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Purpose: This report describes complications using the vertical expandable prosthetic titanium rib (VEPTR) for thoracic insufficiency syndrome (TIS) at a single center., Methods: This is a prospective cohort evaluating 65 patients with rib-rib and rib-spine VEPTR devices for TIS placed between 10/2001 and 11/2014, for children with spinal or chest wall deformity. Patients were classified using the early onset scoliosis classification system (C-EOS)., Results: 65 patients are available for follow up. 23 congenital scoliosis, 12 neuromuscular, 14 syndromic, 2 idiopathic and 14 not classifiable by the C-EOS system including 11 chest wall reconstructions. Average age at implantation was 6.9years (range 1.3-24.8) with average follow up 6.9years (range 0.4-14.8). 22 patients had 37 complications. Those classifiable by C-EOS had complications in the normo- and hyperkyphotic groups. Implant erosion and infection were most common. The majority of complications required one additional unplanned surgery for resolution. Two complications required abandonment of a growth-friendly strategy., Conclusions: Use of VEPTR for TIS is associated with significant and frequent complications. C-EOS suggests that complications are more likely in those with normal or hyperkyphotic curves. Most complications are managed with one unplanned surgery. VEPTR is usually salvaged and abandonment of a growth-friendly strategy is unusual., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Importance: The number of practicing pediatric surgeons has increased rapidly in the past 4 decades, without a significant increase in the incidence of rare diseases specific to the field. Maintenance of competency in the index procedures for these rare diseases is essential to the future of the profession., Objective: To describe the demographic characteristics and operative experiences of practicing pediatric surgeons using Pediatric Surgery Board recertification case log data., Design, Setting, and Participants: We performed a retrospective review of 5 years of pediatric surgery certification renewal applications submitted to the Pediatric Surgery Board between 2009 and 2013. A surgeon's location was defined by population as urban, large rural, small rural, or isolated. Case log data were examined to determine case volume by category and type of procedures. Surgeons were categorized according to recertification at 10, 20, or 30 years., Main Outcome and Measure: Number of index cases during the preceding year., Results: Of 308 recertifying pediatric surgeons, 249 (80.8%) were men, and 143 (46.4%) were 46 to 55 years of age. Most of the pediatric surgeons (304 of 308 [98.7%]) practiced in urban areas (ie, with a population >50 000 people). All recertifying applicants were clinically active. An appendectomy was the most commonly performed procedure (with a mean [SD] number of 49.3 [35.0] procedures per year), nonoperative trauma management came in second (with 20.0 [33.0] procedures per year), and inguinal hernia repair for children younger than 6 months of age came in third (with 14.7 [13.8] procedures per year). In 6 of 10 "rare" pediatric surgery cases, the mean number of procedures was less than 2. Of 308 surgeons, 193 (62.7%) had performed a neuroblastoma resection, 170 (55.2%) a kidney tumor resection, and 123 (39.9%) an operation to treat biliary atresia or choledochal cyst in the preceding year. Laparoscopy was more frequently performed in the 10-year recertification group for Nissen fundoplication, appendectomy, splenectomy, gastrostomy/jejunostomy, orchidopexy, and cholecystectomy (P < .05) but not lung resection (P = .70). It was more frequently used by surgeons recertifying in the 10-year group (used in 11 375 of 14 456 procedures [78.7%]) than by surgeons recertifying in the 20-year (used in 6214 of 8712 procedures [71.3%]) or 30-year group (used in 2022 of 3805 procedures [53.1%])., Conclusions and Relevance: Practicing pediatric surgeons receive limited exposure to index cases after training. With regard to maintaining competency in an era in which health care outcomes have become increasingly important, these results are concerning.

Background/purpose: Optimal outcomes for necrotizing soft tissue infections (NSTI) depend on rapid diagnosis and management. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is a validated diagnostic tool for adult NSTI, but its value for children remains unknown. We hypothesized that modification of the LRINEC score may increase its diagnostic accuracy for pediatric NSTI., Methods: We performed a case-control study of pediatric patients (age <18) with NSTI (cases) and patients with severe soft tissue infections prompting surgical consultation (controls). The LRINEC score was calculated for cases and controls and compared to a modified, pediatric LRINEC (P-LRINEC) score. Diagnostic accuracy was analyzed through receiver operating characteristic (ROC) curves., Results: From 2010 to 2014, 20 cases and 20 controls were identified at two children's hospitals. Median LRINEC score was 3.5 (1-8) for cases and 2 (1-7) for controls (p=0.03). The P-LRINEC was comprised of serum CRP >20 (sensitivity=95% (95%CI 79-100%)) and serum sodium <135 (specificity=95% (95%CI 82-100%)). Area under ROC curves was 0.70 (95%CI 0.54-0.87) for the LRINEC score and 0.84 (95%CI 0.72-0.96) for the P-LRINEC score (p=0.06)., Conclusion: The P-LRINEC is a simplified version of the LRINEC score utilizing only CRP and sodium and may provide superior accuracy in predicting pediatric NSTI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Increasing numbers of programs participating in the pediatric surgery match has resulted in economic and logistical issues for candidates, General Surgery residencies, and Pediatric Surgery training programs (PSTP). We sought to determine the ideal number of interviews conducted by programs based on resultant rank order lists (ROL) of matched candidates., Methods: PSTPs received 4 online surveys regarding interview practices (2011-2012, 2014), and matched candidate ROL (2008-2010, 2012, 2014). Program directors (PD) also provided estimates regarding minimum candidate interview numbers necessary for an effective match (2011-2012, 2014). Kruskal-Wallis equality-of-populations rank tests compared ROL and interview numbers conducted. Quartile regression predicted ROL based on the interview numbers. Wilcoxon signed rank-sum tests compared the interview numbers to the minimal interview number using a matched pair. p Values<0.05 were significant., Results: Survey response rates ranged from 85-100%. Median ROL of matched candidates (2-3.5) did not differ between programs (p=0.09) and the lowest matched ROL for any year was 10-12. Interview numbers did not affect the final candidate ROL (p=0.22). While PDs thought the minimum median interview number should be 20, the number actually conducted was significantly higher (p<0.001)., Conclusion: These data suggest that PSTPs interview excessive numbers of candidates. Programs and applicants should evaluate mechanisms to reduce interviews to limit costs and effort associated with the match., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Abdominal pain is common during chemotherapy for childhood leukemia. Clinically differentiating typhlitis from appendicitis can be difficult. We present an 8-year-old boy with abdominal pain in the setting of acute lymphoblastic leukemia and neutropenia. Following appendectomy for presumed appendicitis, pathology revealed appendiceal typhlitis. Diagnostic and treatment considerations are discussed.

Background: Multiple studies document a correlation between anorectal malformations (ARMs) and vesicoureteral reflux (VUR), development of urinary tract infections (UTIs), and subsequent renal disease. We aimed to determine which patient characteristics are associated with VUR and UTI in this population., Methods: A retrospective review of ARM patients at a free-standing children's hospital from January 1996 to December 2011 was performed. Logistic regression was used to investigate the associations between VUR and UTI and ARM classification and co-morbid diagnoses., Results: Of 190 patients, 41 (31%) received a diagnosis of VUR. Thirty-one of the 190 patients had at least one febrile UTI (16%). Of these, only 16 (51%) had a diagnosis of VUR. On multivariable logistic regression, the only patient variable associated with VUR was having an ectopic kidney (p=0.026). Similarly, the presence of GU malformations was the closest variable associated with developing a UTI (p=0.073)., Conclusions: In ARM patients, VUR as well as UTIs are associated with the presence of GU malformations. Thus, voiding cystourethrogram (VCUG) testing should be pursued when there are other caudal and GU abnormalities, regardless of fistula location. Antibiotic prophylaxis for UTI should be considered in children with ARM and any GU malformation, not only VUR., (© 2014.)

Background: We hypothesize that standardizing operative equipment, and reducing variability can safely achieve cost reduction., Methods: We retrospectively measured supply costs, operative time, intra-operative complications, and length of stay in a cohort of 145 patients at a children's hospital who underwent a laparoscopic appendectomy. A standardized preference card for laparoscopic appendectomy was developed and implemented. Data were prospectively collected on 101 consecutive patients and compared to the retrospective cohort using multiple linear regression. A survey assessing the perception of surgeons, nurses and scrub technologists of the impact of standardization on patient safety, patient care, OR efficiency, and cost was conducted. Wilcoxon rank sum test was used to evaluate associations between clinical role and years of experience with the total level of agreement on the survey., Results: A 20% average reduction was achieved in supply cost per case, with no significant change in operative time (p=0.14), total time in OR (p=0.15), or length of stay (p=0.60). No intra-operative complications were identified in either group. Survey participants agreed that standardization improves cost and safety. Nurses tended to have greater agreement that standardization improved efficiency and patient care compared to other roles (p=0.06)., Conclusions: Standardization of operative equipment can result in a significant cost reduction without impacting quality or delivery of care. Based on average case number per year, a total annual cost savings of >$41,000 could be realized. Survey participants agree that standardization improves cost and patient safety, yet perceptions regarding the impact on efficiency and patient care varied by occupation., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: General surgery (GS) residents in ACGME programs log cases performed during their residency. We reviewed designated pediatric surgery (PS) cases to assess for changes in performed cases over time., Methods: The ACGME case logs for graduating GS residents were reviewed from academic year (AY) 1989-1990 to 2010-2011 for designated pediatric cases. Overall and designated PS cases were analyzed. Data were combined into five blocks: Period I (AY1989-90 to AY1993-94), Period II (AY1994-95 to AY1998-99), Period III (AY1999-00 to AY2002-03), Period IV (AY2003-04 to AY2006-07), and Period V (AY2007-08 to AY2010-11). Periods IV and V were delineated by implementation of duty hour restrictions. Student t-tests compared averages among the time periods with significance at P < .05., Results: Overall GS case load remained relatively stable. Of total cases, PS cases accounted for 5.4% in Period I and 3.7% in Period V. Designated pediatric cases declined for each period from an average of 47.7 in Period I to 33.8 in Period V. These changes are due to a decline in hernia repairs, which account for half of cases. All other cases contributed only minimally to the pediatric cases. The only laparoscopic cases in the database were anti-reflux procedures, which increased over time., Conclusions: GS residents perform a diminishing number of designated PS cases. This decline occurred before the onset of work-hour restrictions. These changes have implications on the capabilities of the current graduating workforce. However, the case log does not reflect all cases trainees may be exposed to, so revision of this list is recommended., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The management of a splenectomy in a boy with an unusual form of somatic overgrowth is presented. Except for a moderately difficult airway, no unusual reactions to anesthesia and surgery were encountered. Possible anesthetic implications of different somatic overgrowth syndromes in children are presented., (Copyright © 2013. Published by Elsevier Inc.)

Pulmonary sequestrations are accessory foregut lesions that are most commonly located within the thorax and occasionally in the abdominal cavity. Sequestrations arising within the diaphragm are exceedingly rare. We describe 2 patients found to have left peridiaphragmatic lesions on prenatal ultrasound and postnatal computed tomography. In the first patient, an initial laparoscopic approach was abandoned in favor of a thoracoscopic approach after no intraabdominal mass was found. The second patient had an uncomplicated thoracoscopic resection of a similar lesion. To our knowledge, these represent the first intradiaphragmatic pulmonary sequestrations to be resected via a minimally invasive approach. The rarity of these lesions makes definitive diagnosis without operative intervention challenging. Thoracoscopy appears to be a reasonable approach for resection of such intradiaphragmatic lesions., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Congenital cervical anomalies are essential to consider in the clinical assessment of head and neck masses in children and adults. These lesions can present as palpable cystic masses, infected masses, draining sinuses, or fistulae. Thyroglossal duct cysts are most common, followed by branchial cleft anomalies and dermoid cysts. Other lesions reviewed include median ectopic thyroid, cervical teratomas, and midline cervical clefts. Appropriate diagnosis and management of these lesions requires a thorough understanding of their embryology and anatomy. Correct diagnosis, resolution of infectious issues before definitive therapy, and complete surgical excision are imperative in the prevention of recurrence., (Copyright © 2012 Elsevier Inc. All rights reserved.)

This case presents a complication of attempted separation of parapagus conjoined twins, related to loss of an intact mesenteric-portal venous axis. Despite known lack of a superior mesenteric artery in the right twin, initial evaluation in the operating room suggested that separation was possible. After hepatic division, however, it became apparent that the mesenteric drainage was not separable; and the operation was aborted. Subsequently, significant growth failure and hypoglycemia were noted in the right twin. The situation was corrected by creating a shunt to reinstitute mesenteric flow to the right twin's liver and separating the twin's mesenteric drainage. One year postoperatively, both twins are independently nourishing themselves and have been free from hospitalization with stable glucoses., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: We have previously reported the use of the vertical expandable prosthetic titanium rib (VEPTR) for treatment of thoracic dystrophy. This report describes our experience with this device and other novel titanium constructs for chest wall reconstruction., Methods: This is a retrospective chart review of all children and adolescents undergoing chest wall reconstruction with titanium constructs between December 2005 and May 2010., Results: Six patients have undergone chest wall reconstruction with VEPTR or other titanium constructs. Four had chest wall resection for primary malignancy, 1 had metastatic chest wall tumor resection, and 1 had congenital chest wall deformity. There were no immediate complications, and all patients have exhibited excellent respiratory function with no scoliosis., Conclusions: Chest wall reconstruction after tumor resection or for primary chest wall deformities can be effectively accomplished with VEPTR and other customized titanium constructs. Goals should be durable protection of intrathoracic organs and preservation of thoracic volume and function throughout growth. Careful preoperative evaluation and patient-specific planning are important aspects of successful reconstruction., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: A quality visit in high volume surgery clinics is challenging. There is variability in numbers of patients seen and care provider behavior. Documentation, regulatory and compliance issues and computerization of patient care systems may decrease clinic efficiency and throughput. We tried to reduce variability and improve patient experience., Methods: Baseline data included: patients seen, time in exam rooms, and spent with providers, and patient satisfaction surveys. Two Rapid Process Improvement Workshops (RPIWs) were conducted to apply lean methods. 5S techniques helped standardize exam rooms. Similar data were collected at 30 days, 60 days, and 1 year. Satisfaction surveys were followed at 6 months and 1 year., Results: Median pre-RPIW room time was 49 minutes. Post-RPIW times were 33 minutes at 30 days, 41 minutes at 60 days, and 42 minutes at 1 year. Face to face provider-patient time increased 30% to 61% at 30 days, 58% at 60 days, and 59% at 1 year. The median number of patients in a 4-hour clinic increased from 10 to 12. Satisfaction survey Problem Scores improved and were sustained., Conclusions: Lean methodology may be used to improve clinic efficiency as well as patient and staff's experience., (Copyright 2010. Published by Elsevier Inc.)

Background: Minimally invasive surgical techniques, specifically the thoracoscopic approach, have been applied to congenital diaphragmatic hernia (CDH) with varying outcomes from selected centers. The aim of our study was to examine the rate of successful completion and compare outcomes between open and thoracoscopic approaches in CDH repair., Methods: We performed a retrospective analysis of infants with CDH repair (From February 2004 to January 2008). Patients were divided into thoracoscopic and open groups, based on operative approach. We analyzed demographic, clinical, and hospitalization characteristics to compare the completion rate and outcomes in these two groups., Results: Analysis of 31 infants with CDH (14 thorascocopic and 17 open) demonstrated no differences in sex (P = 0.132), age (P = 0.807), birthweight (P = 0.256), weight at operation (P = 0.647), pulmonary hypertension (P = 0.067), preoperative intensive care unit (ICU) days (P = 0.673), ventilator days (P = 0.944), or use of a patch (P = 0.999) between the groups. Seventy-nine percent of thoracoscopic operative approaches were completed successfully. There was a significant difference between the open and thoracoscopic groups with respect to estimated gestational age (39 versus 36.5 weeks; P = 0.006) and operating room time (70 versus 145 minutes; P = 0.004). The total (P = 0.662), ICU (P = 0.889), and postoperative (P = 0.619) length of stay and days on ventilator (P = 0.705), as well as days until initial enteral feeds (P = 0.092), were not significantly different between groups. There were no deaths and no evidence of recurrence, with a mean follow-up of 346 days., Conclusions: In our early experience, the thoracoscopic approach for congenital diaphragmatic hernia repair was completed in 80% of our patient population with minimal exclusion criteria. Further study, with larger sample sizes, is needed to ascertain differences in outcomes, such as length of stay and initiation of enteral feeding.

Our objectives are to report patient characteristics, comorbidities, and outcomes for gastroschisis patients and analyze factors associated with mortality and sepsis. Using Pediatric Health Information System data, we examined neonates with both an International Classification of Diseases, 9th Revision diagnosis (756.79) and procedure (54.71) code for gastroschisis (2003 to 2008). We examined descriptive characteristics and conducted multivariate regression models examining risk factors for mortality, during the birth hospitalization, and sepsis. Analysis of 2490 neonates with gastroschisis found 90 deaths (3.6%) and sepsis in 766 (31%). Critical comorbidities and procedures are cardiovascular defects (15%), pulmonary conditions (5%), intestinal atresia (11%), intestinal resection (12.5%), and ostomy formation (8.3%). Factors associated with mortality were large bowel resection (odds ratio [OR] 8.26, 95% confidence interval [CI] 1.17 to 58.17), congenital circulatory (OR 5.62, 95% CI 2.11 to 14.91), and pulmonary (OR 8.22, 95% CI 2.75 to 24.58) disease, and sepsis (OR 3.87, 95% CI 1.51 to 9.91). Factors associated with sepsis include intestinal ostomy (OR 2.94, 95% CI 1.71 to 5.05), respiratory failure (OR 2.48, 95% CI 1.85 to 3.34), congenital circulatory anomalies (OR 1.58, 95% CI 1.10 to 2.28), and necrotizing enterocolitis (OR 4.38, 95% CI 2.51 to 7.67). Further investigation into modifiable factors such as small bowel ostomy and prevention of sepsis and necrotizing enterocolitis is warranted to guide surgical decision making and postoperative management., (Thieme Medical Publishers.)

Objective: To evaluate the impact of the use of a bedside-placed spring-loaded silo (SLS) on practice patterns and on outcomes for infants with gastroschisis., Design: Retrospective review comparing neonates with gastroschisis treated before and after the implementation of selective SLS placement., Setting: Tertiary referral center., Patients: Of 91 consecutive neonates admitted for initial treatment of gastroschisis between January 1998 and August 2007, 45 were admitted before and 46 were admitted after implementation of the SLS., Main Outcome Measures: Immediate fascial closure rate, infection rate, time to fascial closure, time to initiation of enteral feeding, time to achievement of full enteral feeds, time of hyperalimentation requirement, and length of hospital stay., Results: The rate of immediate fascial closure was lower in the postimplementation group (58% before vs 20% after implementation, P < .001). Overall length of stay, time to enteral feeding, and infection rates were not significantly different between the 2 groups., Conclusions: The use of an SLS placed at the bedside has resulted in lower immediate fascial closure rates for infants with gastroschisis without significant detrimental clinical outcome. The main benefit of using the bedside-placed SLS is the avoidance of urgent surgical intervention. For patients undergoing delayed fascial closure, use of the bedside SLS resulted in shorter times to definitive fascial closure.

Purpose: The aim of the study was to investigate the effect of prophylactic cycling of parenteral nutrition (PN) on PN-induced cholestasis in patients with gastroschisis., Methods: Retrospective review of initial hospital admission charts for each patient with gastroschisis from 1996 to 2007 was performed., Results: One hundred seven patients were analyzed (36 prophylactically cycled, 71 control). Prophylactic cycling of PN was initiated at a mean age of 23 days (range, 7-89 days). Patients were followed for a total of 4255 days with 27 developing hyperbilirubinemia (cycled, 5; continuous, 22). Time to hyperbilirubinemia was longer in the prophylactically cycled group (P = .005). Cumulative incidence of hyperbilirubinemia at 25 and 50 days of PN exposure was 5.7% and 9.8% (cycled) vs 22.3% and 48.8% (continuous). At any given time, children in the continuous group were 4.76 times more likely to develop hyperbilirubinemia (95% confidence interval, 1.62-14.00). After adjusting for confounding factors, children in the continuous group were 2.86 times more likely to develop hyperbilirubinemia (95% confidence interval, 0.86-9.53), but the difference was not significant (P = .088)., Conclusions: Prophylactic cyclic PN is associated with a decreased incidence and prolonged time to onset of hyperbilirubinemia. Other factors, however, significantly affect this relationship. Prospective randomized investigation is warranted to investigate for a possible causal relationship.

Purpose: Many different prosthetic materials have been used for repair of large posterolateral congenital diaphragmatic hernias (CDH), with high recurrence rates for hernias that cannot be primarily repaired. Since 1993, we have used a composite patch of Gore-Tex/Marlex to repair large CDHs and hypothesized that this repair leads to fewer recurrences., Methods: This is a retrospective review of 137 consecutive patients with CDH cared for at a single institution from 1993 to 2004. Data collected include timing and method of repair and use of extracorporeal membrane oxygenation. Outcomes include hernia recurrence, complications, and death., Results: One hundred thirty-seven patients with CDH were analyzed. Repair was not attempted in 12 because of disease severity. Primary repair was accomplished in 79 and 46 required patch repair. Of the 46 patients with patch repairs, 32 required extracorporeal membrane oxygenation, and 18 died before discharge. Of the 28 patch repair survivors, 1 (3.57%) developed a recurrence over a median follow-up of 47 months (range, 2-115 months). Overall survival was 77%., Conclusions: Gore-Tex/Marlex composite patch repair of large CDHs in this complex patient population results in a lower recurrence rate than has been reported for other types of prosthetic diaphragm repair.

Purpose: Radiology literature reports potential cancer risk from radiation exposure from computed tomography (CT). We hypothesized that pediatric surgeons' knowledge of potential risks of radiation exposure from CT scan is limited., Methods: We used an anonymous, Internet-based peer assessment survey for members of the American Pediatric Surgical Association (APSA). The survey assessed surgeon's knowledge based on potential risks of radiation exposure from CT as well as current practice patterns for use of CT. The chi2 test of significance was used to detect any differences in responses based on years in training., Results: Twenty percent (147/753) of the American Pediatric Surgical Association members completed the survey. About one half (54%) of surgeons believe that the lifetime risk of cancer was increased because of radiation from one abdominal/pelvic CT scan, although more than 75% of respondents underestimated the radiation dose from a CT scan compared to a chest radiograph. Most surgeons generally did not discuss the potential risks of CT scan with their patients. Surgeons demonstrated a range of responses for use of CT for select clinical scenarios., Conclusions: Pediatric surgeon's knowledge of potential risks of radiation exposure from CT scan is limited. As the radiology literature indicates an increasing awareness for potential cancer risks from radiation exposure from CT, there is also a need for education of subspecialties outside of radiology.

Background/purpose: Over the past several years, increasing attention has been focused on the potential for radiation exposure from computed tomography (CT) for inducing the development of cancers. An understanding of these issues is important for the practice of pediatric surgery., Methods: Medline based clinical review of current medical literature of the risks for the induction of cancers by CT. Data includes estimates of cancer risk from computer models, epidemiologic data from survivors of atomic bomb radiation exposure, and consensus opinions from expert panels., Results: Review of scientific evidence demonstrates varied opinions, but consensus suggests there may be a potential for an increased risk of cancer from low level radiation exposure such as from CT. These calculations suggest that there may be as high as 1 fatal cancer for every 1000 CT scans performed in a young child., Conclusions: Pediatric surgeons should be aware of the potential risks of CT. Minimizing the radiation risks of CT is a complex endeavor, and will require investments from pediatric surgeons as well as pediatric radiologists.

Congenital cervical anomalies are important to consider in the differential of head and neck masses in children and adults. These lesions can present as palpable cystic masses, infected masses, draining sinuses, or fistulae. Thyroglossal duct cysts are most common, followed by branchial cleft anomalies, dermoid cysts, and more rarely median cervical clefts. Other topics discussed include median ectopic thyroid, cervical teratomas, and branchiootorenal syndrome. Appropriate diagnosis and management of these lesions requires a complete understanding of their embryology and anatomy. Correct diagnosis, resolution of infectious issues before definitive therapy, and complete surgical excision are essential to prevent recurrence.

Purpose: The vertical expandable prosthetic titanium rib (VEPTR) thoracoplasty is a new technique devised for the treatment children with thoracic insufficiency syndrome. This study describes our initial experience with this device., Methods: This is a retrospective chart review of all children undergoing VEPTR placement between October 2001 and December 2005., Results: Twenty-two patients had 36 VEPTR devices placed. Two patients had Jeune syndrome, 19 had scoliosis, and 1 had a chest wall resection for tumor. Most had associated carbon dioxide retention, pulmonary restrictive disease, or respiratory failure. Eleven patients had multiple fused ribs requiring opening thoracostomy. All but the most recent patients have undergone sequential VEPTR expansion. All children had intraoperative spinal cord monitoring (somatosensory evoked potential). Four experienced intraoperative somatosensory evoked potential changes that resolved with decreased VEPTR expansion. Seven VEPTR devices required revision for erosion through the bone or dislodgment and 3 were removed. Five were outgrown and removed or replaced. One eroded soft tissue causing superficial infection that resolved with operative revision. Postoperative ventilation/perfusion scans improved most in younger children. Two of three children with carbon dioxide retention pre-VEPTR had carbon dioxide reduction post-VEPTR., Conclusions: Vertical expandable prosthetic titanium rib (VEPTR) is a new and safe method to treat children with thoracic insufficiency syndrome. The VEPTR may decrease carbon dioxide retention in some patients and may be most beneficial in younger children.

Purpose: Traditional treatment of giant omphaloceles with silo closure has been associated with respiratory insufficiency, hemodynamic compromise, dehiscence, and inability to close the abdomen with subsequent death. To minimize such complications, initial nonoperative management with delayed closure of the defect has been used., Methods: Between January 1981 and December 2002, 111 patients with omphaloceles were treated. Twenty-two patients with giant omphaloceles (19 containing liver) underwent initial nonoperative management consisting of silver sulfadiazine dressing changes. After pulmonary and other comorbidities stabilized, the contents were gradually reduced with a loose elastic bandage, and delayed closure was planned at 6 to 12 months. The medical records of these 22 patients were retrospectively reviewed to determine the efficacy and safety of this technique in the setting of severe associated anomalies. Those 15 patients (n = 15) from the latter 10 years were further reviewed to determine additional end points (length of hospital stay, length of intensive care unit stay, duration of mechanical ventilation, time to feed, time to closure, and type of closure)., Results: Of the 15 patients treated during the latter 10 years, mean gestational age and birth weight were 38 +/- 1.4 weeks and 3.1 +/- 0.57 kg, respectively. Median length of stay after birth was 20 days (range, 5-239 days). Median time to full diet was 8 days (range, 4-80 days). Four patients were discharged on oral feedings only, 7 with combination oral/gavage, and 4 with tube feedings. Pulmonary hypoplasia or pulmonary hypertension was present in 11 (50%) of 22 patients. There were 11 patients with major cardiac anomalies, 14 with a patent ductus arteriosus, and 8 with a patent foramen ovale. Three early complications (2 ruptured sacs and 1 bleeding sac) and 1 late complication (gastric necrosis) occurred in the initial nonoperative period. In addition, 4 patients were treated for line sepsis, 1 patient for acute renal insufficiency, and 1 for aspiration pneumonia. Three patients required tracheostomy and were discharged with home ventilators. There were no complications associated with the use of silver sulfadiazine. Of the 22 patients, 16 have undergone delayed repair, 2 did not require repair, 1 is awaiting repair, 2 died before closure, and 1 was lost to follow-up. Delayed closure was achieved at a median age of 14 months (range, 2-28 months) and mean weight of 8.8 +/- 3.3 kg. Four patients required implantation of mesh for definitive closure. Median postoperative length of stay was 4 days (range, 2-21 days). Postoperative complications included prolonged ileus, recurrent ventral hernia, and prolonged intubation. Overall mortality rate was 9.1%. One death occurred after diaphragmatic hernia repair, and 1 death was from overwhelming sepsis in the patient with a late gastric perforation., Conclusion: The use of silver sulfadiazine dressing changes for initial nonoperative management of giant omphaloceles is a safe and effective bridge to delayed closure. We recommend this method as initial nonoperative management given the high incidence of associated cardiopulmonary malformations because it may facilitate enteral feeding, minimize respiratory compromise, and reduce morbidity and mortality.

Branchial anomalies are important lesions to consider in the differential diagnosis of head and neck masses in children. These anomalies are composed of a heterogeneous group of congenital malformations that arise from incomplete obliteration of pharyngeal clefts and pouches during embryogenesis. Although present at birth, many abnormalities do not become evident until later in infancy or childhood. It is common for branchial anomalies to become infected, causing significant morbidity. Surgical removal may be difficult, and inadequate resection of the lesion is likely to cause recurrence. Understanding the embryology and anatomy of these lesions is essential to the provision of adequate therapy.

Background: Laparoscopic pyloromyotomy (LPM) for the treatment of infantile hypertrophic pyloric stenosis (HPS) has gained popularity in recent years. This study examines the learning curve associated with LPM., Methods: We performed a retrospective analysis of patients undergoing LPM at a children's hospital between January 1, 1997 and June 30, 2003. Data including age, weight, complications, operative time, time to feeding, and length of postoperative stay were analyzed using the Student's ttest., Results: A total of 51 patients underwent LPM during the study period. Patient characteristics were similar throughout the study period. Operative time ranged from 12 to 55 minutes (mean, 25 minutes). Mean operative time decreased significantly from 31+/-11 minutes for the first 15 patients, to 25+/-6 minutes for the second 15 patients, to 20+/-7 minutes for the last 15 patients (P<0.05). Operative times were erratic for the early cases but became more consistent over time, especially after 30 cases. Conversion to an open procedure was required in two patients. Complications included an umbilical port site wound dehiscence and readmission for persistent vomiting. There were no mucosal perforations. Time to ad lib feeding and postoperative length of stay did not change over time., Conclusion: LPM has a steep learning curve, especially for the first 15 patients. Operative time decreases and becomes more consistent after about 30 cases. Despite the learning curve, LPM can be performed safely and effectively without an increase in complications.

Background: Ramstedt pyloromyotomy through a right upper quadrant (RUQ) transverse incision has been the traditional treatment for hypertrophic pyloric stenosis. Recently, laparoscopic (LAP) and circumumbilical (UMB) approaches have been introduced as alternative methods to improve cosmesis, but concerns about greater operative times, costs, and complications remain. This study compares the three operative techniques and examines their advantages and complication rates., Study Design: We performed a retrospective review of patients undergoing pyloromyotomy at a children's hospital between January 1997 and June 2003., Results: Two hundred ninety patients underwent pyloromyotomy by LAP (n = 51), RUQ (n = 190), or UMB (n = 49). Complication rate, time to ad libitum feeding, incidence of emesis, and postoperative length of stay did not differ considerably among groups. Two LAP patients were converted to RUQ. Mucosal perforation occurred in three patients each in the RUQ and UMB groups, but none in the LAP group. Operative times were considerably less for LAP (25 +/- 9 minutes) than for RUQ (32 +/- 9 minutes) and UMB (42 +/- 12 minutes) (p < 0.05, ANOVA, Bonferroni). Charges related to operations and anesthesia were considerably greater for UMB (operation: US 1,574 dollars +/- US 433 dollars; anesthesia: US 731 dollars +/- US 190 dollars) compared with the other two groups (p < 0.05, ANOVA, Bonferroni), but did not differ between LAP (operation: US 1,299 dollars +/- US 311 dollars; anesthesia: US 586 dollars +/- US 137 dollars) and RUQ (operation: US 1,237 dollars +/- US 411 dollars; anesthesia: US 578 dollars +/- US 167 dollars). Data are presented as mean +/- SD., Conclusions: Advantages of LAP include a shorter mean operative time without higher complications or costs. UMB is associated with the greatest mean operative time and costs. Laparoscopic pyloromyotomy is a safe and effective approach to the treatment of hypertrophic pyloric stenosis.

Purpose: For normal single births with evidence of first trimester twinning, vanishing twin rates of 13% to 78% have been reported. We propose that blighting of a conjoined twin can result in an infant with a variation of cloacal exstrophy., Materials and Methods: We retrospectively reviewed the records of 26 patients with cloacal exstrophy treated from January 1989 to November 2003, all of whom had prenatal evaluations readily available to determine the presence of twinning. The criterion for establishing the prenatal diagnosis of twins was the documentation of 2 fetal heart tones on Doppler and/or 2 fetal poles on ultrasound., Results: All 26 patients had prenatal care including prenatal fetal Doppler studies and followup ultrasound. Of the patients 15 had classic cloacal exstrophy (58%) with no evidence of twin gestations documented. Of the 26 cloacal exstrophy cases 11 (42%) were cloacal exstrophy variants, including 8 of the 11 (73%) with consistent findings of twin gestation on prenatal studies. All 8 patients had documented 2 fetal heart tones in the first trimester, and 4 had 2 fetal poles in 1 amniotic sac on prenatal ultrasound. Five patients had subsequent ultrasound studies showing a single fetus by the second trimester. Two patients were born conjoined with 1 of the twins lifeless at birth in both cases., Conclusions: We propose that blighted conjoined twinning may be a cause of cloacal exstrophy variant cases.

Background: Hirschsprung's disease is a common cause of neonatal intestinal obstruction. A variety of operations have been used to treat this neurogenic form of bowel obstruction. This report describes an experience with a 1-stage abdominal and transanal pull-through operation in 15 patients with rectosigmoid disease., Methods: Fifteen infants with Hirschsprung's disease included 11 boys and 4 girls. Median age at diagnosis was 3 days, and median age of operation was 30 days. Diagnosis was confirmed by rectal biopsy. Biopsies to confirm the transition zone were performed intraabdominally through a left lower quadrant incision. A Swenson pull-through was performed via transanal dissection., Results: There were no instances of anastomotic leaks, wound infections or postoperative bowel obstructions. All patients survived. Two had postoperative enterocolitis. Twelve of 15 patients did well and had 2-3 bowel motions per day. One with Down's syndrome had enterocolitis and required a colostomy. Two were lost to follow up., Conclusions: A one-stage transanal pull-through procedure in infancy is a safe alternative to staged procedures for Hirschsprung's disease.

Background/purpose: Conjoined twins are some of the most challenging patients faced by surgeons. Pygopagus and ischiopagus twins present particular gastrointestinal and genitourinary reconstructive challenges. This study reviews the authors' experience with the perineal reconstruction of these types of conjoined twins., Methods: Retrospective analysis was performed for 3 sets of female conjoined twins undergoing separation between 1999 and 2001. Particular attention was given to the separation and reconstruction of the distal gastrointestinal and urogenital structures., Results: Three sets of female conjoined twins underwent successful separation 2 pygopagus, one ischiopagus tripus) with 5 surviving infants. The sixth infant died of congenital anomalies incompatible with life. Four of the 5 surviving infants had diverting enterostomies. Two of these enterostomies have been closed. Perineal reconstruction consisted of anoplasty (5 of 5), vaginoplasty (4 of 5), and urethroplasty (4 of 5). Although fecal and urinary continence are not completely measurable at this age (<3 years), all 5 survivors void spontaneously. Three infants with intestinal continuity have apparently normal defecation without the need of a bowel regimen., Conclusions: With careful preoperative planning and a multidisciplinary team of pediatric surgeons and urologists, satisfactory reconstruction and functional outcome of the female perineum can be achieved in conjoined twins., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Background: Chest tubes are often placed in children after elective thoracic surgical procedures. Depending on surgeon preference, tubes can be pulled directly from suction or after a trial of water seal. Removal of the tube without water seal potentially allows earlier removal, decreased postoperative pain, and earlier discharge from the hospital. No randomized, prospective study has been performed to compare the two methods to determine whether omission of the water seal period is safe after elective thoracic surgery in children., Study Design: This is a single-blinded, randomized study conducted between June 1998 and June 2000. Children undergoing elective, noncardiac, nonesophageal thoracic operations were placed into water seal or a nonwater seal groups. Groups were compared for development of pneumothorax or pleural effusion after chest tube removal., Results: Fifty-two children participated in the study, with 28 in group I (suction) and 24 in group II (water seal). Operations included both pulmonary and nonpulmonary thoracic operations performed both thoracoscopically and open. No child developed a major pleural effusion after chest tube removal. Three children (11%) in group I and eight (33%) in group II developed pneumothorax. No child required reinsertion of the chest tube and all were successfully treated with observation and oxygen. There was no marked difference between the groups regarding development of pneumothorax, but the power of the study is low., Conclusions: A water seal trial is not necessary for safe removal of chest tubes in children undergoing elective surgery. Chest tubes can be removed safely and earlier when pulled directly from suction for both pulmonary and nonpulmonary thoracic pediatric procedures.

Purpose: Necrotizing fasciitis and myonecrosis can be rapidly fatal without prompt and aggressive medical and surgical therapy. We reviewed our experience with necrotizing fasciitis and myonecrosis in neutropenic pediatric oncology patients to describe associated clinical characteristics and outline therapeutic interventions., Patients and Methods: A retrospective chart review was performed for all cases of deep soft tissue infection found in neutropenic pediatric oncology patients during an 11-year period., Results: Seven cases of necrotizing fasciitis and/or myonecrosis associated with chemotherapy-induced neutropenia were diagnosed during the study period. Deep soft tissue infection was diagnosed a median of 14 days after the initiation of chemotherapy. All of the patients presented with fever and pain, generally out of proportion to associated physical findings. Most patients (86%) also had tachycardia and subtle induration at the site of soft tissue infection. The pathogenic organism in four of seven patients originated in the gastrointestinal tract. Patients were treated with antibiotics, surgical debridements, granulocyte colony-stimulating factor, and hyperbaric oxygen. Granulocyte transfusions were administered if there were no signs of neutrophil recovery. Five patients survived their deep soft tissue infection., Conclusions: The diagnosis of necrotizing fasciitis and/or myonecrosis should be considered in any neutropenic patient with fever, tachycardia, and localized pain out of proportion to the physical findings. Appropriate therapy includes broad-spectrum intravenous antibiotics and urgent surgical intervention. Granulocyte colony-stimulating factor should be administered to all patients to enhance neutrophil recovery. Granulocyte transfusions should be considered if a prolonged period of neutropenia is anticipated.

Purpose: The aim of this study was to determine the necessity for intraoperative cholangiography (IOC) during pediatric laparoscopic cholecystectomy (LC)., Methods: A retrospective review of 100 consecutive patients undergoing LC was conducted., Results: Ninety-eight children underwent successful LC. The average age was 11.3 years. IOC was successful in 55 of 63 studies. Operating time for patients with IOC averaged 91 minutes, and without IOC, 67 minutes. Twenty children had preoperative ultrasound, laboratory, or clinical evidence of common bile duct (CBD) stones. Fifteen of these 20 children actually had CBD stones. Three additional children who lacked any ultrasound, clinical, or laboratory evidence of choledocholithiasis had unsuspected CBD stones. Eight children, therefore, had ultrasound, clinical, or laboratory findings not predictive of the actual state of the CBD. Sixteen children underwent endoscopic retrograde cholangiopancreatography (ERCP), 9 preoperatively and 7 postoperatively. Four preoperative ERCP studies showed no CBD stones. There were no complications from performing IOC., Conclusions: (1) CBD stones are common in children with gallstones, (18 of 100 patients). (2) Preoperative studies and clinical findings may not predict accurately the presence or absence of CBD stones. (3) IOC should be routinely performed in children before the use of ERCP to avoid unnecessary ERCP unless CBD stones are specifically visualized by ultrasound scan. J Pediatr Surg 36:881-884., (Copyright 2001 by W.B. Saunders Company.)

Background: Laparoscopic splenectomy (LS) is technically difficult compared with open splenectomy. This report examines our experience with LS to define the learning curve., Methods: The first 49 consecutive laparoscopic splenectomies were reviewed. Indications, complications, operative time, and costs were recorded., Results: Indications included hereditary spherocytosis, immune thrombocytopenia purpura, beta-thalassemia, lymphoma, splenic cysts, and abscesses. Surgical time averaged 196 minutes for the first 10 patients, decreasing to 105 minutes for the last 10. Blood loss for the first 10 patients averaged 50 cc and less than 5 cc for the last 10. There were 3 complications and 1 conversion to open operation. Operative and hospital charges averaged $6,670 and $13,402, respectively, for the first 10 cases compared with $5,278 and $10,863 for the last 10., Conclusions: LS can be performed safely with few complications. LS has a steep learning curve in the first 20 patients after which operative times decrease along with overall costs.

Objective: To determine whether the risk of operative management of children with intussusception varies by hospital pediatric caseload., Design: A cohort of all children with intussusception in Washington State from 1987 through 1996., Setting: All hospitals in Washington State., Methods: Five hundred seventy children with a hospital discharge diagnosis of intussusception were identified. Sixty-two were excluded because of missing data. Procedure codes for operative management and radiologic management were also identified., Results: Fifty-three percent of the children had operative reduction and 20% had resection of bowel. Children with operative reduction did not differ from those with nonoperative care by median age or gender; however, children with operative care were significantly more likely to receive care in hospitals with smaller pediatric caseloads and to have a coexisting condition associated with intussusception. Sixty-four percent of children who received care in a large children's hospital had nonoperative reduction, compared with 36% of children who received care in hospitals with 0 to 3000 annual pediatric admissions and 24% of children who had care in hospitals with 3000 to 10 000 annual pediatric admissions. Median length of stay and charges were significantly less in the large children's hospital, compared with other centers., Conclusions: Children who received care for intussusception in a large children's hospital had decreased risk of operative care, shorter length of stay, and lower hospital charges compared with children who received care in hospitals with smaller pediatric caseloads.

Hypothesis: We hypothesized that improved outcomes following renal transplantation in high-risk infants and small children primarily are due to advances in immunosuppression and accurate diagnosis of rejection. Optimizing renal allograft perfusion is critical to achieving good early graft function and decreasing early graft loss., Design: Twenty-eight consecutive recipients (weighing <20 kg) of adult living donor kidneys transplanted at our center from 1984 to 1999 were reviewed. Two groups were identified based on differing immunosuppression protocols and clinical surveillance. Actuarial graft and patient survival reported at 1, 3, and 5 years were compared for group 1 (1984-1991) and group 2 (1992-1999). Graft losses, categorized as immunologic or nonimmunologic, and the incidences of delayed graft function, vascular thrombosis, and rejection were compared., Results: Graft and patient survival in group 1 (n = 13) at 1, 3, and 5 years was 77% and 92%, 54% and 85%, and 54% and 85%, respectively. In group 2, all 15 patients are alive with functioning grafts to date. Immunologic graft loss occurred in 5 of 13 patients in group 1 who developed chronic rejection. Nonimmunologic causes (vascular thrombosis [2 patients]) and patient death [1]) resulted in early graft failure within 2 weeks in 3 of 13 patients in group 1. The overall incidences of delayed graft function (10.7%) and thrombosis (7.1%) were low and did not differ between groups. Percutaneous renal biopsy was used more frequently in group 2 to evaluate graft dysfunction and guide treatment., Conclusions: We conclude that improved overall graft and patient survival in group 2 is owing to advances in immunosuppression and better treatment of rejection. Percutaneous renal biopsy allows prompt and accurate histological diagnosis of graft dysfunction. Surgical technique and aggressive fluid management aimed at maximizing renal allograft perfusion is critical in optimizing early graft function and decreasing vascular complications.

Objectives: To describe the epidemiology of acute appendicitis in children from Washington State, and to determine important risk factors for complications., Design: Retrospective cohort study., Setting: All children (<17 years old) treated in Washington State who were identified by hospital discharge diagnosis codes from 1987 through 1996., Methods: The hospital discharge data were reviewed for all children with a primary diagnosis code for acute appendicitis. Complicated disease was defined as perforation or abscess formation., Results: Young children (0-4 years old) had the lowest annual incidence of acute appendicitis, but they had a 5-fold increased risk of complicated disease (odds ratio: 4.9; 95% confidence interval: 4.0-5.9), compared with teenagers. Children with Medicaid insurance had a 1.3-fold increased risk of complicated disease, compared with children with commercial insurance (odds ratio: 1.3: 95% confidence interval: 1.2-1.4). Children with Medicaid insurance had significantly longer average length of stay (4.0+/-3.7 days) than all other payers (commercial insurance: 3.3+/-4.0 days; health maintenance organization: 3.5+/-3.1 days; and self-insured: 3.7+/-5.8 days)., Conclusions: Very young children had the greatest risk of complicated disease. Children with Medicaid insurance had increased risk of complicated disease, compared with children with commercial health insurance and longer length of stay. Additional studies are needed to evaluate barriers to care for children with Medicaid insurance.

Background: Fascial dehiscence is uncommon in children but can have serious consequences when it occurs. There are multiple risk factors for fascial dehiscence, including the type of incision used. Pediatric surgeons often use a supraumbilical transverse incision particularly in infants because of the access this incision provides to the entire abdomen. This article details the experience with fascial wound dehiscence at a large tertiary children's hospital and focuses on problems with the types of incision used., Study Design: This is a retrospective review of 2,785 intraabdominal operations performed over a 5-year period at Children's Hospital and Regional Medical Center in Seattle. Risk factors for dehiscence were reviewed for each case of fascial dehiscence. Statistical analysis using chi-square was used to examine for differences in complication rates between transverse and vertical incisions., Results: In this series, 2,442 children (88%) had transverse incisions and 343 (12%) had vertical incisions. Twelve children had abdominal fascial dehiscence post-operatively. Six cases involved transverse incisions and six involved vertical incisions. Five of the children suffered evisceration. One child died as a direct result of the dehiscence. There were multiple risk factors for dehiscence in 10 of the 12 children. Vertical incisions were found to be much more likely to dehisce than were transverse incisions, especially in children under 1 year of age (p < 0.001)., Conclusions: Vertical incisions are more apt to dehisce than transverse incisions in children, particularly babies. We recommend the use of transverse incisions whenever possible in babies less than 1 year of age, especially when other risk factors for dehiscence are present.

Background: Minimally invasive surgery (MIS) is an ideal way to obtain biopsy specimens in children with cancer. We examined the safety, reliability and outcome of decisions made based on tissue obtained using MIS., Methods: Fifty-nine oncology patients underwent 62 MIS procedures between January 1994 and July 1998. Complications, biopsy results, and outcomes were reviewed., Results: The study population comprised 32 boys and 27 girls, with an average age of 8.8 years. There were 47 thoracoscopic and 15 laparoscopic operations. Laparoscopic procedures included initial biopsy, determination of resectability, and second-look exam. Thoracoscopic procedures included 40 lung biopsies and seven biopsies/resections of mediastinal masses. Diagnostic accuracy was 100% in all cases. No patient was found retrospectively to have been inadequately treated based on decisions made from tissue obtained by MIS., Conclusion: MIS is a safe and accurate means of obtaining tissue in pediatric oncology patients. Treatment decisions can be made accurately and with confidence using these techniques.

Purpose: To determine the cause of a marked rise in cholecystectomy at a regional children's hospital., Methods: Retrospective review of 185 patients undergoing cholecystectomy since 1984. The years 1984 to 1990 (group I) and 1991 to 1996 (group II) were compared., Results: Cholecystectomy for gallbladder disease increased from 4.4/year (group I) to 16.3/ year (group II). Abdominal ultrasound examinations increased during this time. The ratio of children diagnosed with gallstones and then undergoing cholecystectomy also increased (P = 0.005). In group 11, 43% of children had no apparent etiology for gallstones, and more children developed complications of gallstones and evidence of choledocholithiasis., Conclusions: (1) The increased incidence of cholecystectomy is probably multifactorial. (2) Gallstone identification has increased owing to increased patient visits and more liberal use of ultrasonography in patients with abdominal pain. (3) More patients with cholelithiasis now undergo cholecystectomy perhaps because of a change in physician perception of the disease and an apparent increase in complications from gallstones.

Background: Post-traumatic hepatic artery pseudoaneurysms are rarely seen in children., Materials and Methods: We retrospectively reviewed the radiologic studies and medical records of three patients treated at our institution and reviewed the literature. The patients (ages 5-13 years) presented immediately to 2 months after blunt (two patients) and penetrating (one patient) trauma. The hepatic pseudoaneurysms were discovered during work-up for fever (one patient), gastrointestinal bleeding and hyperbilirubinemia (one patient), or widened mediastinum (one patient) on chest radiograph. In two patients, the diagnosis was initially suspected by computed tomography (CT) examination and confirmed by angiography. In the third patient, the diagnosis was made initially by angiography. All three pseudoaneurysms were treated with transcatheter embolization., Results: All three embolizations were initially technically successful. However, there was recurrence in one case, in which embolization distal to the neck of the pseudoaneurysms was not technically possible. With conservative management, however, the residual lesion demonstrated spontaneous occlusion by ultrasound (US) at 6 months., Conclusion: This uncommon complication of liver trauma in children can have a delayed presentation, can be clinically unsuspected, and can follow blunt or penetrating trauma. Endovascular embolotherapy is the treatment of choice.

Background: Children who have malignant disease and pulmonary nodules frequently need a tissue diagnosis to direct therapy. Computed tomography (CT)-guided needle localization and methylene blue marking allow thoracoscopic resection of nonvisible nodules., Methods: Malignant disease was diagnosed in three patients aged 2, 2.5, and 11 years. Pulmonary nodules seen on chest CT, representing either metastatic disease or infection developed in each patient. All lesions were 1 to 2 cm deep to the pleural surface, precluding thoracoscopic visualization. A Homer mammographic needle was placed near the lesion using CT guidance under general anesthesia. The pleura overlying the lesion was also marked with methylene blue. Under the same anesthetic, patients went to the operating room where the lesions were thoracoscopically resected., Results: Needle localization and methylene blue staining accurately localized the lesion in all cases. Thoracoscopic resection provided a diagnosis of metastatic disease or infection in all cases. There were no complications., Conclusion: CT-guided needle localization of pulmonary lesions deep to the pleural surface, is a safe, accurate method for allowing thoracoscopic resection in these children who would otherwise need open thoracotomy for diagnosis.

Background/purpose: Although apple peel intestinal atresia is a rare lesion associated with significant morbidity and high mortality, the authors have seen no deaths since 1983. Similar success has rarely been reported, and there are no reports of long-term follow-up. This study examines the short-term and long-term complications and outcome for these children, critiques our evolution in care, and gives current recommendations for therapy., Methods: A retrospective review of 12 patients over 11 years was conducted. Perinatal history and operative and perioperative management were examined and end results and complications using different management plans compared. Long-term outcome was determined through clinic follow-up., Results: Mean follow-up was 5.1 years. Children had a mean 61.4 cm of total small bowel. Seven patients underwent a primary anastomosis and five had enterostomies. The proximal jejunum was tapered, plicated, resected or left intact. Eleven children required gastrostomy tubes. All children required total parenteral nutrition. Full enteral feeding was achieved in all children, but three required gastrostomy supplementation. Three patients who had enterostomies suffered bowel obstruction, two with dilated, dysmotile proximal jejunum required subsequent tapering. Eight children maintained a growth curve between the 5th and 50th percentile. None have short bowel physiology, and all have achieved acceptable bowel function., Conclusions: (1) Total parenteral nutrition is essential for initial nutritional management. (2) Use of an enterostomy leads to an increased incidence of complications. (3) The dilated proximal bowel should be resected, tapered, or plicated, and a primary anastomosis should be performed. (4) Gastrostomy tubes are necessary for initial management. (5) Early morbidity is common, though excellent long-term outcome and normal growth and development are expected.

Necrotizing fasciitis is a potentially life-threatening infection of subcutaneous tissues and Scarpa's fascia that rarely affects neonates. We report the occurrence of this devastating infection in two neonates after routine Plastibell circumcision. These case reports highlight the presentation and management of this complication after a relatively routine and frequently performed operation. This report also emphasizes the differences between cellulitis and necrotizing fasciitis and suggests strategies for management.

Objective: To determine whether laparoscopic splenectomy (LS) is a safe, cost-effective alternative to open splenectomy (OS)., Design: Retrospective comparison and economic evaluation., Setting: Tertiary care children's hospital., Patients: Children with hematologic disease involving the spleen., Interventions: Laparoscopic splenectomy (10 patients); OS (10 patients)., Main Outcome Measures: Safety of LS and cost differential between LS and OS., Results: Operative time was longer for LS. Discharge occurred 64 hours postoperatively for LS and 79 hours for OS (P < .03). Patients who underwent LS returned to activity 1 to 5 weeks faster than patients who underwent OS. The average (+/-SD) operative charges for LS was $7176 +/- $2064 and for OS, $1977 +/- $344 (P < .001). Total hospital charges averaged $13,033 +/- $2976 for LS and $7106 +/- $1923 for OS (P < .001)., Conclusions: Laparoscopic splenectomy can be performed safely in children. In our hospital, LS is more expensive than OS. The faster return to school and normal activity warrants the continued use of this procedure despite the increased cost.