Percutaneous endoscopic gastrostomy tube placement via the introducer technique is safe and effective in children when compared to the laparoscopic technique.

PURPOSE: We compare our experience of percutaneous endoscopic gastrostomy, introducer technique (PEG) and laparoscopic technique (LapGT) at a tertiary care pediatric hospital. METHODS: Isolated PEGs and LapGTs placements were reviewed at our institution from August 2016 through January 2018. Demographics, procedure time, operative charges, and 30-day complications were reviewed. Means of quantitative values were compared using the student's t test. Categorical values were compared using the X2 test. RESULTS: Ninety-three isolated gastrostomy tubes were placed in children aged 2 weeks to 19 years. There were 56 PEGs (60%) and 37 LapGTs (40%), based on surgeon preference. There was no significant difference in demographics between the two groups. Mean operative time for PEG was 59% shorter (14 vs. 33 min, p < 0.001). Operating room charges averaged $4500 less in the PEG group ($11,400 vs. $15,900, p < 0.001). Neither group had complications that required a return to the operating room within 30 days postoperatively. There was no difference in the rate of fundoplication after gastrostomy tube placement. In two cases PEGs were converted to LapGTs after safety criteria for PEG were not met. CONCLUSION: The PEG introducer technique, when used with clearly defined safety criteria, decreased operative time and cost without compromising safety. LEVEL OF EVIDENCE: III.

Solid organ transplantation after treatment for childhood cancer: a retrospective cohort analysis from the Childhood Cancer Survivor Study.

BACKGROUND: Serious chronic medical conditions occur in childhood cancer survivors. We aimed to investigate incidence of and risk factors for end-organ damage resulting in registration on a waiting list for or receiving a solid organ transplantation and 5-year survival following these procedures. METHODS: The Childhood Cancer Survivor Study (CCSS) is a retrospective cohort of individuals who survived at least 5 years after childhood cancer diagnosed at younger than 21 years of age, between Jan 1, 1970, and Dec 31, 1986, at one of 25 institutions in the USA. We linked data from CCSS participants treated in the USA diagnosed between Jan 1, 1970, and Dec 31, 1986 (without solid organ transplantation before cohort entry) to the Organ Procurement and Transplantation Network-a database of all US organ transplants. Eligible participants had been diagnosed with leukaemia, lymphoma, malignant CNS tumours, neuroblastoma, Wilms' tumours, and bone and soft tissue sarcomas. The two primary endpoints for each type of organ transplant were date of first registration of a transplant candidate on the waiting list for an organ and the date of the first transplant received. We also calculated the cumulative incidence of being placed on a waiting list or receiving a solid organ transplantation, hazard ratios (HRs) for identified risk factors, and 5-year survival following transplantation. FINDINGS: Of 13 318 eligible survivors, 100 had 103 solid organ transplantations (50 kidney, 37 heart, nine liver, seven lung) and 67 were registered on a waiting list without receiving a transplant (21 kidney, 25 heart, 15 liver, six lung). At 35 years after cancer diagnosis, the cumulative incidence of transplantation or being on a waiting list was 0·54% (95% CI 0·40-0·67) for kidney transplantation, 0·49% (0·36-0·62) for heart, 0·19% (0·10-0·27) for liver, and 0·10% (0·04-0·16) for lung. Risk factors for kidney transplantation were unilateral nephrectomy (HR 4·2, 95% CI 2·3-7·7), ifosfamide (24·9, 7·4-83·5), total body irradiation (6·9, 2·3-21·1), and mean kidney radiation of greater than 15 Gy (>15-20 Gy, 3·6 [1·5-8·5]; >20 Gy 4·6 [1·1-19·6]); for heart transplantation, anthracycline and mean heart radiation of greater than 20 Gy (dose-dependent, both p<0·0001); for liver transplantation, dactinomycin (3·8, 1·3-11·3) and methotrexate (3·3, 1·0-10·2); for lung transplantation, carmustine (12·3, 3·1-48·9) and mean lung radiation of greater than 10 Gy (15·6, 2·6-92·7). 5-year overall survival after solid organ transplantation was 93·5% (95% CI 81·0-97·9) for kidney transplantation, 80·6% (63·6-90·3) for heart, 27·8% (4·4-59·1) for liver, and 34·3% (4·8-68·6) for lung. INTERPRETATION: Solid organ transplantation is uncommon in ageing childhood cancer survivors. Organ-specific exposures were associated with increased solid organ transplantation incidence. Survival outcomes showed that solid organ transplantation should be considered for 5-year childhood cancer survivors with severe end-organ failure. FUNDING: US National Institute of Health, American Lebanese Syrian Associated Charities, US Health Resources and Services Administration.

Swimming Pool Electrical Injuries: Steps Toward Prevention.

OBJECTIVE: Electrical injuries in swimming pools are an important pediatric public health concern. We sought to (1) improve our understanding of the clinical presentation and outcomes following and (2) describe the epidemiology of swimming pool electrical injuries in the United States. METHODS: We reviewed 4 cases of pediatric (<18 y old) electrical injury from a single, urban level 1 pediatric trauma center. We also queried the National Electronic Injury Surveillance System (NEISS) for emergency department visits due to electrical injury associated with swimming pools, occurring between 1991 and 2013. RESULTS: Overall, 566 cases were reported, with a mean (SD) age of 9.2 (4.1) years. Patients were mostly treated and released from the emergency department (91.8%), whereas 8.2% were hospitalized. When stated, injuries occurred most frequently at home (57.0%), followed by public (23.9%) and sports facilities (19.1%). Electrical outlets or receptacles (39.8%) were most commonly implicated, followed by electrical system doors (18.2%), electric wiring systems (17.0%), thermostats (16.3%), hair dryers (4.6%), and radios (4.1%). Pediatric cases represented 48.4% of swimming pool-related electrical injuries reported to NEISS. CONCLUSIONS: Electrical injuries occurring in and around swimming pools remain an important source of morbidity and mortality. Although NEISS monitors sentinel events, current efforts at preventing such cases are less than adequate. All electrical outlets near swimming pools should be properly wired with ground fault circuit interrupter devices. Possible approaches to increasing safe electrical device installation are through strengthening public awareness and education of the potential for injury, as well as changes to current inspection regulations.

Nitrous oxide procedural sedation in non-fasting pediatric patients undergoing minor surgery: a 12-year experience with 1,058 patients.

BACKGROUND: Nitrous oxide's safety and efficacy for minor procedures is an alternative to general anesthesia, complex sedation protocols, or local anesthetic alone. METHODS: A retrospective review of prospectively-collected data (2000-2012) identified 1,058 children who received single-agent nitrous oxide for minor surgery. RESULTS: Children (n = 1,058, male 42 %, female 58 %) aged 1-23 years (mean = 9.8 + 5.1 years) were identified. Only nine children (0.9 %) fasted. ASA status was I-II in 1,053 (99.5 %) of patients; five (0.5 %) had an ASA III. There were no major complications (desaturation, emergency admission, apnea, airway obstruction, bradycardia) or aborted procedures. Minor complications occurred in 1.8 %; there was no association between these complications and ASA, fasting status or maximum nitrous oxide percentage administered (all p > 0.05). Post-operatively, 98 % of patients denied getting an injection. Eighty-two percent reported mild or no procedural pain. CONCLUSION: This is the longest reported study using non-anesthesiologist-administered nitrous oxide as a single-agent for minor surgical procedures. The technique provides safe sedation and excellent amnesia, allowing pain and anxiety-reduced surgery with no fasting or postoperative monitoring.

Spontaneous sternal fracture during labor in a healthy primigravida with female athlete triad: A case report.

INTRODUCTION: This case raises awareness of the diagnosis of sternal fracture during labor and obviates the need for lengthy, expense-consuming workup. This report identifies a subset of women who may be at higher risk for this pathology. METHODS: Upon diagnosing and treating a patient who spontaneously fractured her sternum during labor, we reviewed previously reported cases and highlight key points of this entity. RESULTS: We report the third case of sternal fracture during labor in a healthy primigravida with female athlete triad. After 12 h of labor, the woman underwent epidural placement. By 16 h, the cervix was fully dilated. During the second push in the chin-to-chest position, a healthy baby was delivered, but the mother experienced acute anterior chest pain. Tenderness persisted for three weeks. Plain radiographs confirmed the presence of the fracture, which healed spontaneously. CONCLUSION: While chest pain during labor often results from serious causes including pulmonary embolism, myocardial infarction, and spontaneous pneumothorax, hyperflexion sternal fracture can occur, particularly in a woman with female athlete triad.

Successful cardiopulmonary resuscitation following minimally invasive pectus excavatum repair: A case report.

INTRODUCTION: Pectus excavatum is the most common congenital chest wall deformity. The minimally invasive repair of pectus excavatum (MIRPE) is the most commonly practiced method of surgical treatment and there is concern that the pectus bar will prevent effective CPR. There are no recorded cases of successful cardiopulmonary resuscitation with pectus bars in place. PRESENTATION OF CASE: A 17-year-old male with pectus excavatum underwent MIRPE. Two years later, he experienced out-of-hospital cardiac arrest and underwent successful cardiopulmonary resuscitation (CPR) in the field with a pectus bar in place. DISCUSSION: Successful CPR is possible after MIRPE. Clear identification of patients who have undergone MIRPE and education of CPR providers in providing effective chest compressions and defibrillation for this patient population is necessary. CONCLUSION: This is the first documented case of successful CPR in a patient with a pectus bar in place who experienced out-of-hospital cardiac arrest.

Sapovirus Gastroenteritis in Young Children Presenting as Distal Small Bowel Obstruction: A Report of 2 Cases and Literature Review.

Abdominal pain and distention in children are commonly encountered problems in the pediatric emergency room. The majority of complaints are found to be due to benign entities such as gastroenteritis and constipation. What confounds these diagnoses is that young children often deliver a challenging and unreliable exam. Thus, it often becomes exceedingly problematic to differentiate these benign conditions from surgical conditions requiring prompt attention including small or large bowel obstruction, volvulus, and appendicitis. The cases highlight Sapovirus as a cause of severe abdominal distention and vomiting in children and this report is the first to describe and demonstrate the impressive radiologic findings that may be associated with this infection. Surgeons should heed this information and hesitate to emergently operate on similar children.

Early transition to oral antibiotics for treatment of perforated appendicitis in pediatric patients: Confirmation of the safety and efficacy of a growing national trend.

PURPOSE: We performed a quality improvement initiative to monitor the change in protocol from purely intravenous therapy for perforated appendicitis to oral antibiotics at discharge once patients could tolerate eating. METHODS: Standardized prospective data were gathered on all children with perforated appendicitis treated under the new oral protocol from January 1 to December 31, 2014. Retrospective data through chart review were gathered on all children treated for perforated appendicitis during 2013. We compared demographics, clinical parameters, and hospital charges. RESULTS: Comparing 115 patients in 2013 and 144 in 2014, demographics and clinical characteristics were similar. In 2014, 95% of patients were discharged on oral therapy. Compared to the intravenous group, the enteric group had statistically lower rates of repeat ultrasound imaging (49.6% vs 35.1%) and PICC placement (98.3% vs 9.1%) and similar rates of intraabdominal abscess (20.9% vs 16.0%) and antibiotic change (26.1% vs 22.2%). In 2014, 55% of patients were discharged by postoperative day 5, compared to 33% in 2013. Total antibiotic days and readmission rate were similar, while hospital charges decreased by half. CONCLUSION: Our results reaffirm that transition to oral antibiotics is safe, effective, and cost-efficient in treatment of perforated appendicitis in the child.

Single-Incision Single-Instrument Adnexal Surgery in Pediatric Patients.

Introduction. Pediatric surgeons often practice pediatric gynecology. The single-incision single-instrument (SISI) technique used for appendectomy is applicable in gynecologic surgery. Methods. We retrospectively analyzed the records of patients undergoing pelvic surgery from 2008 to 2013. SISI utilized a 12 mm transumbilical trocar and an operating endoscope. The adnexa can be detorsed intracorporeally or extracorporealized via the umbilicus for lesion removal. Results. We performed 271 ovarian or paraovarian surgeries in 258 patients. In 147 (54%), the initial approach was SISI; 75 cases (51%) were completed in patients aged from 1 day to 19.9 years and weighing 4.7 to 117 kg. Conversion to standard laparoscopy was due to contralateral oophoropexy, solid mass, inability to mobilize the adnexa, large mass, bleeding, adhesions, or better visualization. When SISI surgery was converted to Pfannenstiel, the principal reason was a solid mass. SISI surgery was significantly shorter than standard laparoscopy. There were no major complications and the overall cohort had an 11% minor complication rate. Conclusion. SISI adnexal surgery is safe, quick, inexpensive, and effective in pediatric patients. SISI was successful in over half the patients in whom it was attempted and offers a scarless result. If unsuccessful, the majority of cases can be completed with standard multiport laparoscopy.

Management of spontaneous pneumomediastinum in children.

PURPOSE: We characterize the outcomes of pediatric spontaneous pneumomediastinum in the largest series to date and propose a management pathway. METHODS: All patients at our institution with ICD-9 code 518.1 confirmed to have isolated radiographic findings of spontaneous pneumomediastinum between January 2003 and February 2014 were retrospectively reviewed for admission, intensive care unit (ICU) stay, complications, and outcome. RESULTS: We identified 96 children with 99 episodes, median age 14.1 years (IQR: 8.7-16.4). Primary symptoms were chest pain, cough, and dyspnea. Most were hospitalized (n=91, 91.9%), with 20 (20.2%) admitted to ICU. Median lengths of stay (LOS) were 1 day (IQR: 1-2) for non-ICU admissions and 3 days (IQR: 2-3) for ICU admissions. The surgical service discharged non-ICU patients 0.94 days earlier than medical services (95% CI 0.38-1.50, p=0.0014). Asthma affected neither LOS nor ICU admission rates. Follow-up imaging, when obtained (n=81, 81.8%), did not alter management. Recurrences occurred in three asthmatics, all after one year. Each was rehospitalized and discharged uneventfully. No patient developed pneumomediastinum-related complications (e.g., pneumothorax, pneumopericardium, or mediastinitis). CONCLUSION: Spontaneous pneumomediastinum without associated comorbidities can be managed with expectant outpatient observation without further imaging. Children with asthma should be treated independent of spontaneous pneumomediastinum.

Surgical and anesthetic considerations in histrelin capsule implantation for the treatment of precocious puberty.

BACKGROUND: Precocious puberty treatment traditionally meant anxiety-provoking monthly depot injections until the advent of the annually implanted histrelin capsule. This study is the first to evaluate the surgical and anesthetic aspects of histrelin implantation for precocious puberty. METHODS: All cases from one surgeon at a tertiary pediatric hospital were reviewed for patient age, anesthetic type, technical difficulties, and complications. RESULTS: From 12/2007 to 3/2013, 114 cases (49% implantations, 25% removals/re-implantations, 25% removals) were performed. Local anesthesia was employed in 100% of non-general anesthesia cases (n=109, 96%), augmented by inhaled N2O in 49%. Five patients (4%) underwent general anesthesia: three neurologically-impaired and two coordinated with scheduled MRIs. Procedural difficulties (n=18, 16%) included implant fracture during removal (n=16/58 removals, 28%). Fracture never occurred during implantation. Three children (3%) suffered complications. One infection was treated with antibiotics, and two implants were removed for systemic allergic reaction. Six children (5%) had unscheduled post-operative checks for pain (n=3, 3%), allergy to elastic dressing (n=2, 2%), or rash (n=1, 1%). Mean charges for general anesthesia were $10,188±1292 versus $528±147 for N2O or local alone (p<0.0001). CONCLUSION: While histrelin implantation is straightforward, removal presents technical challenges. Local anesthesia, with possible N2O supplementation, is well-tolerated and introduces substantial resource and cost savings.

Chronic vomiting and recurrent pneumonia in an adolescent female.

A 17-year-old girl presented with episodic vomiting associated with chest pain, a 20-pound weight loss over the past year, and multiple hospitalizations for pneumonia. She was bradycardic, cachectic (<3rd percentile), pale, and had anterior cervical lymphadenopathy. CT angiography suggested an obstructive vascular ring (formed by a right aortic arch with an aberrant left subclavian artery), diverticulum of Kommerell, and a tracheoesophageal fistula (TEF). She underwent left thoracotomy with ligation and division of the ligamentum arteriosum to relieve the vascular ring. Flexible bronchoscopy at the time demonstrated a large H-type TEF. Eight weeks later, she had the TEF closed via a right cervical incision and recovered uneventfully. Our case is unique, with symptomatic presentation of a congenital TEF and vascular ring in a teenager. Such major congenital anomalies are rarely discovered outside of childhood, and TEFs virtually always (>90%) present as neonatal emergencies secondary to esophageal obstruction. They have a high incidence of associated abnormalities, cardiovascular being the most common. Unexplained recurrent respiratory symptoms in an otherwise normal child with dysphagia should prompt the clinician to evaluate patients for foreign bodies, reflux and other more common problems. Unusual etiologies, however, do occur - as in this case - and warrant more complex workup.

Non-pigmented melanoma with nodal metastases masquerading as pyogenic granuloma in a 1-year old.

Malignant melanomas are the most common skin cancer in the pediatric population. Melanoma incidence is extremely low in infants, and metastatic disease is even less common. We present the case of an 11-month-old girl who presented with a non-pigmented lesion that progressed to an ulcerated lesion. Pathology was found to be Spitzoid melanoma of 7.6-mm thickness. Micrometastases were found on examination of the sentinel lymph node. The family chose expectant observation following the excision procedure. A pediatric melanoma registry may be helpful in developing future analyses of incidence in survival in this specialized population.

Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy.

BACKGROUND: Initial antibiotics with planned interval appendectomy (interval AP) have been used to treat patients with complicated perforated appendicitis; however, little experience exists with this approach in children with suspected acute perforated appendicitis (SAPA). We sought to determine the outcome of initial antibiotics and interval AP in children with SAPA. METHODS: Over an 18-month period, 751 consecutive patients underwent appendectomy including 105 patients with SAPA who were treated with initial intravenous antibiotics and planned interval AP ≥ 8 weeks after presentation. All SAPA patients had symptoms for ≤ 96 hours. Primary outcome variables were rates of readmission, abscess formation, and need for interval AP prior to the planned ≥ 8 weeks. RESULTS: Intraabdominal abscess rate was 27%. Appendectomy prior to planned interval AP was 11% and readmission occurred in 34%. All patients underwent eventual appendectomy with pathologic confirmation confirming the previous appendiceal inflammation. White blood cell (WBC) count >15,000, WBC >15,000 plus fecalith on imaging, and WBC >15,000 plus duration of symptoms >48 hours were all significantly associated with higher rates of readmission (p=0.01, p=0.04, p=0.02) and need for interval AP prior to the planned ≥ 8 weeks (p=0.003, p=0.05, p=0.03). CONCLUSIONS: Treatment of SAPA with antibiotics and planned interval AP is successful in the majority of patients; however, complications such as abscess formation and/or readmission prior to planned interval AP occur in up to one-third of patients. Certain clinical variables are associated with increased treatment complications.

Prospective Comparison of Nonnarcotic versus Narcotic Outpatient Oral Analgesic Use after Laparoscopic Appendectomy and Early Discharge.

Purpose. To compare narcotic versus nonnarcotic outpatient oral pain management after pediatric laparoscopic appendectomy. Methods. In a prospective study from July 1, 2010, to March 30, 2011, children undergoing laparoscopic appendectomy on a rapid discharge protocol were treated with either nonnarcotic or narcotic postoperative oral analgesia. Two surgeons in a four-person faculty group employed the nonnarcotic regimen, while the other two used narcotics. Days of medication use, time needed for return to normal activity, and satisfaction rate with the pain control method were collected. Student's t-test was used for statistical analysis. Results. A total of 207 consecutive children underwent appendectomy for acute, nonperforated appendicitis or planned interval appendectomy. The age and time to discharge were equivalent between the nonnarcotic (n = 104) and narcotic (n = 103) groups. Both had an equivalent number of medication days and similar times of return to normal activity. Ninety-seven percent of the parents of children in the nonnarcotic group stated that the pain was controlled by the prescribed medication, compared to 90 percent in the narcotic group (P = 0.049). Conclusion. This study indicates that after non-complicated pediatric laparoscopic appendectomy, nonnarcotic is equivalent to narcoticbased therapy for outpatient oral analgesia, with higher parental satisfaction.

Obstructing apple core lesion of the rectum: a case report of inflammatory pseudotumor masquerading as colorectal carcinoma.

Inflammatory pseudotumor is a rare lesion which can occur, typically in children and young adults, in many different organ systems. The tumor often clinically behaves like a cancer but without histological evidence of malignancy. This case study of a 14 year-old boy is the first report in the literature of an inflammatory pseudotumor presenting as an obstructing apple core lesion, mimicking a rectal carcinoma. A six-week course of non-steroidal, anti-inflammatory drugs (NSAIDs) led to complete resolution of the mass, and following resection of a residual stricture, the patient has been recurrence-free for seven years.

A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis.

BACKGROUND/PURPOSE: This study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery. METHODS: After institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis. RESULTS: Laparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%). CONCLUSION: Routine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

Routine same-day discharge after acute or interval appendectomy in children: a prospective study.

HYPOTHESIS: The outcomes of and parental satisfaction with same-day discharge in children undergoing laparoscopic appendectomy warrant making it the usual and customary pathway. DESIGN: Prospective cohort study. SETTING: Tertiary care children's hospital. PATIENTS: Between July 1, 2010, and March 30, 2011, a total of 207 children were considered for same-day discharge after acute or interval laparoscopic appendectomy. The all-in-one single-incision single-instrument technique was used in 95.7% of children. INTERVENTIONS: Same-day discharge vs overnight admission. MAIN OUTCOME MEASURES: Operative details, postoperative length of stay, adverse events, and parental satisfaction. RESULTS: Of 207 consecutive children undergoing acute (n = 186) or interval (n = 21) appendectomy, 162 (78.3%) were discharged on the day of surgery. The remaining 45 children were admitted overnight because the hour was too late for discharge in 35 (77.8%), medical indications dictated admission in 5 (11.1%), and social reasons required admission in 5 (11.1%). In all the children, oral medication alone was used for postoperative pain. The complication rates were similar in the same-day discharge group (8.0%) and in the admitted group (6.6%), as were the rates of urgent postoperative visits (7.4% vs 4.4%%) and the readmission rates (2.5% vs 2.2%) (P > .05 for all). The same-day discharge group had a reduced postoperative length of stay compared with the admitted group (mean, 5 vs 16 hours, P < .05). At the time of discharge, most parents (87.0%) stated they were happy with the expeditious discharge, whereas 8.0% indicated they felt nervous but were ultimately satisfied. In retrospect, 8 of 162 parents (4.9%) were not sure early discharge was best, but only 1 parent would insist on admission if faced with the situation again. CONCLUSION: Routine same-day discharge after pediatric appendectomy seems safe, with good parental satisfaction.

Disaster response in a pediatric field hospital: lessons learned in Haiti.

PURPOSE: This study outlines the evolution of a pediatric field hospital after the January 2010 Haiti earthquake. METHODS: Project Medishare set up a field hospital in Port-au-Prince 48 hours after the event. Our institution staffed the pediatric component for 45 days, with sequential deployment of 9 volunteer medical teams. Evolving facility and manpower requirements and changing patient demographics over time were evaluated. RESULTS: Delegations consisted of surgeons, pediatricians, nurses, operating room (OR) personnel, physical therapists, pharmacists, and support staff. Primary goals involved creation of a child-specific ward, pediatric OR, and a wound care center. Major inpatient demographic changes occurred as time from the disaster elapsed. Initial census showed that 93% of the patients were surgical admissions with 40% undergoing operations, mostly fracture and wound care, over the first week. Eight weeks later, medical illnesses accounted for 70% of inpatients, whereas OR volume dropped by more than 50%. A second trend involved increasing acuity of care. Initially, children were admitted for serious or limb-threatening, but usually not life-threatening, injuries. Within 2 months, one third of the patients were housed in the developing NICU/PICU; and only 12% were admitted for injuries related to the earthquake. This change in patient needs led to alterations in facility requirements and in staffing and leadership needs. CONCLUSION: A disaster involving significant casualties in a populated area demands the rapid development of a field facility with pediatric personnel. Requirements for equipment, manpower, medical records, and systems addressing volunteer stress and ethical dilemmas can be anticipated.

The "all-in-one" appendectomy: quick, scarless, and less costly.

BACKGROUND: A technique for laparoscopic appendectomy (LAP APPY) that involves brief surgeon and operating room times, results in no appreciable scar, and requires few disposable supplies would be desirable. METHODS: During 2009, 508 children underwent LAP APPY at our institution including 398 (78%) for acute, non-perforated appendicitis. Our "all-in-one" operative procedure involves use of a single instrument through a side-arm viewing operative laparoscope which is inserted through a single, trans-umbilical port. Successful procedure completion rates and operative times ("cut-to-close") were determined. Our data for surgeon-directed, disposable supply costs per procedure were collated by Child Health Corporation of America and compared with 2009 LAP APPY data (n = 5692) from 17 other children's hospitals in the United States. RESULTS: We successfully completed 359 (90.2%) LAP APPY procedures using the all-in-one technique resulting in no appreciable scar. Additional ports were used in 9.8% and there were no conversions to open procedures. Median operative time for the all-in-one technique was 24 minutes (5-66 min). Our median surgeon-directed, disposable supply cost was the lowest in the study group and significantly less than the other 17 children's hospitals ($166 vs $748, P < .001). Median variation of supply costs among surgeons within each institution was $448 ($3-$870). Aggregate savings of nearly $1.3 million are predicted if all study surgeons were to reduce their disposable costs per procedure to the 25th percentile ($551). CONCLUSIONS: We conclude that the all-in-one laparoscopic appendectomy technique is quick, scarless, and less costly than conventional multi-port techniques. Wider application of the all-in-one technique seems indicated.