Lack of Enteral Feeding Associated with Mortality in Prematurity and Necrotizing Enterocolitis.

BACKGROUND: Necrotizing Enterocolitis (NEC) remains a significant cause of morbidity and mortality. Recently, there has been an increased recognition of the importance of intestinal immunity and the associations with antibiotics and enteral feeds in the pathophysiology of NEC. The primary purpose of this study is to examine the association of enteral feeds on the survival of premature neonates with NEC. MATERIAL AND METHODS: A retrospective review using the Vermont Oxford Network for a Level IV NICU from January 1, 2013 through December 31, 2019 was performed. All neonates had a gestational age between 22 to 29 weeks, weighed at least 300 grams (n = 653), had a reported enteral feed status and were treated for NEC (n = 43). Data analysis utilized two-tailed t-tests for NEC and infection rates then Fisher's exact tests for survival status. RESULTS: The incidence of NEC in the population was 6.6% (43/653). Of the 43 neonates treated for NEC, 27 were enterally fed, while the other 16 were not. All 27 neonates with NEC that were able to achieve enteral feeds survived and had an infection rate of 22.2%. Meanwhile, all 16 neonates with NEC that were unable to achieve enteral feeds died and had an infection rate of 62.5%. CONCLUSIONS: There is a significant association between enteral feeds and NEC, survival, and infection rates in premature neonates. These findings support the importance of intestinal immunity and the microbiota in NEC. Given the limitations of the retrospective review, the profound survival advantage with enteral feeds reinforces the need for further study.

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.

Diaphragmatic pacing for respiratory failure in children.

Diaphragm pacing is a ventilation strategy in respiratory failure. Most of the literature on pacing involves adults with common indications being spinal cord injury and amyotrophic lateral sclerosis (ALS). Previous reports in pediatric patients consist of case reports or small series; most describe direct phrenic nerve stimulation for central hypoventilation syndrome. This differs from adult reports that focus most commonly on spinal cord injuries and the rehabilitative nature of diaphragm pacing. This review describes the current state of diaphragm pacing in pediatric patients. Indications, current available technologies, surgical techniques, advantages, and pitfalls/problems are discussed.

Locum Tenens and Pediatric Surgery: A Position Statement and Practice Guidelines From the American Pediatric Surgical Association (APSA).

The American Pediatric Surgical Association (APSA) Practice Committee endorsed by the Board of Governors presents a Position Statement on the role of locum tenens in the practice of pediatric surgery. The Practice Committee also presents a set of guidelines for locum tenens practice. These recommendations highlight safe practice and quality care that protects the patient as well as the pediatric surgeon by offering best practice standards, defining optimal resources and establishing parameters by which hospitals and locum tenens agencies should abide. These guidelines are intended to foster discussion and contract negotiation as well as inform decision making for a) pediatric surgeons considering locum tenens opportunities, b) host organizations (hospitals and practices) seeking the coverage of a pediatric surgeon, and c) locum tenens companies vetting both surgeons and hospitals for appropriateness of such coverage. This Position Statement and foundational set of guidelines align with APSA's Vision (all children receive the highest quality surgical care) and Mission (to provide the best surgical care to our patients and families by supporting an inclusive community through education, discovery and advocacy).

TGF-ß2 suppresses macrophage cytokine production and mucosal inflammatory responses in the developing intestine.

BACKGROUND & AIMS: Premature neonates are predisposed to necrotizing enterocolitis (NEC), an idiopathic, inflammatory bowel necrosis. We investigated whether NEC occurs in the preterm intestine due to incomplete noninflammatory differentiation of intestinal macrophages, which increases the risk of a severe mucosal inflammatory response to bacterial products. METHODS: We compared inflammatory properties of human/murine fetal, neonatal, and adult intestinal macrophages. To investigate gut-specific macrophage differentiation, we next treated monocyte-derived macrophages with conditioned media from explanted human fetal and adult intestinal tissues. Transforming growth factor-ß (TGF-ß) expression and bioactivity were measured in fetal/adult intestine and in NEC. Finally, we used wild-type and transgenic mice to investigate the effects of deficient TGF-ß signaling on NEC-like inflammatory mucosal injury. RESULTS: Intestinal macrophages in the human preterm intestine (fetus/premature neonate), but not in full-term neonates and adults, expressed inflammatory cytokines. Macrophage cytokine production was suppressed in the developing intestine by TGF-ß, particularly the TGF-ß(2) isoform. NEC was associated with decreased tissue expression of TGF-ß(2) and decreased TGF-ß bioactivity. In mice, disruption of TGF-ß signaling worsened NEC-like inflammatory mucosal injury, whereas enteral supplementation with recombinant TGF-ß(2) was protective. CONCLUSIONS: Intestinal macrophages progressively acquire a noninflammatory profile during gestational development. TGF-ß, particularly the TGF-ß(2) isoform, suppresses macrophage inflammatory responses in the developing intestine and protects against inflammatory mucosal injury. Enterally administered TGF-ß(2) protected mice from experimental NEC-like injury.

Liposomal Bupivacaine Injection in Nuss Procedure Allows Narcotic Avoidance and Improved Outcomes.

Background: The Nuss procedure has provided a minimally invasive surgical solution for pectus excavatum with excellent long-term outcomes. However, opioid avoidance, cost reduction, and length of stay (LOS) still offer room for improvement. The focus of this study is to identify the impact of Bupivacaine liposome injectable suspension (Exparel) on outcomes. Methods: A retrospective review at a Pediatric specialty hospital from October 1, 2014 to December 31, 2019 was performed. All patients underwent a Nuss procedure (n = 19) for pectus excavatum. The cohort comprised a control group that did not use liposomal Bupivacaine (Standard, n = 9) and an interventional group that received liposomal Bupivacaine (n = 10). Nonparametric Wilcoxon rank-sum tests and chi-squared or Fisher's exact tests were used to assess significance (P < .05). Results: Overall, the entire population was 68.4% male and had an average age of 15 years. There was a significant difference between the Standard and Liposomal Bupivacaine groups for total cost ($60,746 versus $13,289), total Morphine Milligram Equivalents (MME) (282 versus 76.8 MME) and Epidural Catheter usage (100% versus 0%). There was also a significant difference between groups for LOS (5.00 days versus 3.00 days) and Foley catheter usage (100% versus 20%). Conclusions: There is a significant impact of liposomal Bupivacaine usage on epidural catheter avoidance and opioid administration correlating with a significantly decreased total cost and decreased LOS. While more study is necessary, liposomal Bupivacaine for Nuss procedure offers improvement of postoperative patient outcomes and drastic cost savings.

Size Matters: Early Gastrostomy Tube Dislodgment in Children.

Background: Gastrostomy tube (g-tube) complications are typically minor and site related with major complications related to dislodgment before tract establishment. With the recent adoption of 12F g-tubes; size of tube has not been evaluated. There is limited research on the efficacy and dislodgment rates of 12 and 14F g-tubes within the early dislodgment window (<42 days postsurgery). Materials and Methods: A retrospective study from June 1, 2013 to May 25, 2020 was performed. A total of 888 patient encounters were identified, with a final data set of 835 being used for analysis. A subset of 21 patients was evaluated based on early dislodgment status. Fisher's exact test and Welch's two-sample test analyses were used to test for significance between groups (P < .05). Results: The early dislodgment rate is low at 2.5% (21/835). There was a significant impact of g-tube size on dislodgment rates. When evaluated by g-tube size, 12F g-tubes are nearly four times more likely to dislodge before 6 weeks than 14F g-tubes. In addition, the average age of 12F patients who dislodged early was significantly lower than that of the population for 14F patients. Conclusions: There is a significant difference in early dislodgment rate and age between the 12F g-tube compared with a 14F. These data suggest a trade-off of the smaller balloon in 12F g-tubes and potential for more limited use in our smallest children.

Intraabdominal vascular injury: are we getting any better?

BACKGROUND: Intraabdominal vascular injury (IAVI) as a result of penetrating and blunt trauma carries a high mortality rate. This study was performed to compare current mortality rates with a previously reported historic control. METHODS: The experience at our institution from 1970 to 1981 was previously reported with an overall mortality rate of 32% in 112 patients with penetrating IAVI. In a retrospective analysis, this historic cohort was compared with 248 patients with penetrating and blunt IAVI during a 138-month interval ending in June 2007. RESULTS: Overall mortality rate was 28.6%. The most commonly injured arteries were the iliac artery, aorta, and superior mesenteric artery. The most commonly injured veins were the inferior vena cava, iliac vein, and portal vein. Injury to the aorta, IVC, and portal vein had the highest mortality rates of 67.8%, 42.1%, and 66.6%, respectively. One hundred forty-four patients with one vessel injured had a mortality rate of 18.7%, whereas those with more than one vessel injured had a mortality rate of 48.7% (p < 0.001). A total of 46% of 117 patients in shock died compared with 9.6% of 104 patients not in shock (p < 0.001). Patients with a base deficit of less than -15 had a mortality rate of 72%, whereas those with a base deficit of 0 to -15 (p < 0.001) had a mortality rate of 18.9%. There was no difference in the overall mortality rate for penetrating trauma compared with the previous study. CONCLUSIONS: Although over 20 years have passed, no significant changes have occurred in the mortality associated with IAVI. Patients presenting in shock with IAVI continue to have a high mortality rate.

Engaging the patient and family in the surgical safety process utilizing.

BACKGROUND: Owing to the vulnerable nature of children, parental/caregiver engagement in surgical safety is a crucial aspect of care. Historically, the surgical safety process has been isolated from parent involvement. The digital, tablet-based surgical safety application, SafeStart, requires parent participation and provides multiple instances of verification of patient safety information from preoperative clinic visit, to perioperative care, and into the operating room. METHOD: The SafeStart application was utilized for 100 pediatric general surgery patients in an IRB approved prospective study. Parent assessments of the surgical consent and safety processes were collected in pre- and postoperative surveys with a 100% response rate. Standard consent forms were used and compared as a control. RESULTS: Only 31% of parents had knowledge of the surgical safety checklist process prior to their exposure to the study. 96% of the parents reported that the SafeStart patient portal was easy to use. A majority would prefer SafeStart to the standard consent process. CONCLUSION: The SafeStart program connected the surgical safety process from the preoperative clinic visit through postoperative care. Parent's preferred SafeStart to the standard surgical safety checklist and consent process, felt that they were instrumental in protecting their child's safety, and would recommend SafeStart for the surgical care of others. LEVEL OF EVIDENCE: II.

Failure to thrive: The socioeconomics of pediatric gastrostomy complications.

PURPOSE: One of the most common procedures in the pediatric population is the placement of a gastrostomy tube. There are significant medical, emotional, and social implications for both patients and caregivers. We hypothesized that socioeconomic status had a significant impact on gastrostomy complications. METHODS: A retrospective chart review was performed. Patient and census data including median household income, unemployment rate, health insurance status, poverty level, and caregiver education level were merged. Statistical tests were conducted against a 2-sided alternative hypothesis with a 0.05 significance level. Outcomes examined were minor and major complications in association with socioeconomic variables. RESULTS: Patients with mechanical complications were younger, weighed less, and had a 72% greater chance of having commercial insurance. Patients with Medicare/self-pay were three times more likely to have a minor complication. The average unemployment rate was 23% greater in families with a major complication. Individuals with a minor complication came from community tracts with a lower percentage of families below the poverty level. CONCLUSION: An association between socioeconomic factors and gastrostomy complications was identified. Insurance status and employment status were more significant predictors than poverty level. Further work with variables for targeted interventions to provide specific family support will allow these children and families to thrive. LEVEL OF EVIDENCE: Level II prognosis study.

Epithelial cells in fetal intestine produce chemerin to recruit macrophages.

Macrophages are first seen in the fetal intestine at 11-12 wk and rapidly increase in number during the 12- to 22-wk period of gestation. The development of macrophage populations in the fetal intestine precedes the appearance of lymphocytes and neutrophils and does not require the presence of dietary or microbial antigens. In this study, we investigated the role of chemerin, a recently discovered, relatively selective chemoattractant for macrophages, in the recruitment of macrophage precursors to the fetal intestine. Chemerin mRNA/protein expression was measured in jejunoileal tissue from 10- to 24-wk human fetuses, neonates operated for intestinal obstruction, and adults undergoing bariatric surgery. The expression of chemerin in intestinal epithelial cells (IECs) was confirmed by using cultured primary IECs and IEC-like cell lines in vitro. The regulatory mechanisms involved in chemerin expression were investigated by in silico and immunolocalization techniques. IECs in the fetal, but not mature, intestine express chemerin. Chemerin expression peaked in the fetal intestine at 20-24 wk and then decreased to original low levels by full term. During the 10- to 24-wk period, chemerin accounted for most of the macrophage chemotactic activity of cultured fetal IECs. The maturational changes in chemerin expression correlated with the expression of retinoic acid receptor-beta in the intestine. Chemerin is an important mediator of epithelial-macrophage cross talk in the fetal/premature, but not in the mature, intestine. Understanding the regulation of the gut macrophage pool is an important step in development of novel strategies to boost mucosal immunity in premature infants and other patient populations at risk of microbial translocation.

A simple algorithm to improve quality while reducing resource utilization in evaluation of suspected appendicitis in children.

BACKGROUND: With similar effectiveness of ultrasonography, our institution replaced CT imaging with ultrasound for diagnosing appendicitis in children. An unexpected consequence was the overutilization of ultrasound. Our objective was to establish measures that could help prevent this overuse. METHODS: A retrospective chart review of 327 consecutive pediatric patients evaluated for appendicitis between October 2014 and September 2015 at our institution was performed. Data on clinical, radiographic, and histopathologic findings were reviewed. Diagnostic accuracy of US and white blood cell (WBC) values was determined. An algorithm was created. RESULTS: 327 (100%) patients received an ultrasound for suspected appendicitis. WBC of 10,000/µl was determined to be the primary discriminant for management and ultrasound utilization. If a WBC ≥10,000/µL had been utilized as criteria for imaging, 49.5% fewer patients would have received an ultrasound. CONCLUSIONS: Clinical exam, WBC count, and surgery consultation prior to ultrasonography can lessen then need for ultrasound utilization in children with suspected appendicitis.

Adopting Single-Incision Laparoscopic Appendectomy in Children: Is It Safe During the Learning Curve?

Introduction: Laparoscopic appendectomy is the gold standard for treatment of acute appendicitis. The single-incision laparoscopic surgery (SILS) approach has gained widespread acceptance. This study evaluates the learning curve of contemporarily trained surgeons adopting SILS appendectomy and, more specifically, the safety of the operation during the early phase of this learning curve. Methods: A retrospective review of 974 consecutive pediatric patients younger than 18 years of age, who underwent an appendectomy at a single institution from 2005 to 2018, was performed. Nonperforated and perforated appendicitis cases were included. A subgroup analysis was performed on SILS appendectomy. Outcomes measured included length of operating room and anesthesia time, as well as complication rate. A log-logistics and a Loess smoothing model were used. Results: A total of 438 single-incision laparoscopic appendectomies were reviewed. A trend toward faster operative times was observed for all surgeons as case numbers increased. The odds of still being operated on decreased by 0.997 for each additional case. Based on a 95% confidence band and this experienced time as the standard, we expect adopting surgeons to reach this experienced level after 51 cases. During the early SILS appendectomy learning curve, there was no significant difference in complication rate compared with multiport laparoscopy. Conclusion: As expected, the more single-incision cases were performed, the shorter the operative times. More importantly, there was no increase in complication rate during the learning stage of single-incision appendectomies in either perforated or nonperforated appendicitis.

Human mesenteric adipose tissue plays unique role versus subcutaneous and omental fat in obesity related diabetes.

BACKGROUND/AIMS: Obesity is a common and rapidly growing health problem today. Obesity is characterized by the increase of body fat and an excess of total body fat and, in particular, visceral fat accumulation, is considered to be a risk factor for type 2 diabetes mellitus. To determine whether the malfunction of the mesenteric adipose tissue plays an important role in the diabetic related metabolic syndrome, in this study, lipolysis and gene expression in the subcutaneous, omental and mesenteric adipose tissue of the diabetic subjects were evaluated. METHODS: Lipolysis and real time PCR were utilized to determine adipocyte function. RESULTS: Basal adipose tissue glycerol release is higher in diabetics than that of the non diabetics in all three fat depots. Isoproterenol (ISO) significantly increases glycerol release in subcutaneous, omental and mesenteric adipose tissues of non diabetic subjects but it stimulated glycerol release was significantly impaired in all three fat depots of the diabetic subjects. Gene expression studies indicate that leptin, Peroxisome proliferator-activated receptor-gamma (PPAR-gamma), Fatty acid translocase (FAT/CD36) and 11beta-hydroysteroid dehydrogenase (HSD) gene expression were significantly up regulated in the mesenteric adipose tissue of the diabetic patients. CONCLUSION: Human mesenteric adipose tissue in obese diabetic subjects has high basal glycerol release and impaired isoproterenol stimulated glycerol release. The obesity-related gene expressions in the mesenteric adipose tissue are up regulated, suggesting that the alterations of these genes in mesentery adipose depot may play a critical role in insulin resistance of type 2 diabetes and metabolic syndrome.

Toll-like receptor 2 is protective of ischemia-reperfusion-mediated small-bowel injury in a murine model.

OBJECTIVE: In a murine model of intestinal injury, we hypothesized that Toll-like receptor 2 (TLR2), a recognition molecule for commensal bacteria, plays an important role in the development of mucosal immunity and is protective against ischemia/reperfusion injury via the modulation of both innate and acquired immunity. DESIGN: Interventional laboratory study. SETTING: Academic medical research center. SUBJECTS: Four-week-old C57BL/6 wild-type (n = 12) and C57BL/6 TLR2-deficient mice (TLR2-/-) (n = 12). INTERVENTIONS: Twenty-four mice underwent laparotomy only or laparotomy plus superior mesenteric artery occlusion (n = 6/group) for 60 mins, followed by 90 mins of recovery. MEASUREMENTS AND MAIN RESULTS: Mid-jejunal sections were taken for histopathology and messenger RNA expression (reverse transcriptase-polymerase chain reaction, normalized to 18s and laparotomy-only controls). Intestinal injury was scored from 0 (no injury) to 4 (transmural necrosis). Statistical analyses were performed using Mann-Whitney U test and Student's t-test (p < .05 significant). TLR2-/- mice had elevated intestinal injury scores (mean +/- SEM) after ischemia/reperfusion vs. wild-type (2.17 +/- 0.40 vs. 0.67 +/- 0.33, p < .05). Intestinal cytokine messenger RNA (mean fold change +/- SEM) of interferon-gamma (0.29 +/- 0.12 vs. 3313 +/- 1710), interleukin-4 (0.25 +/- 0.13 vs. 2.70 +/- 1.08), and interleukin-6 (250.63 +/- 69.60 vs. 320,300 +/- 215,964) in TLR2-/- was significantly decreased (p < .05) after ischemia/reperfusion vs. wild-type. Tumor necrosis factor-alpha messenger RNA levels were unchanged. CONCLUSIONS: TLR2-/- mice have a dysregulated mucosal innate immune response and fail to mount a protective response after ischemia-reperfusion compared with wild-type mice. This murine model of intestinal injury may correlate with the early postnatal course of premature infants who may have decreased TLR2 expression and/or decreased luminal commensal bacteria secondary to antibiotic therapy, thus decreasing TLR2-mediated signaling.

Treatment of subcutaneous abscesses in children with incision and loop drainage: A simplified method of care.

PURPOSE: The aim of this study was to expand on our previous report of 115 patients after more than a decade-long experience using incision and loop drainage for pediatric subcutaneous abscess management. This report comprises the largest consecutive series of pediatric abscess patients from a single institution ever recorded. METHODS: A retrospective study was performed of all pediatric patients who underwent incision and loop drainage of subcutaneous abscesses at our institution between January 2002 and December 2014. TECHNIQUE: Two sub 5mm incisions were made at the periphery on the abscess. The abscess cavity was probed to break down loculations and drain pus. The abscess cavity was irrigated with normal saline. A loop drain was passed through one incision and brought out through the other. A simple absorbent dressing was applied over the drain. RESULTS: Five hundred seventy-six consecutive patients underwent loop drainage procedures. Mean values are as follows: age, 3.84years; duration of symptoms, 6.17days; postoperative length of stay (with 4 outliers excluded), 0.69days; drain duration, 8.38days; and number of postoperative visits, 1.28. Twenty-six patients had reoperations (4.5%), 2 of which were planned staged excisions of pilonidal cysts and 1 because of accidental home removal. CONCLUSIONS: Micro-incisions and loop drainage is a safe and effective treatment modality for subcutaneous abscesses in children. The findings eliminate the need for repetitive wound packing and simplify postoperative wound care. Loop drainage offers shorter time to discharge, lower recurrence rates, and minimal scarring. Additionally, there is expected cost reduction. We recommend this minimally invasive procedure to be the standard of care for subcutaneous abscesses in children. TYPE OF STUDY: Treatment study - retrospective review. LEVEL OF EVIDENCE: Level IV - case series with no comparison group.

U-stitch laparoscopic gastrostomy technique has a low rate of complications and allows primary button placement: experience with 461 pediatric procedures.

BACKGROUND: Gastrostomy tube placement is among the most common gastrointestinal procedures performed in children. The U-stitch laparoscopic technique allows primary button placement and the advantages of laparoscopy. The purpose of this study was to quantify the completion rate and the occurrence of complications in a large single-institution experience. MATERIALS AND METHODS: All laparoscopic gastrostomy procedures between April 2000 and May 2005 were reviewed. Complications that required operative treatment or hospital readmission were classified as early (<90 days) or late (> or =90 days). RESULTS: Laparoscopic gastrostomies were created in 461 patients during the study period with primary buttons being placed in 444 (96%). No procedure-related deaths occurred. Early complications included: reoperation secondary to tube dislodgement in 7 patients (1.5%), herniation of omentum postoperatively in 3 patients (0.6%), and development of granulation tissue or everted gastric mucosa requiring excision in 13 patients (3.2%). Late complications occurred in 8 patients (1.7%), with three (0.7%) requiring revision of the gastrostomy due to local site problems. Five patients (1.1%) had intraperitoneal placement of tubes during attempted replacement after 90 days. Age, infancy, and neurological impairment were not associated with a higher rate of complications. CONCLUSION: The U-stitch gastrostomy technique is safe and allows primary button placement in infants and children. Its complication rate compares favorably to other reported gastrostomy techniques.

The Surgical Learning and Instructional Portfolio (SLIP) as a self-assessment educational tool demonstrating practice-based learning.

PURPOSE: Time constraints on the teaching and evaluation of residents continue to alter the way in which medical knowledge must be imparted and assessed. Lifelong learning is a component of the practice-based learning competency. A portfolio is one way to assess practice-based learning, but its use is unfamiliar to most surgical programs. The authors describe the evolution of the Surgical Learning and Instructional Portfolio (SLIP) into a worthwhile educational tool. METHODS: In March 2001, the authors began a program to encourage residents to develop a case-based portfolio to document their experience and demonstrate acquisition of knowledge in caring for a variety of surgical diseases. The monthly case topic was chosen by the resident and reported using a template: case history, supporting diagnostic studies, differential diagnosis, final diagnosis with ICD-9 coding, management options, treatment used, 3 lessons learned, embellishment of 1 lesson, and 2 articles supporting the experience. Initially, cases were submitted to the program coordinator and reviewed every 6 months with a faculty advisor to provide feedback. RESULTS: After the first 18 months of this program, resident compliance was less than 50%, satisfaction was low, and formal review did not occur. In July 2004, a single faculty member became responsible for evaluating and providing feedback on the monthly SLIPs. The assignments were handled electronically with feedback delivered within the month via e-mail. SLIP quality as measured by resident compliance and satisfaction improved. CONCLUSION: These SLIPs have matured into a valuable educational tool satisfying multiple ACGME competencies. This portfolio system required direct faculty feedback to become successful.

Single-incision pediatric endosurgery (SIPES) splenectomy: a case-control series.

BACKGROUND/PURPOSE: Single-incision pediatric endosurgery (SIPES) is gaining popularity. The aim of this study was to review the authors' experience with SIPES splenectomy and compare it with conventional laparoscopic splenectomy. SUBJECTS AND METHODS: After institutional review board approval, data on SIPES splenectomy in children were collected prospectively. The study group was compared with a control group of patients who were retrospectively identified as having undergone conventional laparoscopic splenectomy during the same time period. RESULTS: Sixteen children underwent SIPES splenectomy. Ages ranged from 1 to 15 years, with a median of 7 years, and weights were between 10 and 70 kg, with a median of 24 kg. The control group was similar in age and weight characteristics. The most common diagnoses were hereditary spherocytosis, sickle cell disease, and immune thrombocytopenic purpura. There were two conversions to open splenectomy in the SIPES group and one in the laparoscopic group. Operative times were 40-190 minutes (median, 84 minutes) in the SIPES group and 51-154 minutes (median, 99 minutes) in the conventional laparoscopic group. CONCLUSIONS: The SIPES technique is well suited for splenectomy. Despite instruments and camera being in-line, working angles are not compromised, and visualization is adequate. Operating time and hospital stay are comparable to those with standard laparoscopic splenectomy, but the cosmetic result may be superior.

Single-incision pediatric endosurgery for ovarian pathology.

BACKGROUND AND OBJECTIVES: Despite being pioneered by gynecologists, single-incision endosurgery has not been widely reported for the treatment of ovarian and adnexal pathology in neonates, children, and adolescents. We describe our initial experience using single-incision pediatric endosurgery (SIPES) for these indications and discuss advantages and drawbacks. SUBJECTS AND METHODS: All children who underwent SIPES with a preoperative diagnosis of ovarian or adnexal pathology were included in the study. Data on age, operative time, complications, length of hospital stay, and outcomes were collected. RESULTS: From January 2010 until January 2012, 19 girls (mean age, 11.4 years; range, 6 days-17 years; weight range, 4.0-90 kg) underwent SIPES procedures for ovarian or adnexal diagnoses, including hemorrhagic/follicular/paratubal cysts (n=8), torsion (n=7), tumor (n=3), and parauterine cyst (n=1). The operations included cyst unroofing (n=4), detorsion and oophoropexy (n=7), (salpingo)oophorectomy (n=5), marsupialization of cyst (n=2), and cyst aspiration (n=1). Median operative time was 42 ± 29 minutes; there were no conversions to conventional laparoscopy or open surgery. Fifteen patients (79%) were discharged within 24 hours after the procedure. There were no peri- or postoperative complications. Histopathology showed hemorrhagic/follicular/paratubal cyst (n=7), necrotic/calcified ovarian tissue after torsion (n=6), cystadenofibroma (n=1), granulosa cell tumor (n=1), and mature teratoma (Grade 0) (n=1). CONCLUSIONS: SIPES is an excellent alternative to conventional laparoscopy for the treatment of adnexal pathology. Using a single umbilical incision that can be enlarged instead of three smaller trocar sites facilitates the resection and extraction of ovarian masses without compromising cosmesis.