Single center protocol driven care in 150 patients with gastroschisis 1998-2017: collaboration improves results.

PURPOSE: The treatment of gastroschisis (GS) using our collaborative clinical pathway, with immediate attempted abdominal closure and bowel irrigation with a mucolytic agent, was reviewed. METHODS: A retrospective review of the past 20 years of our clinical pathway was performed on neonates with GS repair at our institution. The clinical treatment includes attempted complete reduction of GS defect within 2 h of birth. In the operating room, the bowel is evaluated and irrigated with mucolytic agent to evacuate the meconium and decompress the bowel. No incision is made and a neo-umbilicus is created. Clinical outcomes following closure were assessed. RESULTS: 150 babies with gastroschisis were reviewed: 109 (77%) with a primary repair, 33 (23%) with a spring-loaded silo repair. 8 babies had a delayed closure and were not included in the statistical analysis. Successful primary repair and time to closure had a significant relationship with all outcome variables-time to extubation, days to initiate feeds, days to full feeds, and length of stay. CONCLUSION: Early definitive closure of the abdominal defect with mucolytic bowel irrigation shortens time to first feeds, total TPN use, time to extubation, and length of stay.

Nuss procedure: decrease in bar movement requiring reoperation with primary placement of two bars.

BACKGROUND: The Nuss procedure, first reported in 1998, is currently the treatment of choice for pectus excavatum. The most significant bar-related complication documented is bar movement, requiring reoperation in 3.4%-27% of reports. Our report compares the initial placement of one Nuss bar versus two to prevent bar displacement. SUBJECTS AND METHODS: An Institutional Review Board-approved, retrospective chart review was performed of all Nuss procedures performed from November 2000 through February 2010. Since November 2006, all initial Nuss procedures were started with the intent of placing two bars. Haller index, patient demographics, duration of surgery, length of stay, postoperative wound infections, and bar movement requiring reoperation were collected and compared for the one-bar versus two-bar patient populations. RESULTS: In total, 85 Nuss procedures (58 with one-bar and 27 with two-bar primary Nuss procedures) were analyzed. Two attending pediatric surgeons performed all the procedures. Reoperation for bar movement when one bar was initially placed occurred in 9 patients (15.5%). No patients with initial placement of two bars required operative revision for a displaced Nuss bar (15.5% versus 0%, P=.05). Patient age and Haller index were not statistically different between groups. CONCLUSIONS: Our data demonstrate improved bar stability with no reoperative intervention when pectus excavatum is initially repaired with two Nuss bars. Primary placement of two bars has now become standard practice in our institution for correction of pectus excavatum by the Nuss procedure and would be our recommendation for consideration by other centers.

Simultaneous carriage of multiple genotypes of Staphylococcus aureus in children.

The co-existence of multiple genotypes in colonization by Staphylococcus aureus has not been fully investigated. The aim of this study was to evaluate the heterogeneity of S. aureus carriage in children. We evaluated 125 nasal and perianal swab samples that were positive for S. aureus from 76 children scheduled for elective surgery. For each sample, at least four colonies with the same or different morphotypes were selected for analysis. Multiple-locus variable-number tandem-repeat fingerprinting was used to determine the genetic relatedness and to characterize the clonality of the S. aureus strains. Of the 125 swabs, 91 (73 %) contained meticillin-sensitive S. aureus (MSSA), 8 (6 %) contained meticillin-resistant S. aureus (MRSA), and 26 (21 %) contained MSSA and MRSA simultaneously. A total of 738 S. aureus strains were evaluated with a mean of 6 colonies (range 4-15) picked from each culture. Of the 125 swabs, 32 (26 %) samples contained two genetically distinct S. aureus strains and 6 (5 %) contained three different genotypes. Multiple S. aureus strains simultaneously carried by individual children were genetically unrelated to each other. We concluded that the co-existence of multiple genotypes of S. aureus was common. The significance of multiple carriage is yet to be determined, but this intraspecies interplay could be important to pathogenicity and virulence in S. aureus.

Transumbilical laparoscopically assisted appendectomy: an alternative minimally invasive technique in pediatric patients.

INTRODUCTION: Transumbilical laparoscopically assisted appendectomy (TULAA) has been reported in the literature as an alternative to traditional three-port laparoscopic appendectomy (LA). Our study compares outcomes between LA and the one-trocar transumbilical technique in a single institution over a concurrent time frame for all cases of pediatric appendicitis. METHODS: An Institutional Review Board-approved retrospective chart review of all appendectomies from July 2007 through June 2009 was performed. All appendectomies were performed either laparoscopically or transumbilically. One surgeon predominantly used the TULAA method, whereas the other 2 surgeons used strictly the LA method. No cases were converted to open. Categorization of specimens as normal, acute, or ruptured was based on pathology reports. Outcomes analyzed for each group included surgical duration, cost, length of stay, fever (>101.5F), wound infection, ileus, and postoperative abdominal-pelvic abscess. RESULTS: A total of 131 appendectomies were performed by 3 surgeons, 83 were LA and 48 were TULAA. For all stages of appendicitis, outcomes differed significantly only for operating room cost, with the TULAA being significantly less expensive. All other outcomes were similar between the two techniques. CONCLUSION: Our study suggests that TULAA is a reasonable alternative to the standard minimally invasive technique for appendicitis in both acute and ruptured situations. All analyzed complications were similar between the groups, suggesting that TULAA is an acceptable surgical method in pediatric patients for all stages of appendicitis.

Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children.

PURPOSE: The aim of the study was to evaluate outcomes after a minimally invasive approach to pediatric subcutaneous abscess management as a replacement for wide exposure, debridement, and repetitive packing. METHODS: A retrospective study was performed of all children who underwent incision and loop drainage for subcutaneous abscesses between January 2002 and October 2007 at our institution. TECHNIQUE: Two mini incisions, 4-5 mm each, were made on the abscess, as far apart as possible. Abscess was probed, and pus was drained. Abscess was irrigated with normal saline; a loop drain was passed through one incision, brought out through the other, and tied to itself. An absorbent dressing was applied over the loop and changed regularly. RESULTS: One hundred fifteen patients underwent drainage procedures as described; 5 patients had multiple abscesses. Mean values (range) are as follows: age, 4.25 years (19 days to 20.5 years); duration of symptoms, 7.8 days (1-42 days); length of hospital stay, 3 days (1-39 days); duration of procedure, 10.8 minutes (4-43 minutes); drain duration, 10.4 days (3-24 days); and number of postoperative visits, 1.8 (1-17). Bacterial culture data were available for 101 patients. Of these, 50% had methicillin-resistant Staphylococcus aureus, 26% had methicillin-sensitive Staphylococcus aureus, and 9% streptococcal species. Of the 115 patients, 5 had pilonidal abscesses, 1 required reoperation for persistent drainage, and 1 had a planned staged excision. Of the remaining 110 patients, 6 (5.5%) required reoperation-4 with loop drains and 2 with incision and packing with complete healing. CONCLUSION: The use of loop drains proved safe and effective in the treatment of subcutaneous abscesses in children. Eliminating the need for repetitive and cumbersome wound packing simplifies postoperative wound care. Furthermore, there is an expected cost savings with this technique given the decreased need for wound care materials and professional postoperative home health services. We recommend this minimally invasive technique as the treatment of choice for subcutaneous abscesses in children and consider it the standard of care in our facility.

Laparoscopic Ladd's procedure: treatment of choice for midgut malrotation in infants and children.

INTRODUCTION: Rotational anomalies of the midgut encompass a broad spectrum of incomplete rotational events with malfixation of the intestines during fetal development. Ladd's procedure, as a correction of these anomalies, has traditionally been performed by laparotomy. In our institution, the laparoscopic Ladd's (LL) procedure was introduced in May 2004 and soon became the standard approach. MATERIALS AND METHODS: A retrospective analysis of all Ladd's procedures in children in our institution between September 1998 and June 2008 was performed. Outcomes between the open (OL) and LL procedures were compared. RESULTS: A total of 156 children underwent Ladd's procedure during the study period. There were 120 open and 36 laparoscopic procedures. Overall, 75% of patients in each group were symptomatic, most commonly with emesis and pain. Duration of surgery was similar in both groups. Time to starting feeds, and amount of time to attain full feeding, was significantly less in the LL group. Postoperative length of stay was significantly less in the patients having LL. Conversion rate to OL from LL was 8.3%. CONCLUSIONS: LL can be performed safely in selected patients with no increase in complications. Short-term results are superior to OL and can be achieved without any increase in operative duration.

Methylene blue: a simple marker for intraoperative detection of gastroduodenal perforations during laparoscopic pyloromyotomy.

INTRODUCTION: We studied the feasibility of using methylene blue (MB) as a marker to detect mucosal perforations during laparoscopic pyloromyotomy using in vitro and in vivo animal models. MATERIALS AND METHODS: MB was initially tested in pig stomachs in vitro. Information gathered from these experiments was then used to test the marker during experimental live piglet laparoscopic surgery. RESULTS: MB stained the gastric mucosa blue; this tint could be seen through the intact mucosal layer exposed via myotomy. Dye extravasation was seen during laparoscopic surgery with mucosal perforations of 1.2 mm and greater with or without air insufflation of the stomach. Air extravasation was seen with perforations of 2.0 mm and greater. CONCLUSION: Full strength 1% MB dye instilled into the gastric lumen can potentially be used as a marker for detection of mucosal perforations of 1.2 mm or greater during laparoscopic pyloromyotomy.

A prospective study of methicillin-resistant Staphylococcus aureus colonization in children scheduled for elective surgery.

BACKGROUND: Staphylococcus aureus is a major cause of surgical wound infections. To obtain contemporary data on S aureus, we performed a prospective study of colonization and infection in children scheduled for elective surgical procedures. METHODS: A nasal swab and clinical information were obtained at the presurgical outpatient visit. At operation, nasal and perianal swabs were obtained. S aureus were isolated and characterized. RESULTS: We enrolled 499 patients from June 2005 to April 2007. Wound classes were 1 (73%), 2 (22%), 3 (5%), and 4 (0.2%). Prophylactic antibiotics were administered for 153 (31%). Postoperative length of stay ranged from 0 (77%) to 6 days, with 19 (4%) staying 4 days or more. Screening cultures grew S aureus for 186 procedures (36.6%); of these, 141 were methicillin-resistant S aureus (MRSA) (76% of all staphylococcal cultures or 28% of all procedures). Most MRSA had Staphylococcal Chromosomal Cassette mec type II and resistance to clindamycin-typical for hospital-associated strains. There were 10 (2%) surgical site infections, including 4 methicillin-sensitive S aureus, 1 MRSA, 2 with no growth, and 2 with no cultures. CONCLUSION: Methicillin-resistant S aureus colonization was common in asymptomatic children. Most strains appeared to be health care-associated and resistant to clindamycin. Wound infection rate remained low despite the high prevalence of staphylococcal colonization.

Practice makes perfect: progressive improvement of laparoscopic pyloromyotomy results, with experience.

INTRODUCTION: Pyloric stenosis can now be treated effectively with laparoscopic pyloromyotomy (LP). Few large outcome studies have been published regarding the laparoscopic technique. In this paper, we describe our experience with the first 185 consecutive LPs. MATERIALS AND METHODS: An institutional review board-approved retrospective outcomes analysis was performed on our first 185 consecutive LPs. Previous publications comparing open pyloromyotomy (OP) and LP are reviewed. Our hypothesis is that, with experience, the outcome of LP will equal or surpass that of OP. RESULTS: A total 185 infants underwent LPs during the study period. The infants had median values of age: 33 days; body weight: 4 kg; surgery duration: 25 minutes; postoperative length of stay (LOS): 25.5 hours; and total LOS: 45 hours. There were 7 complications (3.78%): 4 incomplete pyloromyotomies (2.2%), 1 pyloric mucosal perforation (0.5%), 1 delayed duodenal perforation (0.5%), and 1 wound infection (0.5%). There has been a progressive reduction in the time required for surgery, from a median of 29 minutes in the first 60 cases to 21.5 in the last 65. Postoperative LOS has fallen from a median of 26 hours in the first half to 24.5 in the later half. Complications occurred primarily in the first third of our cases. CONCLUSIONS: We are able to demonstrate that, with experience, one can expect progressive improvement in the outcomes following LP in infants. Our surgery duration and complications in the last 65 cases are better than most published results for OP or LP.

Complications associated with the Nuss procedure: continued evolution of the learning curve.

BACKGROUND: We report unusual and/or significant complications encountered during and after the Nuss Procedure for pectus excavatum. METHODS: This was a retrospective review that was approved by the institutional review board, with parental consent. RESULTS: Seven patients had unique and/or significant complications as follows: (1) laceration of an internal mammary artery during bar placement requiring emergent minithoracotomy; (2) hemopericardium 10 weeks postoperatively after blunt chest trauma requiring exploration of the pericardium and clot evacuation; (3) almost complete recurrence of the pectus excavatum deformity immediately after bar removal; (4 and 5) immediate/early postoperative bar displacement requiring re-operation and placement of 2 bars each; and (6 and 7) almost complete neo-ossification of the Nuss bar, making removal challenging. CONCLUSIONS: The Nuss procedure has met with near-universal acceptance. Complications are just being reported. We describe 7 events to add to the evolving literature as the entire pediatric surgery community participates in the initial learning curve.

Sphincter of Oddi dysfunction in children with recurrent abdominal pain: 5-year follow-up after endoscopic sphincterotomy.

BACKGROUND: Sphincter of Oddi (SO) dysfunction has not been reported as a cause of recurrent abdominal pain (RAP) in children. We present a 5-year follow-up of a group of children with RAP and manometry proven SO dysfunction. METHODS: Retrospective chart review of children who underwent SO manometry and endoscopic sphincterotomy (ES) for recurrent abdominal pain. Long-term follow-up was obtained by telephone survey. RESULTS: Eleven of the 12 children had abdominal pain; one had reproducible postprandial discomfort. Five children localized the pain to the upper abdomen. The same number of children had associated nausea or vomiting. On hepatobiliary scintigraphy study, three children had SO dysfunction type curve, four had low ejection fraction and nine had reproduction of symptoms on cholecystokinin (CCK) infusion. SO manometry revealed elevated pressure in 11 children. The remaining child had paradoxical contraction of the SO. On short-term follow-up, eight children had resolution of symptoms after ES, three did not respond and one had recurrence of symptom in 6 months. Children symptomatic for less than 1 year were more likely to respond to ES (P < 0.01). All children with upper abdominal pain with nausea and/or vomiting, postprandial pain and SO type scintiscan curve responded to ES. On long-term follow-up, seven of the eight responders to ES remained symptom free, one recurred with irritable bowel syndrome-like symptoms. One child with recurrent symptoms had resolution after cholecystectomy and another non-responder improved after an appendectomy. CONCLUSION: SO dysfunction is an uncommon but treatable cause of RAP in children. Awareness of this condition may help a segment of children with RAP.

Biliary dyskinesia: the most common indication for cholecystectomy in children.

BACKGROUND: The purpose of this study is to examine the current indications for cholecystectomy in children and to evaluate the results after such surgery. METHODS: Retrospective analysis of 107 consecutive cholecystectomies performed in children at the Children's Hospital of Illinois between October 1998 and September 2003. Hospital medical charts and outpatient clinic charts were reviewed. Patients' families were contacted by telephone to obtain longer-term follow-up. Results were analyzed with SPSS 12.0 for Windows (SPSS Inc, Chicago, Ill). RESULTS: Biliary dyskinesia (BD) was the indication for surgery for 62 (58%) of the 107 children who underwent cholecystectomy during the study period. Gallbladder calculus (GC) disease was the next most common indication with 29 (27%) children. The duration of symptoms was longer for BD. The most common presenting symptom in both groups was abdominal pain. Food intolerance was reported by 45% of patients with BD, significantly higher than patients with GC. Mean length of stay after cholecystectomy was 17 hours and 45 hours for BD and GC, respectively. Short-term follow-up showed relief or improvement of symptoms in 85% of children with BD and in 97% with GC. There were no deaths. Two (1.9%) children of the total of 107 developed complications; both had intra-abdominal abscesses. Most patients had complete or considerable long-term improvement in symptoms. CONCLUSIONS: Biliary dyskinesia was the most common indication for cholecystectomy in children in our study. More than half of the surgeries were performed on an outpatient basis. Morbidity was minimal and mortality was zero. We had satisfactory short- and long-term symptom resolution with long-term patient satisfaction reaching 95%.

Differences in the outcome of surgically placed long-term central venous catheters in neonates: neck vs groin placement.

BACKGROUND/PURPOSE: Long-term tunneled central venous catheters (CVC) are frequently used in the neonatal intensive care unit (NICU) babies. They are placed either in the neck or groin based primarily upon the surgeon's preference. There is meager published information available about the relative risks of these lines. METHODS: This is a retrospective analysis of all the tunneled central venous catheters placed in NICU babies at a children's hospital over a nearly 5-year period. Single lumen Broviac catheters were used in all cases. RESULTS: A total of 137 catheters were placed in 126 patients. There were 88 neck lines and 49 groin lines. Age, gestational maturity, and body weight were significantly lower for babies who underwent groin line placement. There was no significant difference in the number of days the catheters were live between the 2 groups. Total complication rates and catheter infection rates were significantly higher with neck lines. The accidental removal rate was higher with neck lines but did not reach statistical significance. CONCLUSIONS: Broviac catheters placed in the groin of NICU babies are associated with significantly fewer complications compared with those placed in the neck.

Perinatal management of gastroschisis: analysis of a newly established clinical pathway.

PURPOSE: The authors developed a clinical pathway for optimal management after antenatal diagnosis of gastroschisis. This is the outcomes analysis of our first 30 consecutive patients. METHOD: Antenatal counseling was provided for all families with in-utero diagnosis of gastroschisis. Bowel dilatation, thickness, motility, amniotic fluid volume, and fetal development were followed by ultrasonography every 4 weeks. Babies were delivered by cesarean section between 36 and 38 weeks gestation if the lungs were mature or earlier for bowel complications. Gastroschisis repair was scheduled 90 minutes after birth. Primary repair was attempted in all through the abdominal wall defect without an additional incision, resulting in an umbilicus with no abdominal scar. RESULTS: Primary repair was achieved in 83%. Babies needed assisted ventilation for 3 days, reached full feeds by 19 days, and were discharged by 24 days (all medians). There were 3 (10%) deaths, all after staged repair. CONCLUSIONS: Our new protocol of both scheduled elective cesarean section and early gastroschisis repair resulted in a higher proportion of primary repair, shorter duration of mechanical ventilation, earlier full feeds, and shorter length of stay. There was no increase in mortality or morbidity. The primary-repair babies had no mortality and had excellent cosmesis.

Laparoscopic appendectomy in children: technically feasible and safe in all stages of acute appendicitis.

This is a retrospective outcomes analysis of pediatric open and laparoscopic appendectomy in a children's hospital. One hundred three children underwent appendectomy for appendicitis by two pediatric surgeons from August 1998 to December 2002. Patients were divided into two groups, laparoscopic appendectomy (LAP) and open appendectomy (OAP), and were further subdivided by diagnosis: normal (NL), acute (AA), and ruptured (RA). There were no differences in age, sex, race, or zip codes between groups. Median age was 10 years. In the acute phase, 28 patients underwent OAP and 65 underwent LAP whereas 10 patients underwent interval appendectomy (IA) 6 weeks after percutaneous drainage of established abscesses (eight were LAP vs two OAP). In the remaining patients, the appendix was normal in 17 (18.4%) and ruptured in 24 (25.8%) pathologically. LAP took longer to perform (57 minutes vs 34.5 minutes) at higher cost (3718 dollars vs 1858 dollars) than OAP. Overall complications were lower in the LAP group (17% vs 29%), and LAP for RA had significantly fewer total complications (25% vs 62.5%). Intra-abdominal abscess increased following LAP: 9.2 per cent versus 3.6 per cent. Length of stay was shorter for LAP versus OAP in both AA (2.0 vs 2.5 days) and RA (5.5 vs 7 days).