULTS Overall, 223 infants underwent KP, and 91 (40.8%) survived with their native liver. Mean age at surgery was 63.9 days (± 24.7 days). At 1 year, 78.5% experienced readmission, 56.9% developed cholangitis, 3.8% had a surgical revision, and 5 died. Biliary clearance at 3 months was achieved in 76.6%. Controlling for patient and surgeon-level factors, each additional day of age toward operation was associated with a 2% decrease in likelihood of TFS (OR 0.98, 95% CI 0.97-0.99). CONCLUSION Earlier surgical intervention by Kasai portoenterostomy at tertiary-level centers significantly increases likelihood for TFS. Policy-level interventions to facilitate early screening and surgical referral for infants with biliary atresia are warranted to improve outcomes.

Background Perforated appendicitis is the most common cause of intraabdominal abscess (IAA) in children. The optimal postoperative antibiotic regimen to reduce IAA has evolved in the last decade from triple-drug to 2-drug therapy (CM). Recent retrospective studies show decreased infectious complications with monotherapy PT. To date prospective comparative data are lacking. Therefore, a prospective randomized trial comparing PT versus CM was conducted. Methods A multi-institutional prospective randomized trial was performed in children with perforated appendicitis comparing postoperative antibiotic regimens PT or CM. The primary outcome was 30-day postoperative IAA formation. Perforation was strictly defined as a hole in the appendix or fecalith in the abdomen, documented with intraoperative photographs. Results One hundred sixty-two patients were enrolled during the study period. No differences in age, weight, or duration of presenting symptoms were identified. In addition, length of stay, duration of intravenous antibiotic treatment, discharge oral antibiotic treatment, and antibiotic-related complications did not differ between groups. Compared to the CM group, the PT group had significantly lower IAA rate [6.1% vs 23.8%, odd ratio (OR) 4.80, P = 0.002], lower postoperative computed tomography imaging rate (13.9% vs 29.3%, OR 2.57, P = 0.030), and fewer emergency room visits (8.8% vs 26.4%, OR 3.73, P = 0.022). Multivariate logistic regression analysis found the use of CM versus PT (OR 9.21, P = 0.021) to be the most significant predictor for developing IAA. Conclusions In children with perforated appendicitis, postoperative monotherapy with PT is superior to standard 2-drug therapy with CM and does not increase antibiotic-related complications or antibiotic exposure duration.

Introduction: Cryoanalgesia has been applied to minimally invasive repair of pectus excavatum (MIRPE). After implementation of cryoanalgesia at our institution, we had several cases of del...

After NOM for BLSI, APSA guidelines recommend activity restriction for grade of injury +2 in weeks. This study evaluates activity restriction adherence and 60 day outcomes.Non-parametric tests and logistic regression were utilized to assess difference between adherent and non-adherent patients from a 3-year prospective study of NOM for BLSI (≤18 years).Of 1007 children with BLSI, 366 patients (44.1%) met the inclusion criteria of a completed 60 day follow-up; 170 (46.4%) had liver injury, 159 (43.4%) had spleen injury and 37 (10.1%) had both. Adherence to recommended activity restriction was claimed by 279 (76.3%) patients; 49 (13.4%) reported non-adherence and 38 (10.4%) patients had unknown adherence. For 279 patients who adhered to activity restrictions, unplanned return to the emergency department (ED) was noted for 35 (12.5%) with 16 (5.7%) readmitted; 202 (72.4%) returned to normal activity by 60 days. No patient bled after discharge. There was no statistical difference between adherent patients (n = 279) and non-adherent (n = 49) for return to ED (χ2 = 0.8 [p 0.4]) or readmission (χ2 = 3.0 [p 0.09]); for 216 high injury grade patients, there was no difference between adherent (n = 164) and non-adherent (n = 30) patients for return to ED (χ2 = 0.6 [p 0.4]) or readmission (χ2 = 1.7 [p 0.2]).For children with BLSI, there was no difference in frequencies of bleeding or ED re-evaluation between patients adherent or non-adherent to the APSA activity restriction guideline.Level II, Prognosis.

Focused Abdominal Sonography for Trauma (FAST) examination has long been proven useful in the management of adult trauma patients, however, its utility in pediatric trauma patients is not as proven. Our goal was to evaluate the utility of a FAST examination in predicting the success or failure of nonoperative management (NOM) of blunt liver and/or spleen (BLSI) in the pediatric trauma population.A retrospective analysis of a prospective observational study of patients younger than 18 years presenting with BLSI to one of ten Level I pediatric trauma centers between April 2013 and January 2016. 1,008 patients were enrolled and 292 had a FAST examination recorded. We analyzed failure of NOM of BLSI in the pediatric trauma population. We then compared FAST examination alone or in combination with the pediatric age adjusted shock index (SIPA) as it relates to success of NOM of BLSI.Focused Abdominal Sonography for Trauma examination had a negative predictive value (NPV) of 97% and positive predictive value (PPV) of 13%. The odds ratio of failing with a positive FAST examination was 4.9 and with a negative FAST was 0.20. When combined with SIPA, a positive FAST examination and SIPA had a PPV of 17%, and an odds ratio for failure of 4.9. The combination of negative FAST and SIPA had an NPV of 96%, and the odds ratio for failure was 0.20.Negative FAST is predictive of successful NOM of BLSI. The addition of a positive or negative SIPA score did not affect the PPV or NPV significantly. Focused Abdominal Sonography for Trauma examination may be useful clinically in determining which patients are not at risk for failure of NOM of BLSI and do not require monitoring in an intensive care setting.Prognostic study, level IV; therapeutic/care management, level IV.

Congenital intestinal obstruction occurs in approximately 1 in 2000 live births and is one of the most common causes for admission to a neonatal care unit. Morphologically they are divided into either atresia and stenosis depending the continuity of the intestine. Furthermore, they are divided by the region of the gastrointestinal tract involved: duodenal, jejunoileal and colonic. Prenatally they present as polyhydramnios and dilation of the intestine on ultrasound. Neonatally infants present with obstructive symptoms. Usually a radiograph is enough to make the diagnosis of any of these conditions, depending the point of obstruction there might be a “double-bubble” sign or more diffuse intestinal dilation with or without pneumoperitoneum. For more distal obstruction a contrast enema might be needed. Treatment is surgical with a thorough exploration and repair through a single anastomosis or resection with or without anastomosis depending the portion of the gastrointestinal tract involved, other abnormalities and if perforation had occurred.

Introduction Mentorship in surgical training is critical but differs greatly from the early apprenticeship model and often spans generations. This study evaluates the current state of and desire for structured mentorship in pediatric surgical training from the perspective of program directors (PDs) and trainees. Methods A survey addressing demographics, presence of or desire for structured mentorship, and proposed mentoring topics was emailed to pediatric surgery PDs (n = 58) and trainees completing fellowship in 2018–2020 (n = 72). Results The response rate was 38.5%. 50% of trainees were female versus 15% of PDs (p = 0.02). 19% of trainees reported having a structured mentorship program versus 26% of PDs (p = 0.72). The majority, 83%, of trainees felt a structured mentorship program is warranted versus 40% of PDs (p = 0.002). There were differing opinions between trainees and PDs regarding important components of a mentoring program. Trainees felt the following were more important: transition to practice, job negotiation, CV review, financial planning and performance review. PDs felt the following were more important: quality improvement projects and work/life balance. Both agreed academic development and job search were important. Conclusions The majority of pediatric surgery trainees desire structured mentorship programs; however, few institutions have them. Training programs and program directors warrant a response to this gap. Level of Evidence IV

Umbilical hernias are common in young children. Many resolve spontaneously by age four with very low risk of symptoms or incarceration. Complications associated with surgical repair of asymptomatic umbilical hernias have not been well elucidated. We analyzed data from one hospital to test the hypothesis that repair at younger ages is associated with increased complication rates.A retrospective chart review of all umbilical hernia repairs performed during 2007-2015 was conducted at a tertiary care children's hospital. Patients undergoing repairs as a single procedure for asymptomatic hernia were evaluated for post-operative complications by age, demographics, and co-morbidities.Of 308 umbilical hernia repairs performed, 204 were isolated and asymptomatic. Postoperative complications were more frequent in children 4 years (12.3%) compared to 4 years (3.1%, p = 0.034). All respiratory complications (N = 4) and readmissions (N = 1) were in children 4 years.Age of umbilical hernia repair in children varied widely even within a single institution, demonstrating that timing of repair may be a surgeon-dependent decision. Patients 4 years were more likely to experience post-operative complications. Umbilical hernias often resolve over time and can safely be monitored with watchful waiting. Formal guidelines are needed to support delayed repair and prevent unnecessary, potentially harmful operations.

Contrast-enhanced CT remains the first-line imaging for evaluating postoperative abscess (POA) after appendicitis. Given concerns of ionizing radiation use in children, we began utilizing quick MRI to evaluate POA and summarize our findings in this study.Children imaged with quick MRI from 2015 to 2017 were compared to children evaluated with CT from 2012 to 2014 using an age and weight matched case-control model. Radiation exposure, size and number of abscesses, length of exam, drain placement, and patient outcomes were compared.There was no difference in age or weight (p0.60) between children evaluated with quick MRI (n=16) and CT (n=16). Mean imaging time was longer (18.2±8.5min) for MRI (p0.001), but there was no difference in time from imaging order to drain placement (p=0.969). No children required sedation or had non-diagnostic imaging. There were no differences in abscess volume (p=0.346) or drain placement (p=0.332). Thirty-day follow-up showed no difference in readmissions (p=0.551) and no missed abscesses. Quick MRI reduced imaging charges to $1871 from $5650 with CT.Quick MRI demonstrated equivalent outcomes to CT in terms of POA detection, drain placement, and 30-day complications suggesting that MRI provides an equally effective, less expensive, and non-radiation modality for the identification of POA.Retrospective Case-Control Study.Level III.

Background One of the concerns associated with nonoperative management of splenic injury in children has been delayed splenic bleed (DSB) after a period of hemostasis. This study evaluates the incidence of DSB from a multicenter 3-year prospective study of blunt splenic injuries (BSI). Methods A 3-year prospective study was done to evaluate nonoperative management of pediatric (≤18years) BSI presenting to one of 10 pediatric trauma centers. Patients were tracked at 14 and 60days. Descriptive statistics were used to summarize patient and injury characteristics. Results During the study period, 508 children presented with BSI. Median age was 11.6 [IQR: 7.0, 14.8]; median splenic injury grade was 3 [IQR: 2, 4]. Nonoperative management was successful in 466 (92%) with 18 (3.5%) patients undergoing splenectomy at the index admission, all within 3h of injury. No patient developed a delayed splenic bleed. At least one follow-up visit was available for 372 (73%) patients. Conclusion A prior single institution study suggested that the incidence of DSB was 0.33%. Based on our results, we believe that the rate may be less than 0.2%. Level of evidence Level II, Prognosis.

Background Multicenter clinical research studies in pediatric surgery have been largely limited to relatively small case-series and retrospective reviews because of the rarity of many of the diseases we treat and difficulty coordinating and executing multi-institutional studies. Creation of a collaborative research network can provide the needed patient population and infrastructure to perform high quality multi-institutional studies. Methods In 2013, eleven academic pediatric surgery centers within the United States formed a research consortium to develop and conduct multicenter clinical research projects to advance the practice of pediatric surgery. Results We present our process for creating, developing, and maintaining this consortium including initial regional geographic limitation, charter development with by-laws and procedures for adopting studies, and research infrastructure including a central website for study monitoring and central reliance institutional review board process. Conclusion Our model could be reproduced or adapted by other institutions to develop or strengthen other research collaboratives. Level of evidence Type of study: retrospective, IV.

Purpose Children with blunt liver or spleen injury (BLSI) requiring early transfusion may present without hypotension despite significant hypovolemia. This study sought to determine the relationship between early transfusion in pediatric BLSI and hypotension. Methods Secondary analysis of a 10-institution prospective observational study was performed of patients 18years and younger presenting with BLSI. Patients with central nervous system (CNS) injury were excluded. Children receiving blood transfusion within 4h of injury were evaluated. Time to first transfusion, vital signs, and physical exams were analyzed. Patients with hypotension were compared to those without hypotension. Results Of 1008 patients with BLSI, 47 patients met inclusion criteria. 22 (47%) had documented hypotension. There was no statistical difference in median time to first transfusion for those with or without hypotension (2h vs. 2.5h, p =0.107). The hypotensive group was older (median 15.0 versus 9.5years; p =0.007). Median transfusion volume in the first 24h was 18.2mL/kg (IQR: 9.6, 25.7) for those with hypotension and 13.9mL/kg (IQR: 8.3, 21.0) for those without ( p =0.220). Mortality was 14% (3/22) in children with hypotension and 0% (0/25) in children without hypotension. Conclusion Hypotension occurred in less than half of patients requiring early transfusion following pediatric BLSI suggesting that hypotension does not consistently predict the need for early transfusion. Type of study Secondary analysis of a prospective observational study. Level of evidence Level IV cohort study.

Hiatal and paraesophageal hernia (HH/PEH) can be congenital, resulting from embryologic abnormalities/genetic predisposition, or acquired, most commonly after gastroesophageal surgery such as fundoplication. Minimizing circumferential esophageal dissection at the time of Nissen fundoplication has been shown to decrease the risk of acquired HH/PEH from 36.5% to 12.2%. Gastrointestinal, respiratory, and constitutional symptoms, including anemia and failure to thrive, are common with high rates of associated gastroesophageal reflux. Chest x-ray is often abnormal and upper GI confirms the diagnosis. Treatment is surgical with the goal of reducing the hernia contents, excising the hernia sac, closing the crura, and performing an antireflux procedure. The laparoscopic approach is safe and effective.

Nonoperative management (NOM) is standard of care for most pediatric blunt liver and spleen injuries (BLSI); only 5% of patients fail NOM in retrospective reports. No prospective studies examine failure of NOM of BLSI in children. The aim of this study was to determine the frequency and clinical characteristics of failure of NOM in pediatric BLSI patients.A prospective observational study was conducted on patients 18 years or younger presenting to any of 10 Level I pediatric trauma centers April 2013 and January 2016 with BLSI on computed tomography. Management of BLSI was based on the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium pediatric guideline. Failure of NOM was defined as needing laparoscopy or laparotomy.A total of 1008 patients met inclusion; 499 (50%) had liver injury, 410 (41%) spleen injury, and 99 (10%) had both. Most patients were male (n = 624; 62%) with a median age of 10.3 years (interquartile range, 5.9, 14.2). A total of 69 (7%) underwent laparotomy or laparoscopy, but only 34 (3%) underwent surgery for spleen or liver bleeding. Other (nonexclusive) operations were for 21 intestinal injuries; 15 hematoma evacuations, washouts, or drain placements; 9 pancreatic injuries; 5 mesenteric injuries; 3 diaphragm injuries; and 2 bladder injuries. Patients who failed were more likely to receive blood (52 of 69 vs. 162 of 939; p0.001) and median time from injury to first blood transfusion was 2.3 hours for those who failed versus 5.9 hours for those who did not (p = 0.002). Overall mortality rate was 24% (8 of 34) in those who failed NOM due to bleeding.NOM fails in 7% of children with BLSI, but only 3% of patients failed for bleeding due to liver or spleen injury. For children failing NOM due to bleeding, the mortality was 24%.Therapeutic study, level II.

Abscess rates have been reported to be as low as 1% and as high as 50% following perforated appendicitis (PA). This range may be because of lack of universal definition for PA. An evidence-based definition (EBD) is crucial for accurate wound classification, risk-stratification, and subsequent process optimization. ACS NSQIP-Pediatric guidelines do not specify a definition of PA. We hypothesize that reported postoperative abscess rates underrepresent true incidence, as they may include low-risk cases in final calculations.Local institutional records of PA patients were reviewed to calculate the postoperative abscess rate. The ACS NSQIP-Pediatric participant use file (PUF) was used to determine cross-institutional postoperative abscess rates. A PubMed literature review was performed to identify trials reporting PA abscess rates, and definitions and rates were recorded.20.9% of our patients with PA developed a postoperative abscess. The ACS NSQIP-Pediatric abscess rate was significantly lower (7.61%, p0.001). In the eighteen published studies analyzed, average abscess rate (14.49%) was significantly higher than ACS NSQIP-Pediatric (p0.001). There was significantly more variation in trials that do not employ an EBD of perforation (Levene's test F-value =6.980, p=0.018).A standard EBD of perforation leads to lower variability in reported postoperative abscess rates following PA. Nonstandard definitions may be significantly altering the aggregate rate of postoperative abscess formation. We advocate for adoption of a standard definition by all institutions participating in ACS NSQIP-Pediatric data submission.III.

Complications related to general pediatric surgery procedures are a major concern for pediatric surgeons and their patients. Although infrequent, when they occur the consequences can lead to significant morbidity and psychosocial stress. The purpose of this article is to discuss the common complications encountered during several common pediatric general surgery procedures including inguinal hernia repair (open and laparoscopic), umbilical hernia repair, laparoscopic pyloromyotomy, and laparoscopic appendectomy.

Introduction Postoperative pain control remains the primary reason for inpatient stay after minimally invasive repair of pectus excavatum. In a previous study, our group reported that early pain control was better in patients managed with a thoracic epidural, while late pain control was better in patients managed with patient-controlled analgesia (PCA). After revising our epidural transition and modifying the PCA protocol, we conducted a multi-institutional prospective randomized trial to evaluate these two pain control strategies. Materials and Methods Patients were randomized to epidural or PCA following minimally invasive repair of pectus excavatum with standard protocols for each arm. Primary outcome was length of stay with secondary variables including mean patient pain scores, complications, and parental satisfaction. Scores were pooled for the two groups and reported as means with standard deviation. Results were compared using t-tests and one-way analysis of variance with p-value Results Sixty-five patients were enrolled, 32 epidural and 33 PCA. Enrollment was stopped early when we developed an alternative strategy for controlling these patients' pain. There was no difference in length of stay in hours between the two arms; epidural 111.3 ± 18.5 versus PCA 111.4 ± 51.4, p = 0.98. Longer operative time was found in the epidural group. Nine patients in the epidural group (28%) required a PCA in addition to epidural for adequate pain control. Mean pain scores were lower on postoperative day 0 in the epidural group compared with the PCA groups, but were otherwise similar. Conclusion In our prospective randomized trial, PCA is just as effective as thoracic epidural in decreasing early postoperative pain scores after minimally invasive repair of pectus excavatum.

Background: Recently, several series have reported the use of laparoscopy in pediatric trauma, most commonly for bowel and pancreatic injury within the first 12 or 24 hours. During a multi...

To investigate the association between time to appendectomy and the risk of surgical site infections (SSIs) in children with appendicitis across multiple NSQIP-Pediatrics institutions.Several recently published single institution retrospective studies have reported conflicting relationships between delaying appendectomy and the risk of increasing surgical site infections (SSI) in both children and adults. This study combines data from NSQIP-Pediatrics with institutional data to perform a multi-institutional analysis to examine the effects of delaying appendectomy on surgical site infections.Data from NSQIP-Pediatrics between January 2010 and June 2012 for cases of appendectomy for appendicitis at 6 institutions (preoperative characteristics, time of operation, and postoperative occurrences) were combined with data from medical record review (length of symptoms; times of initial presentation, emergency department (ED) triage, and admission; and diagnosis as simple appendicitis (SA, acute) or complicated appendicitis (CA, gangrenous/ruptured)). Cochran-Armitage tests for trend and multivariable logistic regression models were used to evaluate associations between time to appendectomy and SSI.Of the 1338 patients included, 70% had SA and 30% had CA. Postoperative SSIs were more common in CA (5.7% vs 1.2%, P 0.001). SSI rates did not differ significantly across hospitals (P = 0.17). Compared with patients who did not develop an SSI, patients who developed an SSI had similar times between ED triage and appendectomy (median (interquartile range) 11.5 hours (6.4-14.7) versus 9.7 hours (5.8-15.6, P = 0.36), and similar times from admission to appendectomy (5.5 hours (1.9-10.2) versus 4.3 hours (1.4-9.9), P = 0.36). Independent risk factors for SSI were CA (Odds Ratio (95% CI): 3.46 (1.48-8.10), P = 0.004), longer symptom duration (OR for a 10-hour increase: 1.05 (1.01-1.10), P = 0.02), and presence of sepsis/septic shock (2.70 (1.17-6.28), P = 0.02).A 16-hour delay from ED presentation or a 12-hour delay from hospital admission to appendectomy was not associated with an increased risk for SSI.

Despite evidence from prospective trials and meta-analyses supporting laparoscopic pyloromyotomy (LP) over open pyloromyotomy (OP), the open technique is still utilized by some surgeons on the premise that there is minimal clinical benefit to LP over OP. Although the potential cosmetic benefit of LP over OP is often cited in reports, it has never been objectively evaluated.After internal review board approval, the parents of patients from a previous prospective trial who had undergone LP (n = 9) and OP (n = 10) were contacted. After consent was obtained, the parents and patients were asked to complete a validated scar scoring questionnaire that was compared between groups. Standardized photos were taken of study subjects and controls with no abdominal procedures. Blinded volunteers were recruited to view the photos, identify if scars were present, and complete questions if a scar(s) was seen. Volunteers were also asked about the degree of satisfaction if their child had similar scars on a four-point scale from happy to unacceptable.Mean age was 7 years in both groups. Parental scar assessment scores were superior in the LP group in every category. Blinded volunteers detected abdominal scars significantly more often in the OP group (98%) vs. the LP group (28%; P .001). The volunteers detected a scar in 16% of the controls, comparable to the 28% detected in the LP group (P = .17). The degree of satisfaction estimate by volunteers was 1.78 for OP and 1.02 for LP and controls, generating a Cohen's d effect size of 5.1 standard deviation units comparing OP to either LP or controls (very large ≥1.3).Parents of children scored LP scars superior to OP scars. Surgical scars are almost always identifiable with OP while the surgical scars associated with LP approach invisibility to the observer, appearing similar to patients with no prior abdominal operation.

Recent clinical trials in adults and children have shown that uncomplicated acute appendicitis can be successfully treated with antibiotics alone. As treatment strategies for acute appendicitis diverge, accurate preoperative diagnosis of complicated appendicitis and appendiceal perforation has become increasingly important for clinical decision-making. To examine diagnostic performance of ultrasound for detecting perforated appendicitis in a single institution using a standardized technique. In this retrospective single-center study we evaluated 113 ultrasounds from pediatric patients who underwent appendectomy between November 2014 and December 2015. All ultrasounds were performed using a standardized US protocol including still and cine images of all four abdominal quadrants, with more targeted evaluation of the right lower quadrant (RLQ) using graded compression technique. We compared US findings to intraoperative diagnosis of non-perforated or perforated acute appendicitis. The standardized image protocol generated a reproducible set of ultrasound images in all cases. The most common primary appendiceal finding on US in perforated appendicitis was appendix wall thickening >3 mm (54%, 171/314) and most common secondary finding was echogenic mesenteric fat (75%, 237/314). Thinning of the appendix wall and loculated fluid collection in the right lower quadrant were both highly specific (>90%) for perforation. The diagnostic performance of ultrasound using a standardized US technique was similar to that reported in prior studies for detecting perforated appendicitis. Despite low sensitivity, individual ultrasound findings and overall diagnostic impression of “evidence of appendix perforation” remain highly specific.

Background APSA guidelines do not recommend routine reimaging for pediatric blunt liver or spleen injury (BLSI). This study characterizes the symptoms, reimaging, and outcomes associated with a selective reimaging strategy for pediatric BLSI patients. Methods A planned secondary analysis of reimaging in a 3-year multi-site prospective study of BLSI patients was completed. Inclusion required successful nonoperative management of CT confirmed BLSI without pancreas or kidney injury and follow up at 14 or 60 days. Patients with re-injury after discharge were excluded. Results Of 1007 patients with BLSI, 534 (55%) met inclusion criteria (median age: 10.18 [IQR: 6, 14]; 62% male). Abdominal reimaging was performed on 27/534 (6%) patients; 3 of 27 studies prompting hospitalization and/or intervention. Abdominal pain was associated with reimaging, but decreased appetite predicted imaging findings associated with readmission and intervention. Conclusion Selective abdominal reimaging for BLSI was done in 6% of patients, and 11% of studies identified radiologic findings associated with intervention or re-hospitalization. A selective reimaging strategy appears safe, and even reimaging symptomatic patients rarely results in intervention. Reimaging after 14 days did not prompt intervention in any of the 534 patients managed nonoperatively. Level of evidence Level II, Prognosis.

Right sided aortic arch (RAA) is a rare anatomic finding in infants with esophageal atresia with or without tracheoesophageal fistula (EA/TEF). In the presence of RAA, significant controversy exists regarding optimal side for thoracotomy in repair of the EA/TEF. The purpose of this study was to characterize the incidence, demographics, surgical approach, and outcomes of patients with RAA and EA/TEF.A multi-institutional, IRB approved, retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals in the United States over a 5-year period (2009 to 2014) was performed. All patients had a minimum of one-year follow-up.In a cohort of 396 infants with esophageal atresia, 20 (5%) had RAA, with 18 having EA with a distal TEF and 2 with pure EA. Compared to infants with left sided arch (LAA), RAA infants had a lower median birth weight, (1.96 kg (IQR 1.54-2.65) vs. 2.57 kg (2.00-3.03), p = 0.01), earlier gestational age (34.5 weeks (IQR 32-37) vs. 37 weeks (35-39), p = 0.01), and a higher incidence of congenital heart disease (90% vs. 32%, p 0.0001). The most common cardiac lesions in the RAA group were ventricular septal defect (7), tetralogy of Fallot (7) and vascular ring (5). Seventeen infants with RAA underwent successful EA repair, 12 (71%) via right thoracotomy and 5 (29%) through left thoracotomy. Anastomotic strictures trended toward a difference in RAA patients undergoing right thoracotomy for primary repair of their EA/TEF compared to left thoracotomy (50% vs. 0%, p = 0.1). Side of thoracotomy in RAA patients undergoing EA/TEF repair was not significantly associated with mortality, anastomotic leak, recurrent laryngeal nerve injury, recurrent fistula, or esophageal dehiscence (all p 0.29).RAA in infants with EA/TEF is rare with an incidence of 5%. Compared to infants with EA/TEF and LAA, infants with EA/TEF and RAA are more severely ill with lower birth weight and higher rates of prematurity and complex congenital heart disease. In neonates with RAA, surgical repair of the EA/TEF is technically feasible via thoracotomy from either chest. A higher incidence of anastomotic strictures may occur with a right-sided approach.Level III.

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.

In children, severe, life-threatening traumatic injuries of the thoracic aorta can be seen after motor vehicle collisions (MVCs) resulting in a sudden deceleration. Concurrent injuries in the thorax and abdomen can make treatment prioritization difficult and require early recognition and prompt intervention. With the increased utilization of minimally invasive endovascular approaches to traumatic aortic (TA) injuries, patients are often spared the increased surgical morbidity (spinal cord ischemia and renal insults) that can be seen with an open technique. The aim of this study was to evaluate a single American College of Surgeons level 1 pediatric trauma center's 22-y experience with TA injuries in children.After the Institutional Review Board approval, a 22-y (January 1990-April 2013) retrospective review of all pediatric trauma patients admitted with TA injuries was performed. Patient demographics including age, injury detail, treatment, and outcomes were recorded for analysis.17 children (21-y old) were identified with ages ranging from 13-20 y old. The most common mechanism of injury was MVC with all 17 children sustaining TA injuries. The traumatic injuries included aortic transection (9), intimal flap (5), pseudoaneurysm (2), and contained thoracic rupture (1). All children were managed operatively with those before 2008 using an open technique. The endovascular approach was used in 7/17 (41%) cases with the median length of hospitalization 12 d versus 22.5 d using the open approach (P0.05). No child required conversion from an endovascular to an open technique for treatment of the aortic injury. There were no operative deaths, no procedure-related paraplegia and all children were discharged home from the hospital. Two children had mild mental deficits as a result of head trauma.TA injuries are an uncommon injury in children and can result from MVCs or other sudden deceleration mechanisms. Surgical intervention is required in most of the cases and can be performed safely and effectively with low morbidity using an endovascular approach, which is the evolving approach of choice for thoracic aortic injuries. Lengthy follow-up care is recommended in children treated with an endovascular device to monitor for endoleaks and device complications.

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

Background The ability of ultrasound to identify specific features relevant to nonoperative management of pediatric appendicitis, such as the presence of complicated appendicitis (CA) or an appendicolith, is unknown. Our objective was to determine the reliability of ultrasound in identifying these features. Methods We performed a retrospective study of children who underwent appendectomy after an ultrasound at four children's hospitals. Imaging, operative, and pathology reports were reviewed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasound for identifying CA based on pathology and intraoperative findings and an appendicolith based on pathology were calculated. CA was defined as a perforation of the appendix. Equivocal ultrasounds were considered as not indicating CA. Results Of 1027 patients, 77.5% had simple appendicitis, 16.2% had CA, 5.4% had no evidence of appendicitis, and 15.6% had an appendicolith. Sensitivity and specificity of ultrasound for detecting CA based on pathology were 42.2% and 90.4%; the PPV and NPV were 45.8% and 89.0%, respectively. Sensitivity and specificity of ultrasound for detecting CA based on intraoperative findings were 37.3% and 92.7%; the PPV and NPV were 63.4% and 81.4%, respectively. Sensitivity and specificity of ultrasound for detecting an appendicolith based on pathology were 58.1% and 78.3%; the PPV and NPV were 33.1% and 91.0%, respectively. Results were similar when equivocal ultrasound and negative appendectomies were excluded. Conclusions The high specificity and NPV suggest that ultrasound is a reliable test to exclude CA and an appendicolith in patients being considered for nonoperative management of simple appendicitis.

Perioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF.The Midwest Pediatric Surgery Consortium conducted a multicenter, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009-2014), with a minimum 1-year follow up, across 11 centers.292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p=0.005). Postoperative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n=127; 43%); anastomotic leak (n=54; 18%); recurrent fistula (n=15; 5%); vocal cord paralysis/paresis (n=14; 5%); and esophageal dehiscence (n=5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p=0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p0.001), but no difference in the incidence of recurrent fistula (p=0.3). Empiric postoperative antibiotics for24h were used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤24h (all p0.3). Hospital volume was not associated with postoperative complication rates (p0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7.Morbidity after primary repair of proximal EA and distal TEF patients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24h and empiric acid suppression may not prevent complications. Use of a transanastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine postoperative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds.Treatment study.III.

Gastroesophageal reflux (GER) in infants, also known as chalasia of infancy, represents a common physiological phenomenon during the first year of life [1–3]. Regurgitation occurs more than once a day in 60–70 % of 3–4-month-old infants and decreases to approximately 20 % in infants between 6 and 7 months of age. By 10–12 months of age, less than 10 % of infants experience regurgitation [4–6].

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.

Inguinal hernia repair is one of the most common operations performed by pediatric surgeons. Although the practice of sending the hernia sac for histologic examination after routine hernia repair is common, the indications and practice patterns for this have not been evaluated. The objective of this survey was to determine practice patterns and indications for histologic analysis of the pediatric inguinal hernia sac.A 9-question online survey was sent to all members of the International Pediatric Endosurgery Group (IPEG). A Kruskal-Wallis test was used to determine whether practice patterns of sending the hernia sac for histologic evaluation were associated with respondent characteristics. The chi-squared test with Yates's correction was used where appropriate.The survey was completed by 315 IPEG members, for a response rate of 54.4%. Hernia sacs were sent for histologic evaluation always by 23.9%, often by 5.1%, rarely by 17.5%, and never by 53.5%. The respondent characteristics were not associated with whether or not specimens were sent for histology review. Of the 128 who reported sending the inguinal hernia sac, the most common reasons were hospital/state requirements (47.6%), followed by routine practice (25.7%) and concern for missed pathology (24.2%).The majority of IPEG respondents report never sending the inguinal hernia sac for histologic analysis. Of those that do, most are influenced by hospital/state requirements. The value of sending the hernia sac after routine inguinal hernia repair should be validated if it is to remain an institutional requirement.

Background Despite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP). Methods Multicenter study of all pyloromyotomies (May 2007–December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers. Results Data relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI 0.006–4.083]; P =0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI −0.096 to 3.365]; P =0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P =0.2) and grade of primary operator did not affect the rate of either complication. Conclusions This is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure.

The approach to inguinal hernia in the pediatric population has historically been via an open technique. Over the last decade there have been numerous reports and descriptions of laparoscopic techniques to repair inguinal hernias in this population. This article highlights different techniques and clearly outlines the currently utilized approach in our institutions.

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.

Background: The prevalence of Hirschsprung disease (HD) in the premature infant population is not well documented. However, delayed passage of stool is common in premature infants, and suction rectal biopsy (SRB) is often used to evaluate for HD in this population. The use of SRB is unknown. Therefore, we evaluated the role of SRB in premature infants with abnormal stooling patterns. Methods: After Institutional Review Board approval, a retrospective study was conducted on all infants having an SRB performed to exclude HD from January 2000 to December 2010. Infants were divided into two groups according to gestational age (premature < 37 wk; term � 37 wk). Demographics, diagnosis, treatments, and outcomes were collected. A subset analysis was performed on patients diagnosed with HD. Results: Two hundred sixty-nine infants were identified (113 premature and 156 term). Six premature infants (5.3%) and 79 term infants (50.6%) were found to have HD (P < 0.01). As expected, gestational age was significantly different between groups (31.7 versus 38.9 wk, P< 0.01) (Table 1). Premature infants were less likely to have prenatal care (35% versus 55%, P < 0.01) and had longer lengths of hospital stay (45.6 versus 17.6 d, P < 0.01). The most common locationofaganglionosiswasrectosigmoidinbothgroups(group1,50%;group2,33%,P ¼0.7). Conclusions: HD occurs significantly less often in premature infants than in term infants. Alternative diagnoses should be investigated in this population when delayed stooling patterns are encountered. SRB should be used more selectively in this group.

Purpose We instituted a clinical pathway for the care of patients with perforated appendicitis based on outcomes from several clinical trials. The objective of this study was to review effects on resource utilization with this protocol. Methods A retrospective review was conducted to compare all patients undergoing appendectomy during initial admission for perforated appendicitis prior to the pathway (July 2001 to December 2003) to after (December 2008 to March 2011). Demographics and management strategies were evaluated. Results Charts of 151 patients prior to and 259 after the start of the pathway were reviewed. The percentage of patients leaving the operating room with a nasogastric tube (NGT) was significantly lower in the after-group, while similar numbers of patients during each period had a NGT placed on the floor. The proportion of patients receiving peripherally inserted central catheters and total parenteral nutrition, and the number of intravenous antibiotics per day and lab draws were significantly reduced with the protocol. Patients were started on a regular diet significantly earlier, and length of stay was shortened by more than one day. Conclusion The evidence-based clinical pathway developed from prospective trials has drastically reduced resource utilization for children with perforated appendicitis.

Perforated appendicitis is associated with abscess formation before or after appendectomy. Many abscesses are not amenable to drainage due to size or location. In this study, we compare patients who had a drain placed for an abscess to those who were treated without a drain.Data were retrospectively collected from January 2000 to March 2011. Abscess before or after appendectomy was assessed. CT scans were reviewed and abscess size was estimated using the product of the greatest anteroposterior and lateral dimensions from an axial image. Patients with abscess smaller than 5 cm(2) were excluded. Patients treated with a drain were compared to those without using t test for continuous variables and Fisher's exact for categorical variables.Of 217 patients, those with drains had significantly more CT scans, total healthcare visits and larger abscess size. When match controlled for size, drain patients accrued more CT scans and healthcare visits. In a subset analysis of aspiration versus antibiotics only, there were more CT scans but no difference between length of stay, total healthcare visits, abscess size, recurrence, or complications.Appendicitis-associated abscesses may be treated with antibiotics alone based on size, which improves resource utilization with fewer CT scans and healthcare visits.

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.

Background Gastrostomy tube placement is common in children. Many of the conditions associated with need for gastrostomy are also associated with gastroesophageal reflux. It is not clear how many patients without complicated reflux will subsequently require a fundoplication or which conditions increase this risk. Therefore, we performed a two-center review to determine the disease-specific propensity for fundoplication after gastrostomy tube placement. Methods The data set was retrospectively collected from two centers from 2000 to 2008. All patients underwent gastrostomy tube placement without fundoplication owing to the surgeon's discernment that fundoplication was not needed at the time. Pearson's correlation was used to evaluate the influence of patient variables and operative approach against the subsequent need for fundoplication. Significance was defined as two-tailed P ≤ 0.01. Logistic regression analysis was used to evaluate independence. Results A total of 684 patients underwent gastrostomy tube placement only, of which 124 were open, 282 laparoscopic, and 278 endoscopic (percutaneous endoscopic gastrostomy). The mean patient age was 2.9 years. Subsequent fundoplication was performed in 62 patients (9.1%). The mean interval to fundoplication was 20.7 months. Cerebral palsy and anoxic brain injury had the most significant correlation with subsequent fundoplication. These were also independent predictors. The laparoscopic approach had a negative correlation with the subsequent need for fundoplication. Conclusions The low incidence of subsequent fundoplication in children who undergo gastrostomy tube placement justifies conservative use of fundoplication in the absence of complicated reflux. Those with cerebral palsy and anoxic brain injury appeared to have the greatest risk of the need for subsequent fundoplication.

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.

Thoracoscopy is the preferred approach for lung biopsy or lobectomy in infants and children. The indications for surgical intervention are classified as congenital (congenital pulmonary malformations, sequestrations, congenital lobar emphysema) or acquired (metastatic and infectious etiologies, spontaneous pneumothorax, primary lung disease). The practicing pediatric surgeon should have a good working knowledge of the indications, diagnostic evaluation, and anesthetic and surgical considerations surrounding both the open and thoracoscopic approaches in these patients.