Clinical Utility of Laser Speckle Contrast Imaging and Real-Time Quantification of Bowel Perfusion in Minimally Invasive Left-Sided Colorectal Resections.

BACKGROUND: Left-sided colorectal surgery demonstrates high anastomotic leak rates, with tissue ischemia thought to influence outcomes. Indocyanine green is commonly used for perfusion assessment, but evidence remains mixed for whether it reduces colorectal anastomotic leaks. Laser speckle contrast imaging provides dye-free perfusion assessment in real-time through perfusion heat maps and quantification. OBJECTIVE: This study investigates the efficacy of advanced visualization (indocyanine green versus laser speckle contrast imaging), perfusion assessment, and utility of laser speckle perfusion quantification in determining ischemic margins. DESIGN: Prospective intervention group using advanced visualization with case-matched, retrospective control group. SETTINGS: Single academic medical center. PATIENTS: Forty adult patients undergoing elective, minimally invasive, left-sided colorectal surgery. INTERVENTIONS: Intraoperative perfusion assessment using white light imaging and advanced visualization at 3 time points: T1-proximal colon after devascularization, before transection, T2-proximal/distal colon before anastomosis, and T3-completed anastomosis. MAIN OUTCOME MEASURES: Intraoperative indication of ischemic line of demarcation before resection under each visualization method, surgical decision change using advanced visualization, post hoc laser speckle perfusion quantification of colorectal tissue, and 30-day postoperative outcomes. RESULTS: Advanced visualization changed surgical decision-making in 17.5% of cases. For cases in which surgeons changed a decision, the average discordance between the line of demarcation in white light imaging and advanced visualization was 3.7 cm, compared to 0.41 cm ( p = 0.01) for cases without decision changes. There was no statistical difference between the line of ischemic demarcation using laser speckle versus indocyanine green ( p = 0.16). Laser speckle quantified lower perfusion values for tissues beyond the line of ischemic demarcation while suggesting an additional 1 cm of perfused tissue beyond this line. One (2.5%) anastomotic leak occurred in the intervention group. LIMITATIONS: This study was not powered to detect differences in anastomotic leak rates. CONCLUSIONS: Advanced visualization using laser speckle and indocyanine green provides valuable perfusion information that impacts surgical decision-making in minimally invasive left-sided colorectal surgeries. See Video Abstract . UTILIDAD CLNICA DE LAS IMGENES DE CONTRASTE MOTEADO CON LSER Y LA CUANTIFICACIN EN TIEMPO REAL DE LA PERFUSIN INTESTINAL EN RESECCIONES COLORRECTALES DEL LADO IZQUIERDO MNIMAMENTE INVASIVAS: ANTECEDENTES:La cirugía colorrectal del lado izquierdo demuestra altas tasas de fuga anastomótica, y se cree que la isquemia tisular influye en los resultados. El verde de indocianina se utiliza habitualmente para evaluar la perfusión, pero la evidencia sobre si reduce las fugas anastomóticas colorrectales sigue siendo contradictoria. Las imágenes de contraste moteado con láser proporcionan una evaluación de la perfusión sin colorantes en tiempo real a través de mapas de calor de perfusión y cuantificación.OBJETIVO:Este estudio investiga la eficacia de la evaluación de la perfusión mediante visualización avanzada (verde de indocianina versus imágenes de contraste moteado con láser) y la utilidad de la cuantificación de la perfusión con moteado láser para determinar los márgenes isquémicos.DISEÑO:Grupo de intervención prospectivo que utiliza visualización avanzada con un grupo de control retrospectivo de casos emparejados.LUGARES:Centro médico académico único.PACIENTES:Cuarenta pacientes adultos sometidos a cirugía colorrectal electiva, mínimamente invasiva, del lado izquierdo.INTERVENCIONES:Evaluación de la perfusión intraoperatoria mediante imágenes con luz blanca y visualización avanzada en tres puntos temporales: T1-colon proximal después de la devascularización, antes de la transección; T2-colon proximal/distal antes de la anastomosis; y T3-anastomosis completa.PRINCIPALES MEDIDAS DE VALORACIÓN:Indicación intraoperatoria de la línea de demarcación isquémica antes de la resección bajo cada método de visualización, cambio de decisión quirúrgica mediante visualización avanzada, cuantificación post-hoc de la perfusión con láser moteado del tejido colorrectal y resultados posoperatorios a los 30 días.RESULTADOS:La visualización avanzada cambió la toma de decisiones quirúrgicas en el 17,5% de los casos. Para los casos en los que los cirujanos cambiaron una decisión, la discordancia promedio entre la línea de demarcación en las imágenes con luz blanca y la visualización avanzada fue de 3,7 cm, en comparación con 0,41 cm (p = 0,01) para los casos sin cambios de decisión. No hubo diferencias estadísticas entre la línea de demarcación isquémica utilizando láser moteado versus verde de indocianina (p = 0,16). El moteado con láser cuantificó valores de perfusión más bajos para los tejidos más allá de la línea de demarcación isquémica y al mismo tiempo sugirió 1 cm adicional de tejido perfundido más allá de esta línea. Se produjo una fuga anastomótica (2,5%) en el grupo de intervención.LIMITACIONES:Este estudio no tuvo el poder estadístico suficiente para detectar diferencias en las tasas de fuga anastomótica.CONCLUSIONES:La visualización avanzada utilizando moteado láser y verde de indocianina proporciona información valiosa sobre la perfusión que impacta la toma de decisiones quirúrgicas en cirugías colorrectales mínimamente invasivas del lado izquierdo. (Traducción-Dr. Ingrid Melo).

Impact of Neurodevelopmental Disorders on Bowel Management Outcomes in Children with Functional Constipation.

OBJECTIVES: Patients experiencing functional constipation (FC) can participate in structured bowel management programs (BMPs) to manage constipation or fecal incontinence when standard management fails. We sought to evaluate the efficacy of BMPs for children with FC with and without neurodevelopmental disorders. METHODS: We performed a retrospective review of children with FC who participated in our BMP from 2014 to 2021. Stool/urinary continence, bowel regimen, surgical history, parent-reported outcomes measures (PROMs: Cleveland Clinic Constipation Score, Baylor Continence Scale, Vancouver Symptom Score for Dysfunctional Elimination), and Pediatric Quality of Life Inventory (PedsQL) were assessed pre- and at least 9 months post-BMP. RESULTS: The cohort included 156 patients with a median age of 9 years and follow-up of 627 days (IQR: 389-808 days). Two sub-cohorts included patients with FC only (69%) and FC plus a neurodevelopmental disorder (31%): 59% attention-deficit/hyperactivity disorder, 33% autism spectrum disorder, and 8% obsessive-compulsive disorder. Both groups had significantly improved follow-up bowel movement frequency and continence (39%-90% neurodevelopmental, 44%-82% FC only, P < 0.001) and urinary continence (65%-90% neurodevelopmental, 69%-91% FC only, P < 0.02). There was a significant improvement in most of the PROMs at follow-up. Both groups experienced a clinically meaningful improvement in overall PedsQL scores (pre- and postBMP difference of >4.5). CONCLUSIONS: Patients with FC with and without a neurodevelopmental disorder had significant improvement in stool and urinary continence after undergoing a BMP. Further studies are needed to see if this improvement is durable over a longer period of time in this challenging cohort.

Disparate Use of Chemoradiation in Elderly Patients With Localized Anal Cancer.

BACKGROUND: The incidence of squamous cell carcinoma of the anus (SCCA) is increasing, particularly among the elderly (age ≥65 years). We sought to compare patterns of care for the treatment of SCCA in elderly versus nonelderly patients. METHODS: Data for patients with stages I-III SCCA diagnosed from 2004 through 2015 were obtained from the National Cancer Database. Patients were categorized as having received standard-of-care (SOC) chemoradiation (CRT) with multiagent chemotherapy, non-SOC therapy, palliative therapy, or no treatment. Differences in treatment groups were tested using the chi-square test. We used logistic regression to identify predictors of SOC CRT and multiagent versus single-agent chemotherapy in patients receiving CRT. Propensity score matching was used to compare overall survival (OS) in elderly patients receiving multiagent versus single-agent chemotherapy for those receiving CRT. RESULTS: We identified 9,156 elderly and 17,640 nonelderly patients. A lower proportion of elderly versus nonelderly patients (54.5% vs 65.0%; P<.0001) received SOC CRT than other treatments or no treatment. In multivariate analysis, elderly patients were 38% less likely than nonelderly patients to receive SOC CRT (odds ratio, 0.62; 95% CI, 0.58-0.65; P<.0001). A higher proportion of the elderly were treated with single-agent versus multiagent chemotherapy (16.9% vs 11.8%; P<.0001), which resulted in a >1.5-fold increase in the likelihood of elderly patients receiving single-agent chemotherapy (odds ratio, 1.52; 95% CI, 1.39-1.66) in multivariate analysis. After propensity score matching, 3-year OS was higher in elderly patients who received CRT with multiagent versus single-agent chemotherapy (77.1% vs 67.5%; hazard ratio, 0.78; 95% CI, 0.68-0.89; P=.0002). CONCLUSIONS: In this comprehensive study of patients with stages I-III SCCA, elderly patients were less likely than nonelderly patients to receive SOC CRT. The low proportion of elderly patients receiving SOC CRT with multiagent chemotherapy for localized anal cancer suggests that the optimal treatment approach for this vulnerable population remains undefined.

Evaluation and Management of Persistent Problems After Surgery for Hirschsprung Disease in a Child.

PURPOSE OF REVIEW: Ideally, after operative intervention, a child born with Hirschsprung disease (HD) should thrive, achieve fecal continence, and avoid recurrent episodes of abdominal distention and enterocolitis. However, a significant number of patients continue to struggle following their pull-through procedure. The purpose of this review is to present an organized and practical approach to the evaluation and management of the symptomatic patient post pull-through operation for HD. RECENT FINDINGS: Children diagnosed with HD who are not doing well after their initial operation can be categorized in three distinct groups: (1) those that have fecal incontinence, (2) those with obstructive symptoms, and (3) those with recurrent episodes of enterocolitis. It is important to have a systematic diagnostic approach for these patients based on a comprehensive protocol. All three of these patient groups can be treated with a combination of either medical management, reoperation when a specific anatomic or pathologic etiology is identified, or botulinum toxin for non-relaxing sphincters contributing to the obstructive symptoms or recurrent enterocolitis. For patients not doing well after their initial pull-through, a systematic workup should be employed to determine the etiology. Once identified, a multidisciplinary and organized approach to management of the symptomatic patients can alleviate most post pull-through symptoms.

Hirschsprung Disease: The Rise of Structured Transition and Long-term Care.

Hirschsprung disease, like most surgically correctable congenital anomalies, is now survivable well into adulthood. Patients are, therefore, presenting later in life with problems that were previously infrequently encountered by colorectal surgeons or gastroenterologists. The goals of our review are to describe the current state of care transition for this patient population, identify the specific needs for these patients, and propose guidelines which could inform a future model of transition from the pediatric to adult setting. This is a review of the current state of care transition and long-term outcomes for patients with Hirschsprung disease. Although these patients report a generally good quality of life, the majority suffer from some degree of lifelong gastrointestinal complication, regardless of the type of operative repair. A more formalized transition of care will provide a guide for pediatric surgeons and patients, alleviate colorectal surgeon and gastroenterologist concerns, and provide better long-term care for these patients.

Transcending Dimensions: a Comparative Analysis of Cloaca Imaging in Advancing the Surgeon's Understanding of Complex Anatomy.

Surgeons have a steep learning capacity to understand 2-D images provided by conventional cloacagrams. Imaging advances now allow for 3-D reconstruction and 3-D models; but no evaluation of the value of these techniques exists in the literature. Therefore, we sought to determine if advances in 3-D imaging would benefit surgeons, lead to accelerated learning, and improve understanding for operative planning of a cloaca reconstruction. Questionnaires were used to assess the understanding of 2-D and 3-D images by pediatric surgical faculty and trainees. For the same case of a cloacal malformation, a 2D contrast study cloacagram, a 3D model rotatable CT scan reconstruction, a software enhanced 3D video animation (which allowed the observer to manipulate the structure in any orientation), and a printed physical 3D cloaca model that could be held in the observer's hand were employed. Logistic mixed effect models assessed whether the proportion of questions about the case that were answered correctly differed by imaging modality, and whether the proportion answered correctly differed between trainee and attending surgeons for any particular modality. Twenty-nine pediatric surgery trainees (27 pediatric general surgery and 2 pediatric urology surgery trainees) and 30 pediatric surgery and urology faculty participated. For trainees, the percentage of questions answered correctly was: 2-D 10.5%, 3-D PACS 46.7%, 3-D Enhanced 67.1%, and 3-D Printed 73.8%. For faculty, the total percentage of questions answered correctly was: 2-D 22.2%, 3-D PACS 54.8%, 3D Enhanced 66.2%, and 3-D printed 74.0%. The differences in rates of correctness across all four modalities were significant in both fellows and attendings (p < 0.001), with performance being lowest for the 2-D modality, and with increasing percentage of correct answers with each subsequent modality. The difference between trainees and attendings in correctness rate was significant only for the 2-D modality, with attendings answering correctly more often. The 2-D cloacagram, as the least complex model, was the most difficult to interpret. The more complex the modality, the more correct were the responses obtained from both groups. Trainees and attendings had similar levels of correct answers and understanding of the cloacagram for the more advanced modalities. Mental visualization skills of anatomy and complex 3-D spatial arrangements traditionally have taken years of experience to master. Now with novel surgical education resources of a 3-D cloacagram, a more quickly advancing skill is possible.

Pregnancy in Medical Training: A Survey of Physician Moms on Their Experiences During Residency and Fellowship.

OBJECTIVE: Resident physicians undergo physically and emotionally rigorous training; this is particularly difficult for the pregnant resident and affects their unborn child. This study aims to elucidate pregnant residents' perspectives regarding their prenatal and postnatal experiences, across all specialties, with a focus on pregnancy complications, postpartum health, and policy execution. DESIGN: This is a nationwide cross-sectional survey study developed to characterize resident and fellow perceptions about work schedules while pregnant, perceived discrimination, complications during pregnancy, lactation and lactation support, marital distress, parental leave policy, and overall satisfaction with the parental leave period. Descriptive statistics were used to characterize survey responses. SETTING/PARTICIPANTS: The experiences of physician mothers in online Facebook support groups: Physician Mom Group, Surgeon Mom Group, and Dr Mothers Interested in Lactation Knowledge, were queried by an electronic survey distributed using Qualtrics XM. Physicians who had children during their U.S. residency training were eligible to participate and 1,690 physician mothers from all specialties completed the survey. RESULTS: One thousand six hundred and ninety responses from members of the Facebook support groups were analyzed. Most surveyed physicians (1353/1519, 89.1%) were required to work until delivery and 63.6% (993/1561) of women took in-house calls during the last month of pregnancy. Half (820/1560, 52.6%) thought that the physical demands of their jobs compromised their own health and safety, or that of their child, and 1259 complications were reported among 1690 respondents, an average of three complications for every four respondents. Twenty-nine percent (442/1519, 29.1%) of physician mothers suffered from postpartum depression. Ninety-two percent (1479/1602, 92.3%) of respondents breastfed, but only one-third (483/1456, 33.2%) breastfed for more than 12 months and 52.7% (769/1458) would have liked to breastfeed longer. Marital distress was reported by nearly half (756/1650, 45.8%) of respondents during pregnancy and/or the first year of their child's life due to parental leave policies. The majority (957/1688, 56.7%) did not have a parental leave policy at their institution. Nearly two-thirds (946/1518, 62.3%) of respondents took 6 or fewer weeks off, and 79.7% (1211/1520) felt their duration of time off was inadequate. Nearly 30% (457/1593, 28.7%) stated they would recommend against a female medical student going into their field of medicine based upon their own experiences during pregnancy. CONCLUSIONS: Many mothers experienced discrimination from colleagues and worked until delivery despite concerns about the health and safety of themselves or their unborn children, and many reported experiencing a pregnancy-related complication. Most did not have a parental leave policy, which likely contributed to the disproportionately higher rates of postpartum depression among physician mothers compared to the general public. Residency training parental leave policies should be more accommodating to improve mental health, career satisfaction, and retention of the next generation of physician mothers.

Social Determinants of Health Are Associated with Failed Bowel Management for Children with Anorectal Malformations.

INTRODUCTION: Children with anorectal malformations (ARMs) benefit from bowel management programs (BMPs) to manage constipation or fecal incontinence. We aimed to understand the role of social determinants of health (SDOH) in outcomes following BMPs in this population. MATERIALS AND METHODS: A single-institution, institutional review board (IRB) approved, retrospective review was performed in children with ARM who underwent BMP from 2014 to 2021. Clinical, surgical, and SDOH data were collected. Children were stratified as clean or not clean per the Rome IV criteria at the completion of BMP. Descriptive statistics were computed. Categorical variables were analyzed via Fisher's exact tests and continuous variables with Mood's median tests. RESULTS: In total, 239 patients who underwent BMP were identified; their median age was 6.62 years (interquartile range [IQR]: 4.78-9.83). Of these, 81 (34%) were not clean after completing BMP. Children with prior history of antegrade enema procedures had a higher rate of failure. Children who held public insurance, lived within driving distance, had unmarried parents, lived with extended family, and lacked formal support systems had a significant association with BMP failure (p < 0.05 for all). Type of ARM, age at repair, type of repair, age at BMP, and type of BMP regimen were not significantly associated with failure. CONCLUSIONS: There is a significant correlation of failure of BMPs with several SDOH elements in patients with ARM. Attention to SDOH may help identify high-risk patients in whom additional care may lead improved outcomes following BMP.

Laparoscopic-Assisted Colonic Derotation in Patients With Hirschsprung Disease.

BACKGROUND: Children with Hirschsprung disease (HSCR) proximal to the splenic flexure or those needing a redo pull-through (PT) are at risk for tension and ischemia of the PT which could result in leak, stricture, or loss of ganglionated bowel. Colonic derotation is a technique used to minimize tension and avoid duodenal obstruction. The aim of this study was to describe this technique and outcomes in a series of patients requiring this intervention. METHODS: All patients underwent initial diversion and colonic mapping. The derotation procedure involves mobilization of the remaining colon, counterclockwise rotation via the stoma closure site, placement of the pull through (the right colon) lying on the right of the pelvis, and ligation of the middle colic artery with preservation of the marginal branch running from the ileocolic artery. This maneuver prevents compression of the duodenum by the mesenteric vessels and allows for an isoperistaltic, tension-free anastomosis. Intraoperative indocyanine green fluorescence angiography (ICG-FA) was utilized in many of the cases to map the blood supply of the pull-through colon. We reviewed outcomes for all children with HSCR who underwent colonic derotation from 2014 to 2023. Descriptive statistics were performed. RESULTS: There were 37 children included. Most were male (67.5%) with the original transition zone proximal to the rectosigmoid (81.1%). The median age at PT was 9.3 months [6.1-39.7]. Median operative time was 6.6 h [4.9-7.4] and 19 cases (51.4%) used ICG-FA. Most children had no 30-day postoperative complications (67.6%); in those who did develop complications, readmissions for electrolyte imbalance was most common (50.0%). There were zero cases of anastomotic leak at PT anastomosis. At long-term follow up, median 4.4 years [2.3-7.0], three children (8.1%) developed an anastomotic stricture, all were amenable to anal dilation, and five experienced episodes of enterocolitis (14.7%). Most children had between 1 and 4 stools per day (58.8%). CONCLUSION: Colonic derotation is a useful strategy to ensure well-perfused colonic length, protect the marginal artery blood supply, avoid duodenal compression, and ensure a tension-free anastomosis with minimal complications. TYPE OF STUDY: Original research, retrospective cohort. LEVEL OF EVIDENCE: III.

Long-term patient perception of pain control experience after participating in a trial between patient-controlled analgesia and epidural after pectus excavatum repair with bar placement.

BACKGROUND: Pain control is the dominant management issue after bar placement for pectus excavatum. We previously conducted a prospective, randomized trial comparing patient-controlled analgesia (PCA) to thoracic epidural (EPI) documenting similar objective outcomes. Our impression is that the subjective cognitive experience differs between the groups, which impacts trial results interpretation. Therefore, we conducted a survey to ascertain patient recollection and impression of their experience. METHODS: By telephone questionnaire, yes/no questions included early course recall, anxiety, if they would choose the same arm, do the operation again, or recommend it to friends. Qualitative questions included description, location, and time of peak pain. The graded question addressed severity of pain (1-5). RESULTS: We contacted 27 EPI and 38 PCA patients with a median follow-up of 3.2 y. The majority (~/= 85%) of both groups remembered the first 2 d. Mean pain severity was 3.0 in both groups (3 = bad, but tolerable). Description, location, and time of peak pain responses did not differ. Anxiety was reported by 30% of EPI group and 18% of PCA group (P = 0.37). Approximately 15% of both groups still think about the pain. No differences were seen in nausea, emesis, constipation, itching, or sleepiness. Most patients would choose the same group (87% PCA, 81% EPI, P = 0.73), have the operation again (87% PCA, 74% EPI, P = 0.21), and recommend the operation to friends (100% PCA, 96% EPI, P = 0.42). CONCLUSIONS: Long-term recall after repair of pectus excavatum with bar placement does not substantially differ between those managed with an epidural or PCA.

Need for subsequent fundoplication after gastrostomy based on patient characteristics.

BACKGROUND: Gastrostomy tube placement is common in children. Many of the conditions associated with need for gastrostomy are also associated with gastroesophageal reflux. It is not clear how many patients without complicated reflux will subsequently require a fundoplication or which conditions increase this risk. Therefore, we performed a two-center review to determine the disease-specific propensity for fundoplication after gastrostomy tube placement. METHODS: The data set was retrospectively collected from two centers from 2000 to 2008. All patients underwent gastrostomy tube placement without fundoplication owing to the surgeon's discernment that fundoplication was not needed at the time. Pearson's correlation was used to evaluate the influence of patient variables and operative approach against the subsequent need for fundoplication. Significance was defined as two-tailed P ≤ 0.01. Logistic regression analysis was used to evaluate independence. RESULTS: A total of 684 patients underwent gastrostomy tube placement only, of which 124 were open, 282 laparoscopic, and 278 endoscopic (percutaneous endoscopic gastrostomy). The mean patient age was 2.9 years. Subsequent fundoplication was performed in 62 patients (9.1%). The mean interval to fundoplication was 20.7 months. Cerebral palsy and anoxic brain injury had the most significant correlation with subsequent fundoplication. These were also independent predictors. The laparoscopic approach had a negative correlation with the subsequent need for fundoplication. CONCLUSIONS: The low incidence of subsequent fundoplication in children who undergo gastrostomy tube placement justifies conservative use of fundoplication in the absence of complicated reflux. Those with cerebral palsy and anoxic brain injury appeared to have the greatest risk of the need for subsequent fundoplication.

Ghost publications in the pediatric surgery match.

INTRODUCTION: Pediatric surgery fellowship is considered one of the most competitive subspecialties in medicine. With fierce competition increasing the stakes, publications and first authorship are paramount to the success rate of matching. We analyzed Electronic Residency Application Service applications for verification of authorship to determine rate of misrepresentation. METHODS: After institutional review board approval, the bibliographies of fellowship applications from 2007-2009 were reviewed to allow time for publication. Only peer-reviewed journal articles were evaluated. A Medline search was conducted for the article, by author or by title. If the article could not be found, other authors and journal were used as search parameters. If the article was still not found, the website for the journal was searched for abstract or manuscript. Finally, an experienced medical sciences librarian was consulted for remaining unidentified articles. Differences between misrepresented and accurate applications were analyzed, including: age, gender, medical and undergraduate school parameters, advanced degrees, other fellowships, number of publications, first author publications, American Board of Surgery In-Training Examination scores, and match success. RESULTS: There were 147 applications reviewed. Evidence of misrepresentation was found in 17.6% of the applicants (24/136), with 34 instances in 785 manuscripts (4.3%). Manuscripts classified as published were verified 96.7% of the time, were not found in 1.4%, and had incorrect authors or journal in less than 1% each. "In press" manuscripts were verified 88.3% of the time, 6.4% could not be found, and 4.3% had an incorrect journal listing. Number of publications (P = 0.026) and first author publications (P = 0.037) correlated with misrepresentation. None of the remaining variables was significant. CONCLUSIONS: The pediatric surgical pool has a very low incidence of suspicious citations; however, authorship claims should be verified.

Management of peripherally inserted central catheter associated deep vein thrombosis in children.

INTRODUCTION: No protocol exists for prophylaxis or therapeutic management of peripherally inserted central catheter (PICC) related deep venous thrombosis (DVT) in children. Currently, very few patients are provided prophylaxis for DVT. In this study, we analyzed our current practice of PICC placement to identify the frequency of DVT, analyze risk factors and determine current treatment patterns in order to determine the need for protocols. METHODS: The dataset was retrospectively collected from January 1, 2000 to December 31, 2011. Patients with an upper extremity PICC were assessed for subsequent DVT formation. Variables included: demographics, co-morbidities, method of DVT diagnosis, treatment course, and recurrence. RESULTS: There were 1,289 PICC placements, with 24 (1.9 %) per line events of DVT in 23 patients, of which 3 had recent surgery, 2 had sepsis, 1 had a family history of clots, and 2 had a malignancy. All but one was symptomatic. Diagnosis was made in 92 % by ultrasound, the remaining with CT. No patients had prophylaxis. Of the seven patients who underwent hypercoagulable work-up, three were positive. 15 patients were treated with enoxaparin, 5 patients were treated with heparin, 2 treated with tissue plasminogen activator and 2 were observed. 84 % were treated with long-term enoxaparin for a mean of 3.3 months with 54 % proven clot resolution and 1 patient had recurrence of UE DVT. CONCLUSIONS: The risk of DVT with PICC placement is small in children and prophylaxis can probably be reserved for those with previous DVT or known hypercoagulable state.

To drain or not to drain: an analysis of abscess drains in the treatment of appendicitis with abscess.

BACKGROUND/PURPOSE: Perforated appendicitis is associated with abscess formation before or after appendectomy. Many abscesses are not amenable to drainage due to size or location. In this study, we compare patients who had a drain placed for an abscess to those who were treated without a drain. METHODS: Data were retrospectively collected from January 2000 to March 2011. Abscess before or after appendectomy was assessed. CT scans were reviewed and abscess size was estimated using the product of the greatest anteroposterior and lateral dimensions from an axial image. Patients with abscess smaller than 5 cm(2) were excluded. Patients treated with a drain were compared to those without using t test for continuous variables and Fisher's exact for categorical variables. RESULTS: Of 217 patients, those with drains had significantly more CT scans, total healthcare visits and larger abscess size. When match controlled for size, drain patients accrued more CT scans and healthcare visits. In a subset analysis of aspiration versus antibiotics only, there were more CT scans but no difference between length of stay, total healthcare visits, abscess size, recurrence, or complications. CONCLUSIONS: Appendicitis-associated abscesses may be treated with antibiotics alone based on size, which improves resource utilization with fewer CT scans and healthcare visits.

Predictive factors for successful balloon catheter extraction of esophageal foreign bodies.

INTRODUCTION: Foreign bodies in the esophagus are common in children. Time from ingestion to presentation is variable, and may not be known. Our center usually performs Foley catheter balloon extraction under fluoroscopy as the first step to attempt removal to prevent all patients from going to the operating room. The efficacy of this procedure has been reported. However, information is lacking about the relationship between presentation variables and the likelihood of success. METHODS: After IRB approval, we performed a retrospective single-center review from January 1988 to August 2011 of children with an esophageal foreign body. Pearson's correlation was used to evaluate the relationship between variables and successful balloon extraction for P < 0.05. A logistic regression was done to evaluate for independence. RESULTS: 819 patients presented with esophageal foreign bodies, with a mean age of 3.3 years. 572 patients underwent balloon extraction, 83 % successful. Mean ingestion duration was 16.6 h with fluoroscopy time of 2.3 min and mean number of attempts was 1.5. Successful balloon extraction had a negative correlation with refusal to eat, respiratory distress, cough, wheeze, upper respiratory infection symptoms, stridor, fever, duration of ingestion >1 day, unwitnessed ingestion, fluoroscopy time and number of balloon catheter attempts. There was a positive correlation between success and both age and duration of ingestion <1 day. Independent predictive factors were number of balloon catheter attempts. CONCLUSIONS: Patients with longer duration of ingestion, symptoms from the foreign body and increased number of removal attempts have a decreased likelihood of success with balloon catheter extraction and should not undergo prolonged efforts of removal.

Reduced use of computed tomography in patients treated with interval appendectomy after implementing a protocol from a prospective, randomized trial.

BACKGROUND: In 2009, we instituted a protocol to standardize care for patients undergoing interval appendectomy based on results from a prospective trial that demonstrated a reduction in the mean number of computed tomography (CT) scans performed. The goal of this study was to determine if our current practice now resulted in fewer CT scans as a result of this trial. METHODS: A retrospective review of all patients undergoing interval appendectomy for perforated appendicitis from March 2009 to March 2011 was performed. Demographics and outcomes were compared to previously collected data from a retrospective study prior to institution of the protocol and to the prospective trial. RESULTS: During the study period, 45 patients underwent interval appendectomy. There were no differences in demographics among the three studies. Similar numbers of patients underwent aspiration or percutaneous drainage. There continues to be a significant reduction in the number of CT scans (3.5 ± 2.0 vs. 2.1 ± 1.3, P = 0.0001) and health care visits (7.6 ± 2.8 vs. 4.5 ± 1.4, P = 0.0001) when comparing management prior to the prospective trial to management since its completion. CONCLUSION: A protocol for management of patients undergoing interval appendectomy care results in fewer health care visits and CT scans.

Multi-institutional analysis of long-term symptom resolution after cholecystectomy for biliary dyskinesia in children.

PURPOSE: Current literature for resolution of abdominal pain after cholecystectomy in children with biliary dyskinesia shows variable outcomes. We sought to compare early outcomes with long-term symptom resolution in children. METHODS: Telephone surveys were conducted on children who underwent cholecystectomy for biliary dyskinesia between January 2000 and January 2011 at two centers. Retrospective review was performed to obtain demographics and short-term outcomes. RESULTS: Charts of 105 patients' age 7.9-19 years were reviewed; 80.9 % were female. All were symptomatic with an ejection fraction (EF) <35 % or pain with cholecystokinin administration. At the postoperative visit, 76.1 % had resolution of symptoms. Fifty-six (53.3 %) patients were available for follow-up at median 3.7 (1.1-10.7) years. Of these, 34 (60.7 %) reported no ongoing abdominal pain. Of the 22 patients with persistent symptoms, satisfaction score was 7.3 ± 2.7 (scale of 1-10) and 19 (86.4 %) were glad that they had a cholecystectomy performed. EF, body mass index percentile (BMI %), and pain with cholecystokinin (CCK) were not predictive of ongoing pain at either follow-up periods. CONCLUSION: Short-term symptom resolution in children undergoing cholecystectomy for biliary dyskinesia is not reflective of long-term results. Neither EF, BMI % nor pain with CCK was predictive of symptom resolution. The majority of patients with ongoing complaints do not regret cholecystectomy.

A Modification of the Anoplasty Technique during a Posterior Sagittal Anorectoplasty and Anorectal Vaginal Urethroplasty Closure: The Para-U-Stitch to Prevent Wound Dehiscence.

OBJECTIVE: Wound dehiscence after posterior sagittal anorectoplasty (PSARP) or anorectal vaginal urethroplasty (PSARVUP) for anorectal malformation (ARM) is a morbid complication. We present a novel anoplasty technique employing para-U-stitches along the anterior and posterior portions of the anoplasty, which helps buttress the midline U-stitch and evert the rectal mucosa. We hypothesized that, in addition to standardized pre- and postoperative protocols, this technique would lower rates of wound dehiscence. MATERIALS AND METHODS: A retrospective review of patievnts who underwent primary PSARP or PSARVUP with the para-U-stitch technique from 2015 to 2021 was performed. Wound dehiscence was defined as wound disruption requiring operative intervention within 30 days of the index operation. Superficial wound separations were excluded. Descriptive statistics were calculated. The final cohort included 232 patients. RESULTS: Rectoperineal fistula (28.9%) was the most common ARM subtype. PSARP was performed in 75% and PSARVUP in 25%. The majority were reconstructed with a stoma in place (63.4%). Wound dehiscence requiring operative intervention occurred in four patients, for an overall dehiscence rate of 1.7%. The dehiscence rate was lower in PSARPs compared with PSARVUPs (0.6 vs. 5.2%) and lower for reconstruction without a stoma compared with a stoma (1.2 vs. 2.0%). There were additional six patients (2.6%) with superficial wound infections managed conservatively. CONCLUSION: We present the para-U-stitch anoplasty technique, which is an adjunct to the standard anoplasty during PSARP and PSARVUP. In conjunction with standardized pre- and postoperative protocols, this technique can help decrease rates of wound dehiscence in this patient population.

Sexual and Reproductive Health Outcomes in Females With Cloacal Malformations and Other Anorectal Malformations.

STUDY OBJECTIVE: To improve our understanding of reproductive health and sexual function in women with cloacal malformations and other anorectal malformations (ARMs) METHODS: An observational cross-sectional survey was administered to individuals assigned female at birth aged 12 to 55 with ARMs and cloacal malformations cared for at our institution. Data included age of thelarche/menarche and questions on body image, gynecologic anatomy, sexual function, and pregnancy. RESULTS: Twenty-one patients responded in the ARM group and 30 in the cloacal malformation group. There were no differences in median age of thelarche/menarche in patients with ARMs (11/12.5 years) compared with patients with cloacal malformation (11/12 years). Patients with ARMs were more likely to have native vaginal tissue than those with cloacal malformations (n = 18, 82% vs n = 12, 40%; P = .03). There were no differences between groups regarding concerns about dyspareunia and functionality of their vagina (P > .05). Forty-two percent of patients with cloacal malformations and 30% of patients with ARMs reported having been sexually active. Two patients with cloacal malformations and 2 with ARMs reported having been pregnant. Patients with cloacal malformations reported a lower quality of life score (80.4) compared with those with ARMs (87.0) (difference > 4.5). CONCLUSIONS: Patients with a cloacal malformation were less likely to have native vaginal tissue and reported a lower quality of life than those with ARMs. Despite this, patients with a cloacal malformation had similar reproductive health and sexual function compared with patients with ARMs. Our results reinforce the need for comprehensive sexual and reproductive health care for all women with ARMs.