Modified laparoendoscopic gastrostomy tube (LEGT) placement.

PURPOSE: The purpose of this study was to report the outcomes of our modified LEGT technique. METHODS: Charts of 26 children who underwent modified LEGT technique between May 2008 and February 2010 were retrospectively reviewed. Their age ranged from 7 days to 16 years. Under general anesthesia, a gastroscope was placed in the stomach and laparoscopic visualization was obtained through a 5 mm umbilical port. Using laparoscopic and gastroscopic visualization, four 2'0' PDS 'T'-Fasteners were placed around a proposed gastrostomy site in the stomach. These sutures were pulled externally and tied subcutaneously so that nothing was visible outside. The gastrostomy button was then placed in the center of these four sutures at the proposed gastrostomy button site. Once the gastrostomy balloon was inflated, the four sutures were pulled taut and tied subcutaneously to pexy the stomach to the abdominal wall. Visualization with the gastroscope and laparoscope ensured proper gastrostomy button placement. RESULTS: At a median follow-up of 9 months (range 10 days-2 years), none of the patients had major complications and only five had minor gastrostomy site infection which completely resolved after antibiotic therapy. CONCLUSIONS: LEGT is a safe and effective technique for placement of primary G buttons/tubes in children. The laparoscopic visualization of the LEGT avoids accidental gastro-enteric fistula formation and allows primary placement of the gastrostomy button without need for subsequent procedures. LEGT ensures that the G-button is placed within the gastric lumen. Additionally, the four 'T'-Fastener technique gives optimal fixation of the stomach to the abdominal wall, avoids accidental disruption of sutures as they are placed subcutaneously and has no need for suture removal at a post-operative visit as in other techniques. Since there are no other ports used except the umbilicus this technique provides excellent cosmetic results.

Recurrent tracheoesophageal fistula after thoracoscopic repair: vanishing clips as a potential sign.

We present a case of a neonate who underwent surgery for esophageal atresia (EA) with tracheoesophageal fistula (TEF) with an unusual finding on postoperative chest radiographs. In retrospect, this was a clue to a recurrent TEF: disappearance of the surgical clips from the site of surgical repair. Knowledge of this radiographic finding could aid in the diagnosis of a recurrent fistula in patients with previous repair of EA.

Transumbilical repair of umbilical hernia in children: The covert scar approach.

BACKGROUND: Umbilical hernia repairs are one of the most commonly performed operations in children. The traditional repair involves an infraumbilical incision, which produces a visible scar. We report a novel technique of umbilical hernia repair through a transumbilical incision, which eliminates the scar by hiding it within the umbilicus. METHODS: We performed a retrospective chart review of 134 patients who had undergone a transumbilical hernia repair at a single institution between 2008 and 2016. Satisfaction with cosmesis and the presence of complications were assessed through parental interviews during follow up visit or by telephone survey. These data were compared to a large volume retrospective analysis of the standard infraumbilical approach. RESULTS: 121 of the 134 patients were evaluated in the clinic or by telephone interview. The overall complication rate was 7.44%. Parents of 118 patients reported satisfaction with the cosmetic result (97.52%). In comparison to the largest study of pediatric infraumbilical repair, there was an improvement in subjective cosmesis without a significant increase in complications. CONCLUSION: Transumbilical hernia repair is a safe and cosmetically appealing technique for umbilical hernia repair in children. LEVEL OF EVIDENCE: Treatment study, level III.

Outcomes after peritoneal dialysis catheter placement.

BACKGROUND: The purpose of this study was to review surgical outcomes after elective placement of peritoneal dialysis (PD) catheters in children with end-stage renal disease. METHODS: Children with PD catheters placed between February 2002 and July 2014 were retrospectively reviewed. Outcomes were catheter life, late (>30days post-op) complications (catheter malfunction, catheter malposition, infection), and re-operation rates. Comparison groups included laparoscopic versus open placement, age<2, and weight<10kg. Univariate and multivariate analysis were performed. RESULTS: One hundred sixteen patients had 173 catheters placed (122 open, 51 laparoscopic) with an average patient age of 9.7±6.3years. Mean catheter life was similar in the laparoscopic and open groups (581±539days versus 574±487days, p=0.938). The late complication rate was higher for open procedures (57% versus 37%, p=0.013). Children age<2 or weight<10kg had higher re-operation rates (64% versus 42%, p=0.014 and 73% versus 40%, p=0.001, respectively). Adjusted for age and weight, open technique remained a risk factor for late complications (OR 2.44, 95% CI 1.20-4.95) but not re-operation. DISCUSSION: Laparoscopic placement appears to reduce the rate of late complications in children who require PD dialysis catheters. Children <2years age or <10kg remain at risk for complications regardless of technique.

Routine gastrostomy tube placement in children: Does preoperative screening upper gastrointestinal contrast study alter the operative plan?

BACKGROUND: Upper GI (UGI) studies are routinely ordered to screen for malrotation before routine placement of gastrostomy (G) tubes. However, the usefulness of this study is unknown. METHODS: A retrospective review of children with surgically placed G-tubes over a 2 year period (2011-2013) was performed. Patients with concomitant fundoplications were excluded. RESULTS: Three hundred ninety-three patients underwent G-tube placement. Of these, 299 patients (76%) had preoperative UGI, and 11 patients (3.7%) were identified with malrotation on UGI. Five (1.7%) patients underwent a Ladd's procedure. The remaining 6 either had malrotation associated with gastroschisis (n=5) or were lost to follow-up (n=1). Children <1 year did not have different rates of malrotation compared to older children (4.3% vs. 3.2%, p=0.617). Likewise, children with neurologic impairment (NI) had similar rates of malrotation compared to neurologically normal (NN) children (2.6% vs. 3.8%, p=0.692). The only significant difference in malrotation rate was between those with congenital gastrointestinal anomalies (24%) and those without (1.5%) (p<0.001). CONCLUSION: Preoperative screening UGI before routine G-tube placement led to an unexpected diagnosis of malrotation in only 1.7%. Given the added radiation risk associated with an UGI, our data suggest that an UGI is unnecessary prior to routine G-tube placement. A larger prospective study is warranted to validate these results.

Esophageal bronchus in an infant--a rare cause of recurrent pneumonia.

A 4-month-old female infant presented to our institute with recurrent pneumonia and was diagnosed with a right lower lobe esophageal bronchus. This congenital anomaly is extremely rare with very few cases reported in the literature. We describe the diagnostic workup and management that led to a successful outcome.

Cervicothoracic neuroblastoma arising from the stellate ganglion in children: the use of muscle and bone sparing transmanubrial transcostal approach.

Cervicothoracic neuroblastoma arising from the stellate ganglion in children has always been a challenge to the pediatric surgeon. Localized thoracic neuroblastoma in children has a very good prognosis if excised completely even without adjuvant therapy. Several approaches have been described to resect cervicothoracic neuroblastoma arising from the stellate ganglion with limited success. The muscle and bone sparing transmanubrial transcostal approach which spares the clavicle and the sternomastoid muscle provides excellent exposure for the complete excision of the tumor and excellent functional outcome. We report a 2-year-old girl with cervicothoracic neuroblastoma who had an excellent outcome with this approach.