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Background: There is little information available to inform choice of technique for appendiceal stump control in pediatric laparoscopic appendectomy (LA). We compared complications (stump leak, intra-abdominal abscess formation [IAA], surgical site infection [SSI]) in children undergoing LA for perforated (PA) and nonperforated appendicitis (NPA) by technique of appendiceal stump control. Methods: All children who underwent LA for confirmed acute appendicitis between 2006 and 2009 were reviewed. Choice of stump control (endoloop [EL] or endostapler [ES]) was determined by surgeon preference. Interactions between stump closure techniques and other potential confounders (intra-abdominal drain, irrigation, different antibiotic regimens) were explored using a logistic regression model. Results: Of 242 patients undergoing LA, 57 (23.6%) had PA. In the PA group the appendiceal stump was closed with EL in 47 (82.5%) patients, while in the NPA group EL was used in 161 (87%) patients. Among PA patients, IAA was more common in the ES than the EL group (5 of 10 [50%] v. 6 of 47 [12.7%]). There was no significant difference in rates of SSI. Among NPA patients, there were no differences in rates of IAA or SSI. There were no stump leaks in either group. Logistic regression analysis confirmed the predictive effect of ES use on IAA formation in PA (adjusted odds ratio 7.09; 95% confidence interval 1.08-46.13; p = 0.042). Conclusion: Our data suggest that in most cases of PA, the appendiceal stump can be safely controlled with EL. Within the PA group, the higher rates of IAA seen in ES patients may be attributable to the quality of the appendiceal stump rather than the technique of closure. Contexte : Il y a peu d'information disponible pour eclairer le choix de la technique de controle du moignon de l'appendice au cours d'une appendicectomie par laparoscopie (AL) en pediatrie. Nous avons compare les complications (fuite au niveau du moignon, apparition d'un abces intra-abdominal [AIA], infection du champ operatoire [ICO]) chez des enfants qui ont subi une AL a cause d'une appendicite perforee (AP) et non perforee (ANP) effectuee au moyen de la technique du controle du moignon de l'appendice. Methodes : Nous avons etudie les dossiers de tous les enfants qui ont subi une AL a cause d'une appendicite aigue confirmee entre 2006 et 2009. Le choix de la technique de controle du moignon (ligature endoloop [EL] ou agrafe endostapler [ES]) a ete determine par la preference du chirurgien. Nous avons explore les interactions entre les techniques de fermeture du moignon et d'autres facteurs confusionnels possibles (drain intra-abdominal, irrigation, antibiotherapie differente) au moyen d'un modele de regression logistique. Resultats : Sur 242 patients qui ont subi une AL, 57 (23,6 %) avaient une AP. Chez les patients qui avaient une AP, le moignon de l'appendicite a ete referme par ligature EL dans 47 cas (82,5 %), tandis qu'on a utilise la ligature EL chez 161 (87 %) des patients qui avaient une ANP. Chez les patients qui avaient une AP, l'ICO etait plus frequente chez ceux qui ont recu des agrafes ES que chez ceux qui ont recu une ligature EL (5 sur 10 [50 %] c. 6 sur 47 [12,7 %]). Il n'y avait pas de difference significative sur le plan des taux d'ICO. Chez les patients qui avaient une ANP, on n'a constate aucune difference quant au taux d'apparition d'un AIA ou d'une ICO. Il n'y avait pas de fuite au niveau du moignon chez les membres des 2 groupes. L'analyse par regression logistique a confirme l'effet predicteur de l'utilisation de l'agrafe ES sur l'apparition d'AIA dans les cas d'AP (ratio d'incidence ajuste 7,09; intervalle de confiance a 95 %, 1,08-46,13;p = 0,042). Conclusion : Nos donnees indiquent que dans la plupart des cas d'AP, il est possible de controler le moignon de l'appendice en toute securite au moyen d'une ligature EL. Chez les patients qui ont subi une AP, les taux plus eleves d'AIA constates chez ceux qui ont recu des agrafes ES peuvent etre attribuables a la qualite du moignon d'appendice plutot qu'a la technique de fermeture., Appendectomy is one of the most common operations performed by pediatric surgeons, and whereas laparoscopic appendectomy (LA) has increased in popularity, its ability to offer a definitive outcome advantage over [...]

Objective: Coin-shaped button battery foreign bodies have a similar initial presentation to coin ingestion, but delayed retrieval of a battery from the esophagus can have devastating consequences. Variations in timing of retrieval for children with ingestion of coin foreign bodies have been reported. The study assesses the sensitivity and specificity of conventional and digital radiographs to differentiate button batteries from coin foreign bodies. Study Design: 3B case control study. Study Setting: Tertiary academic medical center. Methods: A radiographic study of the 12 most common commercially available button batteries and 66 coins of varying international origins was performed. Foreign bodies were placed at the cervical esophagus of a cadaver, and anteroposterior (AP) and lateral conventional radiographs of the neck were obtained. Digital AP and lateral radiographs of standalone coins and batteries were also obtained. Images were blindly read by 2 otolaryngologists and 2 radiologists. Statistical analysis was performed to determine accuracy in identifying coins vs batteries. Results: Using conventional radiographs to identify button batteries yielded a sensitivity of 0.88 and a specificity of 0.92 (positive predictive value [PPV] = 0.75, negative predictive value [NPV] = 0.97). Digital radiography yielded an overall sensitivity of 0.98 and specificity of 0.97 (PPV = 0.87, NPV = 0.99). Features of button batteries were only seen on AP conventional radiographs using reverse contrast. Conclusions: Neither conventional nor digital radiographic imaging had perfect accuracy in identifying coins vs batteries. Features of common disc batteries were identified, which may aid in diagnosis. With potential devastating consequences from retained battery in the esophagus, emergent removal of any possible disc battery foreign body should be considered. [ABSTRACT FROM AUTHOR]

Gastroschisis (GS) is a structural defect of the anterior abdominal wall, usually diagnosed antenatally, that occurs with a frequency of approximately 4 per 10,000 pregnancies. Babies born with GS require neonatal intensive care and surgical management of the abdominal wall defect soon after birth. Although contemporary survival rates for GS are over 90%, these babies are at risk for significant morbidity, and require 4 to 6 weeks of costly, resource-intensive care in specialized neonatal units. Much consideration has been given to how best to treat the abdominal wall defect of GS. The traditional approach, necessitated by a need to establish enteral feeding as quickly as possible, consists of early postnatal visceral reduction and sutured abdominal closure. Advances in neonatal nutritional support have enabled the development of surgical approaches, which permit gradual visceral reduction and delayed abdominal closure. In cases where early visceral reduction cannot be achieved, delayed closure enabled by the initial placement of a prosthetic silo has been a live-saving alternative. The development of preformed silos has simplified their use and led to an interest in treating all cases with a delayed closure philosophy. Most recently, a sutureless technique of abdominal closure has been reported, which has the benefit of avoiding general anesthesia and offers other outcome improvements over sutured closure of the defect. The debate over primary closure versus silo placement and delayed closure continues to receive much attention. The goal of this article is to review historical aspects of gastroschisis closure, and then focus on current surgical techniques, including the innovative sutureless closure, with an analysis of the comparative clinical effectiveness of these approaches to treatment of the abdominal wall defect in GS.

Options for intracorporeal appendiceal stump closure span a variety of techniques including ligation using intra-corporeal knots, extra-corporeal knots, or an endo-loop (EL), closure with endoscopic clips (EC), or endoscopic stapled (ES) closure. The guiding principles are the need for secure, inert closure of the appendiceal base without injury to the appendiceal stump or cecum, with minimal risks of complication attributable to the closure technique. Safety and complication rates, as well as cost data, should guide the techniques used for pediatric laparoscopic appendectomy. Based on the literature available there is not a clear answer as to the best method for closing the appendiceal stump in pediatric patients, with each of the methods described providing safe closure. Many institutions and surgeons may favor a selective approach, with choice of closure determined by the condition of the appendix at laparoscopy.

Background: Identification of attributes of residency training that predict competency would improve surgical education. We hypothesized that case experience during residency would correlate with self-reported competency of recent graduates., Methods: Aggregate case log data of residents enrolled in 2 general surgery programs were collected over a 12-month period and stratified into Surgical Council on Resident Education (SCORE) categories. We surveyed recent (< 5 yr) residency graduates on procedural competency. Resident case volumes were correlated with survey responses by SCORE category., Results: In all, 75 residents performed 11 715 operations, which were distributed by SCORE category as follows: essential-common (EC) 9935 (84.8%), essential-uncommon (EU) 889 (7.6%) and complex 891 (7.6%). Alimentary tract procedures were the most commonly performed EC (2386, 24%) and EU (504, 56.7%) procedures. The least common EC procedure was plastic surgery (4, 0.04%), and the least common EU procedure was abdomen-spleen (1, 0.1%). The questionnaire response rate was 45%. For EC procedures, self-reported competency was highest in skin and soft tissue, thoracic and head and neck (each 100%) and lowest in vascular-venous (54%), whereas for EU procedures it was highest in abdomen-general (100%) and lowest in vascular-arterial (62%). The correlation between case volume and self-reported competency was poor (R = 0.2 for EC procedures)., Conclusion: Self-reported competency correlates poorly with operative case experience during residency. Other curriculum factors, including specific rotations and timing, balance between inpatient and outpatient surgical experience and competition for cases, may contribute to procedural competency acquisition during residency.

Background: Tuberculosis (TB) continues to be a major health problem in developing countries. Contact investigation is the most appropriate strategy to interrupt transmission and subsequent development of TB., Methods: This cross-sectional study was conducted to assess the impact of contact screening on case-finding by using tuberculin skin test chest radiography. Contacts of smear-positive patients with pulmonary TB (index cases) were diagnosed and registered in our center during 2002 - 2004. Contacts, defined as household members living with index cases for >30 days, were screened by sputum examination, tuberculin skin test, and chest radiography., Results: Sixty-eight patients with smear-positive pulmonary TB were considered as index cases. A total of 224 close contacts with index cases (an average of 3 contacts for each index case) were detected. Age among contacts ranged from 6 months to 74 years. Eighty-three percent of contacts were Iranians and 17% were Afghans. Abnormal radiographs were seen in 49.6% of contacts. Sixteen point five percent of contacts had a positive tuberculin skin test of >10 mm; 7.6% had a positive sputum smear. The mean +/- SD age of Iranian contacts (29.1 +/- 16.6 years) was significantly (P < 0.001) higher than that of Afghans (18.6 +/- 14.1 years). Cavitary formation, nodular pattern, and infiltration were found to have a strong association with a positive sputum smear for acid fast bacilli (100%, 100%, and 87%, respectively)., Conclusion: The rate of TB in contacts was higher than other similar studies. Earlier detection and treatment of adults with TB could interrupt transmission and be a step towards eliminating childhood TB. Contact control and source-case investigations should be emphasized for TB control. Novel strategies are needed to maximize the number of contacts who are not only identified and evaluated, but also completely treated.