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Pediatric Crohn disease is characterized by clinical and endoscopic relapses. The inflammatory process is considered to be progressive and may lead to strictures, fistulas, and penetrating disease that may require surgery. In addition, medically refractory disease may be treated by surgical resection of inflamed bowel in an effort to reverse growth failure. The need for surgery in childhood suggests severe disease and these patients have an increased risk for recurrent disease and potentially more surgery. Data show that up to 55% of patients had clinical recurrence in the first 2 years after initial surgery. The current clinical report on postoperative recurrence in pediatric Crohn disease reviews the risk factors for early surgery and postoperative recurrence, operative risk factors for recurrence, and prevention and monitoring strategies for postoperative recurrence. We also propose an algorithm for postoperative management in pediatric Crohn disease.

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

Over the last decade, our institution has experienced a relative increase in the number of mundane cases, such as appendectomy and incision and drainage of abscess, versus index (complex) cases. We sought to determine if this trend is present at the national level.A retrospective review of surgical case volume at 36 freestanding children's hospitals was performed between January 2004 and December 2013 using the Pediatric Health Information System (PHIS) database. Procedures were classified as "mundane" or "index", and 10 procedures of each type were selected for analysis. Results were reported as a percentage of total cases. Statistical analysis of linear trends was performed with the Mann-Kendall test.Overall, index procedures had a significant downward trend (p0.01), whereas mundane procedures had a significant upward trend (p0.01). Individually, 5 mundane procedures had significant upward trends, and 3 had downward trends. Five index procedures had significant downward trends, and none had an upward trend.The field of pediatric surgery is undergoing change with mundane procedures constituting an increasing proportion of the surgical caseload, while complex procedures are proportionately decreasing. These trends may be useful to inform decisions regarding future pediatric surgery workforce planning.

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

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

Tracheobronchial disorders refer to a wide variety of both congenital and acquired diseases involving the lower airway. Rigid and flexible bronchoscopy plays a role in both the diagnosis and treatment of many of these disorders. Foreign body aspiration is the most commonly encountered entity. This chapter provides an overview of many of the tracheobronchial disorders, as well as equipment and technique.

In any age group, creation of an intestinal stoma is a significant event with major physiologic, body image, lifestyle, and psychosocial implications. Management and indications for ostomies in infants and young children are often different than in adolescents and adults. This is a consequence of the differing diagnoses, physiology, size, growth and development issues, complications, and unique patient and parental adjustment concerns.

Since the introduction of robotic surgery in children in 2001, it has been employed by select pediatric laparoscopic surgeons, but not to the degree of adult surgical specialists. It has been suggested that the technical capabilities of the robot may be ideal for complex pediatric surgical cases that require intricate dissection. However, due to the size constraints of the robot for small pediatric patients, the tight financial margins that pediatric hospitals face, and the lack of high level data displaying patient benefit when compared to conventional laparoscopic surgery, it may be some time before the robotic surgical platform is widely embraced in pediatric surgical practice.

Obstruction and thrombosis of major systemic veins can occur due to indwelling central venous catheters. If obstruction of the innominate vein or superior vena cava occurs, lymphatic drainage can be impaired due to an increase in pressure in the thoracic duct and lymphatics. We describe a case where superior vena cava syndrome, chylopericardium and chylothorax occurred in a 16-year-old girl due to an indwelling central venous catheter. This was successfully treated with removal of the line, anticoagulation and angioplasty of the innominate vein and superior vena cava.

Purpose: The aim of this study was to assess the utility of technetium (Tc) 99m pertechnetate scintigraphy in the diagnostic workup of the pediatric patient with gastrointestinal (GI) bleeding and a suspected Meckel's diverticulum. Methods: The charts of 235 consecutive patients evaluated with a Meckel's scan (n = 165) or with the discharge diagnosis of Meckel's diverticulum (n = 70) between January 1975 and October 1997 were reviewed for presenting symptoms, bleeding characteristics, diagnostic studies and pathological diagnosis. Those patients with lower GI bleeding and a serum hemoglobin level less than 11.0 g/dL who underwent a 99m Tc pertechnetate scan (n = 43) were assessed for utility of the scan. Results: In all patients the Meckel's scan had a positive and negative predictive value of 0.93. However, in patients with lower GI bleeding and a hemoglobin less than 11.0 g/dL the Meckel's scan had a sensitivity of 0.60, a positive predictive value of 1.0, a specificity of 0.96, but only a negative predictive value of 0.74. As such, the probability that a child who presents with GI bleeding and a serum hemoglobin less than 11 g/dL will have a Meckel's diverticulum despite a negative Meckel's scan of 0.26. We further evaluated the eight patients with a false-negative scan: ectopic gastric mucosa was present on pathological examination in all eight patients. Pentagastrin stimulation was performed at the time of scintigraphic study in three of eight. Six of these eight patients had duplicate scans that also were negative. Patients with a false-negative (FN) scan had significantly increased hospital charges when compared with those with a true positive (TP) scan (TP = $5012 ± 1992; FN=$8554 ± 1506; P = .0001). Clinical suspicion had a major effect on the decision-making process in these patients independent of the results of the Meckel's scan, and all eight patients ultimately underwent exploratory laparoscopy-laparotomy with Meckel's diverticulectomy despite the scan results. Conclusions: The relatively low negative predictive value of the Meckel's scan may result in the need for operative evaluation despite the scan data. As such, the contribution of the scan to clinical decision making is low. These findings suggest that exploratory laparotomy or laparoscopy may be indicated instead of scintigraphic scanning in the assessment of the anemic (hemoglobin less than 11 g/dL) pediatric patient with lower GI bleeding, especially in patients in whom a high suspicion for a bleeding Meckel's diverticulum exists.

ADHD has been estimated to affect between 1 and 20% of children although most estimates range between 3% and 5%. Treatment of children with ADHD begins with making the correct diagnosis and this is based upon criteria delineated in the Diagnostic and statistical manual of mental disorders, 4th ed. (DSM-IV) in addition to other clinical factors that are assessed by the physician.9 When the diagnosis of ADHD is confirmed, a combination of behavioural therapy and pharmacological treatment with stimulants is commonly instituted. Some practitioners and many parents opt to withhold these stimulant medications during the summer months when children are out of school and not expected to perform academically. Traumatic injury is a major cause of death and disability in children. A recent report suggests that more than 50% of deaths in children between the ages of 1 and 19 are related to traumatic injury. Continued improvements in automobile safety, the widespread institution of injury prevention programs and the installation of smoke detectors and sprinklers appear to have decreased the rate of death due to accidental injury but as of 1997, trauma continues to be the leading killer of children in the United States. Compared to 21,727 childhood deaths due to injuries in 1979, 11,694 children died due to unintentional injuries in 1997, a reduction by nearly 50%. Despite these optimistic figures, many children still die or are seriously injured each year due to preventable causes. While automobile safety and injury prevention programs have clearly improved safety for children, there may be additional underappreciated factors that place many children at risk for injury and death. One of these factors may be the presence of attention-deficit/hyperactivity disorder (ADHD), which is now believed to be the most common neurobehavioral disorder in children. The purpose of this report is to describe the cases of two children with a diagnosis of ADHD who suffered severe, disabling lower extremity injuries and to highlight the possible importance of this co-morbidity and its treatment in the context of paediatric trauma. The two cases described in this report occurred during the same summer and are examples of the consequences of risk-taking behaviour on the part of two children with ADHD. While safety measures such as seatbelts, smoke detectors and bicycle helmets may be having a favourable impact upon the incidence and severity of paediatric trauma, children with psychological or behavioural disorders constitute a high-risk cohort that should not be ignored. Both of the children reported were on summer vacation and had been counselled to discontinue their ADHD medications while out of school. Since children with ADHD may be at increased risk for injury and even death, the following recommendations may be made for emergency department paediatricians, psychiatrists, primary care providers as well as parents. First, clinicians should encourage parents to be particularly watchful of their children during the summer while the child is not in school. Adequate parental supervision of children should be particularly stressed as lack of adequate supervision has been clearly linked to a significant percentage of paediatric injuries. Bicycle helmets and assistance to children in busy streets and neighbourhoods should be actively recommended as all children and especially those with ADHD appear to be in danger while on bicycles and while crossing or playing in streets. Second, health care providers should look for symptoms of ADHD when evaluating any injured child. A recent study suggests that a significant number of primary care paediatric office visits occur for evaluation and treatment of relatively minor injuries such as lacerations, sprains and contusions. Early recognition of symptoms of ADHD in this setting may allow for referral of a potentially injury prone child to a paediatric psychiatrist or primary care paediatrician for treatment of ADHD before a more serious or life-threatening injury occurs. Third, when providing care to children with ADHD, the clinician should attempt to educate the parents about the risks of trauma and the importance of preventive measures such as seatbelts and helmets. Finally, it would be our recommendation that consideration be given to continuation of medications prescribed for treatment of ADHD during the summer months when children are involved in outdoor activity and at increased risk for trauma.

Sacrococcygeal teratoma is the most common type of extragonadal germ cell tumor in infants and young children. Sacrococcygeal teratomas can uncommonly present in an intra-abdominal fashion, with minimal clinical findings. Dermatologic lesions overlying the vertebrae or buttocks are often associated with sacrococcygeal teratoma and may be the only clue to their presence. Here, we report a case of an intra-abdominal sacrococcygeal teratoma presenting with an anatomically separate buttock hemangioma.

Osteosarcoma metastasis to the gastrointestinal tract is a rare phenomenon (Horiuchi A, Watanabe Y, Yoshida M, et al.: Metastatic osteosarcoma in the jejunum with intussusception: report of a case. Surg Today 2007;37:440-2). Gastrointestinal metastases may cause intussusception, bowel obstruction, or hemorrhage (Horiuchi A, Watanabe Y, Yoshida M, et al.: Metastatic osteosarcoma in the jejunum with intussusception: report of a case. Surg Today 2007;37:440-2; Chondramohan K, Somanathan T, Kusamakumary P: Metastatic osteosarcoma causing intussusception. J Pediatr Surg 2003;38(E44):1-3; Hung GY, Chiou TJ, Hsieh YL, et al.: Intestinal metastasis causing intussusception in a patient treated for osteosarcoma with history of multiple metastases: a case report. Jpn J Clin Oncol 2001;31:165-167). We report a case of a 17 year old male with osteosarcoma metastatic to the stomach and ascending colon, causing significant chronic gastrointestinal hemorrhage. Surgical resection was performed due to persistent, symptomatic anemia. The patient is free of recurrent hemorrhage at 24months after metastectomy. Resection of gastrointestinal metastases of osteosarcoma offers good palliation of chronic hemorrhage related to these lesions.

Stomas of the gastrointestinal tract represent some of the most commonly performed surgical procedures, and most frequent management dilemmas, in the practice of pediatric surgery. The wide variety of congenital anomalies and functional disorders of the intestinal tract encountered by the pediatric surgeon has led to the development of a creative and sometimes unconventional repertoire of options for providing access and decompression of the GI tract at every level. Some of the first surviving patients of decompressive enterostomy operations were children with congenital intestinal obstructions, and over the long history of stomal development by general surgeons treating adults there has been a parallel development of stoma techniques directed at addressing pediatric diseases. Often, the techniques first developed in adults were adapted for children with good results. On occasion, a surgical problem unique to children required a solution that had no corollary in the adult surgical experience, requiring the development of an innovative approach for a rare disease process that did not present a large enough clinical volume to submit new ideas to objective analysis. Over the years, accumulated experience has played a large role in selecting and discarding these techniques. In this chapter, we present an overview of gastrointestinal stoma techniques that have proven to be useful over time and which have been widely adopted as standard options in the care of children with gastrointestinal problems. A number of selected references are also offered for further reading.

Purpose The aim of this study was to determine the role of thyrotropin receptor messenger RNA as a novel blood test for evaluation of thyroid nodules and cancer in children. Methods We reviewed thyroid disease management of patients younger than 18 years with thyrotropin receptor messenger RNA measurements identified from a prospective, institutional review board-approved registry during 2008 to 2010. Results Thirty-nine thyrotropin receptor messenger RNA measurements were made in 21 female patients (12-17 years old; median, 16 years). Four patients with fine-needle aspiration only had benign thyroid cytology, and 3 of 4 had undetectable thyrotropin receptor messenger RNA. Seventeen patients underwent 22 thyroid operations. Preoperative thyrotropin receptor messenger RNA was measured in 9 patients: 3 of 4 with thyroid cancer had elevated levels and 3 of 5 with goiters undetectable. Postthyroidectomy surveillance (median, 16 months; range, 6-24) of 11 thyroid cancer patients (8 papillary, 3 follicular) showed that thyrotropin receptor messenger RNA was concordant with thyroglobulin in 14 (73%) of 19 measurements. In 3 (16%) of 19 measurements, thyrotropin receptor messenger RNA was the only blood test useful for disease assessment because of elevated antithyroglobulin antibodies. Overall, to predict thyroid cancer, thyrotropin receptor messenger RNA demonstrated 73% sensitivity, 82% specificity, 62% positive predictive value, 88% negative predictive value, and 79% accuracy. Conclusion Thyrotropin receptor messenger RNA provides complementary evaluation to thyroglobulin and fine-needle aspiration for pediatric thyroid nodule management.

Background. The Nuss procedure was introduced in 1987 for the correction of pectus excavatum. In this procedure, a stainless steel bar is placed underneath the sternum. Objectives. To report cutaneous reactions associated with Nuss bar placement. Methods. Over a period of 30 months, 50 patients underwent the Nuss procedure. The study population was limited to those who developed clinically significant cutaneous reactions postoperatively. Patient information was obtained from electronic medical records. All patients had been patch tested preoperatively with stainless steel discs supplied by the bar manufacturer. When performed, expanded patch testing was carried out in accordance with the North American Contact Dermatitis Group guidelines. Results. Postoperatively, 3 patients developed areas of protuberant granulation tissue at one or more incision sites. One patient developed localized oedema, dermatitis, and lymphadenopathy. Two of these 4 patients underwent further patch testing. Of these 2, 1 with dermatitis had a positive reaction to nickel and the other, with granulation tissue, tested negative for metal allergy. Conclusions. Despite clinical evidence of cutaneous reactions or putative allergy, no patient required early removal of the bar(s). Cutaneous testing with stainless steel discs supplied by the bar manufacturer does not provide accurate screening for allergy to the implant used in the Nuss procedure.

Congenital infantile fibrosarcoma is a rare soft tissue malignancy that occurs in both axial and extremity locations. We report a case of this tumor arising from the left colon in a newborn presenting with an intrauterine perforation and meconium peritonitis.

Cancer can be preferentially damaged and killed at temperatures above 41.0 degrees C. However, the heart and brain malfunction at this temperature, limiting the application of systemic hyperthermia in the treatment of metastatic cancer. We created a hyperthermic perfusion system that maximizes the temperature differential produced and extends the safe hyperthermic time. Mongrel dogs were anesthetized and mechanically ventilated. Temperature probes were placed in the rectum, bladder, peritoneal cavity, proximal aorta, pulmonary artery, and right tympanic canal. Venoarterial perfusion was instituted and the perfusate was warmed to 44 to 45 degrees C. The dogs' rectal temperature was elevated toor = 42 degrees C for 4 hours. A small amount of venous blood was cooled to 28 to 30 degrees C and reperfused into the right atrium to maintain the pulmonary artery temperatureor = 38 degrees C. At the end of the perfusion, the dogs were decannulated, recovered, and returned to their cages for observation. Ten of 11 dogs survived the operative procedure, and no neurologic deficits were observed. The rectal temperature was successfully elevated toor = 42 degrees C for 4 hours while maintaining the heart and brain ator = 38 degrees C. Moderate serum biochemical changes were observed postprocedure. However, only the aspartate transaminase and alkaline phosphatase levels remained elevated above both the baseline and canine reference values by day 7. Lower abdominal and pelvic hyperthermia at 42 degrees C can be safely produced and maintained for 4 hours using an extracorporeal perfusion circuit, while protecting the heart and brain from temperature elevation.

Stable and reproducible large animal models of hepatic failure, which allow the assessment of liver-assist devices, are not available. Our objective was to develop a physiologically stable animal model of hepatic failure on which the safety and efficacy of an extracorporeal liver-assist device can be tested. We hypothesized that a surgical model which consists of an end-to-side portocaval shunt combined with common bile duct ligation and transection would create hepatic failure with: (1) elevations in amino transferases, total bilirubin, and ammonia; (2) a decrease in the ratio of branched chain to aromatic amino acids; and (3) histologic evidence of hepatic injury.Eleven mongrel dogs underwent common bile duct transection and an end-to-side portocaval shunt. Aminotransferases (AST, ALT), total bilirubin, ammonia, and branched chain and aromatic amino acids were measured prior to operation (baseline) and after 9 days. A necropsy was performed on Postoperative Day 9 and liver biopsies were obtained for histology.By Postoperative Day 9, AST, ALT, total bilirubin, and ammonia values were significantly elevated compared to baseline (P0.02). The ratio of branched chain to aromatic amino acids was significantly reduced compared to baseline (P0.003). There was histologic evidence of cholestasis and inflammation.Portocaval shunt with common bile duct transection produces liver failure with elevations in aminotransferases, total bilirubin, and ammonia, a decreased branched chain to aromatic amino acid ratio, and histologic inflammation. Unlike ischemic or chemically induced models of liver failure, the dogs were hemodynamically and neurologically stable. This model can be used to test the safety and efficacy of liver-assist devices aimed at temporizing the detoxification functions of the failing liver.

The aim of this study was to identify factors associated with malignant etiologies of childhood peripheral lymphadenopathy and to construct a model that may be used to assess the risk of malignancy.The medical records of 60 consecutive patients 18 years old or less who underwent peripheral lymph node biopsies were reviewed.Increasing node size, number of sites of adenopathy, and age were associated with an increasing risk of malignancy (P.05 for all variables). Graphs useful for risk determination were constructed based on these variables. Additional factors associated with malignancy included the presence of supraclavicular adenopathy (P.01), an abnormal chest x-ray (P.01), and fixed nodes (P.01). Variables that were not statistically different between patients with benign and malignant adenopathy included the duration of adenopathy (P = .43), the presence of fever (P = .36), cough (P = .14), splenomegaly (P = .93), skin involvement (P = .39), tenderness (P = .49), and bilateral adenopathy (P = .39). Fluctuance was associated with benign adenopathy (P.04).The risk of malignancy increased with increasing size and number of sites of adenopathy and age. Other significant predictors of malignancy included supraclavicular location, an abnormal chest x-ray, and fixed nodes. These data may be used to supplement clinical judgment to predict the risk of malignancy.

Traditionally, adult sepsis has been considered a contraindication to extracorporeal life support (ECLS). The objective of this study was to review the authors' institutional experience with a subgroup of adult patients requiring ECLS for severe respiratory failure and sepsis. Hospital records from 100 consecutive adult patients with respiratory failure placed on ECLS between 1990 and 1996 were retrospectively reviewed. Patients with sepsis as a primary indication were identified, and blood culture data reviewed. Data were analyzed with t tests and chi-square and are presented as mean +/- standard deviation. Multiple logistic regression determined the impact of sepsis and positive blood cultures (PBCs) on survival. Fourteen patients required ECLS for sepsis; 36 had PBCs during hospitalization (15 before or during ECLS). Septic patients had lower pre-ECLS PaO2/FIO2 ratios (septic: 53 +/- 14 mmHg, nonseptic: 70 +/- 68 mmHg, p = 0.04). Patients with PBCs before or during ECLS were younger (PBC: 29 +/- 6 years, no PBC: 35 +/- 13 years, p = 0.003), remained on ECLS longer (PBC: 485 +/- 336 hours, no PBC: 232 +/- 212 hours, p = 0.01), and were more frequently cannulated within 12 hours (PBC: 15/15, no PBC 60/85 p = 0.02). Neither group differed in organ dysfunction (incidence or type), frequency of respiratory recovery, or survival. Neither sepsis nor positive blood cultures were independently predictive of mortality. Sepsis and positive blood cultures do not adversely affect outcome in adult patients with respiratory failure requiring ECLS.

Pulmonary sequestration is a focal area of nonfunctioning, dysplastic lung parenchyma that lacks communication with the normal tracheobronchial tree. It is supplied by the systemic arterial circulation and has two types, intralobar and extralobar, that can be differentiated from each other by the pleural covering and the venous drainage. Their coexistence is extremely rare. We report the imaging findings of a patient who had coexisting but completely separate intralobar and extralobar sequestrations at the left lower lung. We elucidated the complex vascular anatomy using three dimensional volume rendering and multiplanar reconstructions from a 64-detector helical CT scanner.