Adolescent Vaping-Associated Trauma in the Western United States.

INTRODUCTION: Electronic cigarettes (e-cigarettes) are handheld, battery-powered vaporizing devices. It is estimated that more than 25% of youth have used these devices recreationally. While vaping-associated lung injury is an increasingly recognized risk, little is known about the risk of traumatic injuries associated with e-cigarette malfunction. METHODS: A multi-institutional retrospective study was performed by querying the electronic health records at nine children's hospitals. Patients who sustained traumatic injuries while vaping from January 2016 through December 2019 were identified. Patient demographics, injury characteristics, and the details of trauma management were reviewed. RESULTS: 15 children sustained traumatic injuries due to e-cigarette explosion. The median age was 17 y (range 13-18). The median injury severity score was 2 (range 1-5). Three patients reported that their injury coincided with their first vaping experience. Ten patients required hospital admission, three of whom required intensive care unit admission. Admitted patients had a median length of stay of 3 d (range 1-6). The injuries sustained were: facial burns (6), loss of multiple teeth (5), thigh and groin burns (5), hand burns (4), ocular burns (4), a radial nerve injury, a facial laceration, and a mandible fracture. Six children required operative intervention, one of whom required multiple operations for a severe hand injury. CONCLUSIONS: In addition to vaping-associated lung injury, vaping-associated traumatic injuries are an emerging and worrisome injury pattern sustained by adolescents in the United States. This report highlights another means by which e-cigarettes pose an increasing risk to a vulnerable youth population.

The need for early Kasai portoenterostomy: a Western Pediatric Surgery Research Consortium study.

PURPOSE: The purpose of this study was to investigate factors impacting transplant-free survival among infants with biliary atresia. METHODS: A multi-institutional, retrospective cohort study was performed at nine tertiary-level children's hospitals in the United States. Infants who underwent Kasai portoenterostomy (KP) from January 2009 to May 2017 were identified. Clinical characteristics included age at time of KP, steroid use, surgical approach, liver pathology, and surgeon experience. Likelihood of transplant-free survival (TFS) was evaluated using logistic regression, adjusting for patient and surgeon-level factors. Secondary outcomes at 1 year included readmission, cholangitis, reoperation, mortality, and biliary clearance. RESULTS: Overall, 223 infants underwent KP, and 91 (40.8%) survived with their native liver. Mean age at surgery was 63.9 days (± 24.7 days). At 1 year, 78.5% experienced readmission, 56.9% developed cholangitis, 3.8% had a surgical revision, and 5 died. Biliary clearance at 3 months was achieved in 76.6%. Controlling for patient and surgeon-level factors, each additional day of age toward operation was associated with a 2% decrease in likelihood of TFS (OR 0.98, 95% CI 0.97-0.99). CONCLUSION: Earlier surgical intervention by Kasai portoenterostomy at tertiary-level centers significantly increases likelihood for TFS. Policy-level interventions to facilitate early screening and surgical referral for infants with biliary atresia are warranted to improve outcomes.

Attitudes Affecting Decision-Making for Use of Radiologic Enteral Contrast in the Management of Pediatric Adhesive Small Bowel Obstruction: A Survey Study of Pediatric Surgeons.

BACKGROUND: Pediatric surgeons are often asked to treat clinical problems for which little high-quality data exist. For adults with adhesive small bowel obstruction (ASBO), water soluble contrast-based protocols are used to guide management. Little is known about their utility in children. We aimed to better understand key factors in clinical decision-making processes and integration of adult based data in pediatric surgeon's approach to ASBO. METHODS: We administered a web-based survey to practicing pediatric surgeons at institutions comprising the Western Pediatric Surgery Research Consortium. RESULTS: The response rate was 69% (78/113). Over half of respondents reported using contrast protocols to guide ASBO management either routinely or occasionally (n = 47, 60%). Common themes regarding the incorporation of adult-based data into clinical practice included the need to adapt protocols for pediatric patients, the dearth of pediatric specific data, and the quality of the published adult evidence. CONCLUSIONS: Our findings demonstrate that pediatric surgeons use contrast-based protocols for the management of ASBO despite the paucity of pediatric specific data. Furthermore, our survey data help us understand how pediatric surgeons incorporate adult based evidence into their practice.

Diagnostic performance of standardized ultrasound protocol for detecting perforation in pediatric appendicitis.

BACKGROUND: Recent clinical trials in adults and children have shown that uncomplicated acute appendicitis can be successfully treated with antibiotics alone. As treatment strategies for acute appendicitis diverge, accurate preoperative diagnosis of complicated appendicitis and appendiceal perforation has become increasingly important for clinical decision-making. OBJECTIVE: To examine diagnostic performance of ultrasound for detecting perforated appendicitis in a single institution using a standardized technique. MATERIALS AND METHODS: In this retrospective single-center study we evaluated 113 ultrasounds from pediatric patients who underwent appendectomy between November 2014 and December 2015. All ultrasounds were performed using a standardized US protocol including still and cine images of all four abdominal quadrants, with more targeted evaluation of the right lower quadrant (RLQ) using graded compression technique. We compared US findings to intraoperative diagnosis of non-perforated or perforated acute appendicitis. RESULTS: The standardized image protocol generated a reproducible set of ultrasound images in all cases. The most common primary appendiceal finding on US in perforated appendicitis was appendix wall thickening >3 mm (54%, 171/314) and most common secondary finding was echogenic mesenteric fat (75%, 237/314). Thinning of the appendix wall and loculated fluid collection in the right lower quadrant were both highly specific (>90%) for perforation. CONCLUSION: The diagnostic performance of ultrasound using a standardized US technique was similar to that reported in prior studies for detecting perforated appendicitis. Despite low sensitivity, individual ultrasound findings and overall diagnostic impression of "evidence of appendix perforation" remain highly specific.

Can ultrasound reliably identify complicated appendicitis in children?

BACKGROUND: The ability of ultrasound to identify specific features relevant to nonoperative management of pediatric appendicitis, such as the presence of complicated appendicitis (CA) or an appendicolith, is unknown. Our objective was to determine the reliability of ultrasound in identifying these features. METHODS: We performed a retrospective study of children who underwent appendectomy after an ultrasound at four children's hospitals. Imaging, operative, and pathology reports were reviewed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasound for identifying CA based on pathology and intraoperative findings and an appendicolith based on pathology were calculated. CA was defined as a perforation of the appendix. Equivocal ultrasounds were considered as not indicating CA. RESULTS: Of 1027 patients, 77.5% had simple appendicitis, 16.2% had CA, 5.4% had no evidence of appendicitis, and 15.6% had an appendicolith. Sensitivity and specificity of ultrasound for detecting CA based on pathology were 42.2% and 90.4%; the PPV and NPV were 45.8% and 89.0%, respectively. Sensitivity and specificity of ultrasound for detecting CA based on intraoperative findings were 37.3% and 92.7%; the PPV and NPV were 63.4% and 81.4%, respectively. Sensitivity and specificity of ultrasound for detecting an appendicolith based on pathology were 58.1% and 78.3%; the PPV and NPV were 33.1% and 91.0%, respectively. Results were similar when equivocal ultrasound and negative appendectomies were excluded. CONCLUSIONS: The high specificity and NPV suggest that ultrasound is a reliable test to exclude CA and an appendicolith in patients being considered for nonoperative management of simple appendicitis.

Evolution in management of adolescent blunt aortic injuries--a single institution 22-y experience.

BACKGROUND: In children, severe, life-threatening traumatic injuries of the thoracic aorta can be seen after motor vehicle collisions (MVCs) resulting in a sudden deceleration. Concurrent injuries in the thorax and abdomen can make treatment prioritization difficult and require early recognition and prompt intervention. With the increased utilization of minimally invasive endovascular approaches to traumatic aortic (TA) injuries, patients are often spared the increased surgical morbidity (spinal cord ischemia and renal insults) that can be seen with an open technique. The aim of this study was to evaluate a single American College of Surgeons level 1 pediatric trauma center's 22-y experience with TA injuries in children. METHODS: After the Institutional Review Board approval, a 22-y (January 1990-April 2013) retrospective review of all pediatric trauma patients admitted with TA injuries was performed. Patient demographics including age, injury detail, treatment, and outcomes were recorded for analysis. RESULTS: 17 children (<21-y old) were identified with ages ranging from 13-20 y old. The most common mechanism of injury was MVC with all 17 children sustaining TA injuries. The traumatic injuries included aortic transection (9), intimal flap (5), pseudoaneurysm (2), and contained thoracic rupture (1). All children were managed operatively with those before 2008 using an open technique. The endovascular approach was used in 7/17 (41%) cases with the median length of hospitalization 12 d versus 22.5 d using the open approach (P < 0.05). No child required conversion from an endovascular to an open technique for treatment of the aortic injury. There were no operative deaths, no procedure-related paraplegia and all children were discharged home from the hospital. Two children had mild mental deficits as a result of head trauma. CONCLUSIONS: TA injuries are an uncommon injury in children and can result from MVCs or other sudden deceleration mechanisms. Surgical intervention is required in most of the cases and can be performed safely and effectively with low morbidity using an endovascular approach, which is the evolving approach of choice for thoracic aortic injuries. Lengthy follow-up care is recommended in children treated with an endovascular device to monitor for endoleaks and device complications.

Nursing preference of topical silver sulfadiazine versus collagenase ointment for treatment of partial thickness burns in children: survey follow-up of a prospective randomized trial.

We performed a nursing survey to inquire about nursing preferences toward the use of silver sulfadiazine (SSD) and collagenase (CO). We performed a survey between September 2012 and December 2012 asking nurses to rate the application/removal of both products and provide a description of their preferences. Ten study nurses (83%) preferred CO over SSD (P < .001). Two nurses (17%) had no preference. Negative comments on SSD were pseudoeschar (50%), difficult application burns (25%), messiness (67%), and increased number of dressing changes (25%). Negative comments on CO were the need for an additional antimicrobial agent (58%), although 1 nurse noted the higher expense with CO. Nurses preferred CO because of cleanliness of dressing (17%), lack of pseudoeschar (25%), and less pain with dressing changes (8%). Despite no difference in outcomes between SSD and CO, experienced burn nurses prefer CO because of perceptions of decreased trauma and frequency of dressing changes.

Opioid Prescriptions at Discharge After Minimally Invasive Repair of Pectus Excavatum Are Reduced With Cryoablation.

BACKGROUND: The minimally invasive repair of pectus excavatum (MIRPE) is associated with significant postoperative pain and opioid use. The objective of this study was to determine the effect of intercostal nerve cryoablation (Cryo) on inpatient and post-hospital opioid prescription practices following MIPRE. METHODS: A retrospective review at a single pediatric center was conducted of patients ≤21 years old who underwent MIRPE. Oral morphine equivalents (OME) of inpatient and discharge opioids were compared between Cryo and no-Cryo cohorts. RESULTS: 579 patients were identified (82.8% male, mean age 15.4 ± 2.0 years). Cryo was performed in 73.5% of patients. The total inpatient OME use was less in the Cryo group (0.89 ± 0.68 vs. 1.6 ± 0.5 OME/kg/day; p < 0.001). Patients who underwent Cryo were prescribed significantly less OME at discharge compared to the no-Cryo group (3.9 ± 1.7 vs. 10.0 ± 4.1 OME mg/kg, p < 0.001). There was no statistically significant difference in the proportion of patients who required an opioid prescription refill (Cryo 12.4% vs. no-Cryo 11.5%, p = 0.884) or were readmitted (Cryo 5.3% vs. no-Cryo 4.6%, p = 0.833). CONCLUSION: Patients who underwent cryoablation during MIRPE were prescribed significantly less opioid at the time of discharge without increasing the need for opioid refills or hospital readmissions. LEVEL OF EVIDENCE: Treatment study; Level III evidence.

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.

The prevalence of Hirschsprung disease in premature infants after suction rectal biopsy.

BACKGROUND: The prevalence of Hirschsprung disease (HD) in the premature infant population is not well documented. However, delayed passage of stool is common in premature infants, and suction rectal biopsy (SRB) is often used to evaluate for HD in this population. The use of SRB is unknown. Therefore, we evaluated the role of SRB in premature infants with abnormal stooling patterns. METHODS: After Institutional Review Board approval, a retrospective study was conducted on all infants having an SRB performed to exclude HD from January 2000 to December 2010. Infants were divided into two groups according to gestational age (premature < 37 wk; term ≥ 37 wk). Demographics, diagnosis, treatments, and outcomes were collected. A subset analysis was performed on patients diagnosed with HD. RESULTS: Two hundred sixty-nine infants were identified (113 premature and 156 term). Six premature infants (5.3%) and 79 term infants (50.6%) were found to have HD (P < 0.01). As expected, gestational age was significantly different between groups (31.7 versus 38.9 wk, P < 0.01) (Table 1). Premature infants were less likely to have prenatal care (35% versus 55%, P < 0.01) and had longer lengths of hospital stay (45.6 versus 17.6 d, P < 0.01). The most common location of aganglionosis was rectosigmoid in both groups (group 1, 50%; group 2, 33%, P = 0.7). CONCLUSIONS: HD occurs significantly less often in premature infants than in term infants. Alternative diagnoses should be investigated in this population when delayed stooling patterns are encountered. SRB should be used more selectively in this group.

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.

Cryoablation in 350 Nuss Procedures: Evolution of Hospital Length of Stay and Opioid Use.

INTRODUCTION: Current studies show cryoablation decreases opioid requirements and lengths of stay (LOS) in patients undergoing the Nuss procedure for pectus excavatum. This study evaluated the relationship between cryoablation and clinical outcomes for the Nuss procedure. METHODS: A retrospective single-center chart review was performed on patients undergoing the Nuss procedure with intercostal cryoablation from December 2017-August 2021. Demographics, hospital course, and postoperative complications were abstracted. To evaluate the evolution of outcomes over time, the earliest quarter (Q1) of cryoablation patients was compared to the last quarter (Q4). RESULTS: Over 45 months, 350 Nuss procedures with cryoablation were performed. The mean age at operation was 15.7 ± 2.3 years with an average Haller Index of 5.4 ± 4.2. The mean operative time was 136 ± 40.5 minutes. On average, patients used 2.8 ± 2.5 OME/kg of opioid in hospital with a LOS of 2.7 ± 1.1 days. The Q4 patients were discharged 1.3 days earlier (p<0.05) than Q1 patients, with 80% of Q4 discharged by postoperative day #2 vs. 23% in Q1 (p<0.05). Q4 patients received 74% (p<0.05) less opioid in hospital and 21% (p<0.05) less on discharge. Within 90 days postoperatively, complication rates (chest tube placement, wound infection, readmission, neuropathic pain) were similar. Only two patients (0.6%) required reoperation for bar migration/slippage. CONCLUSION: With increased experience, cryoablation for the Nuss procedure decreased opioid use by 74% and was associated with 80% of patients achieving early discharge. Major complication rates were not increased. Cryoablation can be successfully implemented as an effective method of postoperative analgesia. LEVEL OF EVIDENCE: Level III.

Hemodilution in pediatric trauma: Defining the expected hemoglobin changes in patients with liver and/or spleen injury: An ATOMAC+ secondary analysis.

BACKGROUND: Many children with blunt liver and/or spleen injury (BLSI) never bleed intraperitoneally. Despite this, decreases in hemoglobin are common. This study examines initial and follow up measured hemoglobin values for children with BLSI with and without evidence of intra-abdominal bleeding. METHODS: Children ≤18 years of age with BLSI between April 2013 and January 2016 were identified from the prospective ATOMAC+ cohort. Initial and follow up hemoglobin levels were analyzed for 4 groups with BLSI: (1) Non bleeding; (2) Bleeding, non transfused (3) Bleeding, transfused, and (4) Bleeding resulting in non operative management (NOM) failure. RESULTS: Of 1007 patients enrolled, 767 were included in one or more of four study cohorts. Of 131 non bleeding patients, the mean decrease in hemoglobin was 0.83 g/dL (+/-1.35) after a median of 6.3 [5.1,7.0] hours, (p = 0.001). Follow-up hemoglobin levels in patients with and without successful NOM were not different. For patients with an initial hemoglobin >9.25 g/dL, the odds ratio (OR) for NOM failure was 14.2 times less, while the OR for transfusion was 11.4 times less (p = 0.001). CONCLUSION: Decreases in hemoglobin are expected after trauma, even if not bleeding. A hemoglobin decrease of 2.15 g/dL [0.8 + 1.35] would still be within one standard deviation of a non bleeding patient. An initial low hemoglobin correlates with failure of NOM as well as transfusion, thereby providing useful information. By contrast, subsequent hemoglobin levels do not appear to guide the need for transfusion, nor correlate with failure of NOM. These results support initial hemoglobin measurement but suggest a lack of utility for routine rechecking of hemoglobin. LEVEL OF EVIDENCE: Level II Prognostic Study.

Irrigation versus suction alone during laparoscopic appendectomy for perforated appendicitis: a prospective randomized trial.

BACKGROUND: The efficacy of irrigating the peritoneal cavity during appendectomy for perforated appendicitis has been debated extensively. To date, prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing peritoneal irrigation to suction alone during laparoscopic appendectomy in children. METHODS: Children younger than 18 years with perforated appendicitis were randomized to peritoneal irrigation with a minimum of 500 mL normal saline, or suction only during laparoscopic appendectomy. Perforation was defined as a hole in the appendix or fecalith in the abdomen. The primary outcome variable was postoperative abscess. Using a power of 0.8 and alpha of 0.05, a sample size of 220 patients was calculated. A battery-powered laparoscopic suction/irrigator was used in all cases. Pre- and postoperative management was controlled. Data were analyzed on an intention-to-treat basis. RESULTS: A total of 220 patients were enrolled between December 2008 and July 2011. There were no differences in patient characteristics at presentation. There was no difference in abscess rate, which was 19.1% with suction only and 18.3% with irrigation (P = 1.0). Duration of hospitalization was 5.5 ± 3.0 with suction only and 5.4 ± 2.7 days with group (P = 0.93). Mean hospital charges was $48.1K in both groups (P = 0.97). Mean operative time was 38.7 ± 14.9 minutes with suction only and 42.8 ± 16.7 minutes with irrigation (P = 0.056). Irrigation was felt to be necessary in one case (0.9%) randomized to suction only. In the patients who developed an abscess, there was no difference in duration of hospitalization, days of intravenous antibiotics, duration of home health care, or abscess-related charges. CONCLUSIONS: There is no advantage to irrigation of the peritoneal cavity over suction alone during laparoscopic appendectomy for perforated appendicitis. The study was registered with clinicaltrials.gov at the inception of enrollment (NCT00981136).

A review: the role of high dose methylprednisolone in spinal cord trauma in children.

BACKGROUND: The use of steroids in traumatic spinal cord injury (SCI) in children is controversial. There is a paucity of literature on its usage. To help clarify recommendations on steroid use in children, we reviewed the current literature on the administration of high dose methylprednisolone (MP) use in traumatic spinal cord injuries with an emphasis in pediatric spinal cord trauma. METHODS: A retrospective review of the current literature on traumatic spinal cord injuries was conducted. Outcomes were critically reviewed from the National Acute Spinal Cord Injury Studies (NASCIS) II and III and Cochrane review; as well as, other randomized and retrospective studies. Papers describing objective neurological outcomes were only included. RESULTS: The outcomes of neurological improvement following steroid infusion have not been reproducible outside of the NASCIS and one single Japanese trial. High dose steroids significantly increase the risk of infections leading to prolonged hospital stay and ventilator dependence. CONCLUSION: Data from adult studies remains controversial with insufficient data to support administration of MP for treatment of traumatic spinal cord injuries. Randomized controlled trials are needed in the pediatric population to assess the advantages of steroid use after SCI in children. On the basis of the current evidence, the use of steroids in patients is associated with increased infectious risks and no neurological improvements.

Intercostal Nerve Cryoablation in Minimally Invasive Repair of Pectus Excavatum: Effect on Pulmonary Function.

Introduction: Cryoablation of intercostal nerves is performed for pain control after minimally invasive repair of pectus excavatum (MIRPE). Cryoablation affects both sensory and motor neurons, resulting in temporary anesthesia to the chest wall and loss of intercostal motor function. The study objective is to determine the effect of cryoablation on incentive spirometry (IS) volumes, as a measure of pulmonary function, after MIRPE. Materials and Methods: A single-institution retrospective review of pediatric patients undergoing MIRPE was performed. All patients received a multimodal regimen (MMR) of analgesics postoperatively. Three groups were compared-cryoablation (CRYO), elastomeric pain pump (EPP), and MMR alone. The primary outcomes were postoperative IS volumes and IS volumes as a ratio of preoperative forced vital capacity (FVC). Secondary outcomes included pain scores, opioid use, length of stay (LOS), and infectious complications. Results: MIRPE was performed in 115 patients: 50 CRYO, 50 EPP, and 15 MMR alone. Groups were similar for demographics and pectus excavatum severity. Postoperative spirometry measurements were similar across groups: IS (CRYO 750 mL [500,961] versus EPP 750 mL [590,1019] versus MMR 696 mL [500,1037], P = .77); IS/FVC (CRYO 0.19 [0.14,0.26] versus EPP 0.20 [0.16,0.26] versus MMR 0.16 [0.15,0.24], P = .69). Although pain scores were also similar across groups, CRYO patients used less opioid (P < .05) and had shorter LOS (P < .05). Postoperative pneumonia was rare and similar across groups (P = 1.00). Conclusion: Intercostal nerve cryoablation during MIRPE does not adversely affect postoperative IS volumes or increase pneumonia rate, despite the temporary loss of motor innervation to intercostal muscles. Cryoablation provides effective pain control with less opioid use.

Single incision versus standard 3-port laparoscopic appendectomy: a prospective randomized trial.

BACKGROUND: Laparoscopic appendectomy through a single umbilical incision is an emerging approach supported by several case series. However, to date, prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing single site umbilical laparoscopic appendectomy to 3-port laparoscopic appendectomy. METHODS: After Internal Review Board approval, patients were randomized to laparoscopic appendectomy via a single umbilical incision or standard 3-port access. The primary outcome variable was postoperative wound infection. Using a power of 0.9 and an alpha of 0.05, 180 patients were calculated for each arm. Patients with perforated appendicitis were excluded. The technique of ligation/division of the appendix and mesoappendix was left to the surgeon's discretion. There were 7 participating surgeons dictated by the call schedule. All patients received the same preoperative antibiotics and postoperative management was controlled. RESULTS: There were 360 patients were enrolled between August 2009 and November 2010. There were no differences in patient characteristics at presentation. There was no difference in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity. Operative time, doses of narcotics, surgical difficultly and hospital charges were greater with the single site approach. Also, the mean operative time was 5 minutes longer for the single site group. CONCLUSION: The single site umbilical laparoscopic approach to appendectomy produces longer operative times resulting in greater charges. However, these small differences are likely of marginal clinical relevance. The study was registered with clinicaltrials.gov at the inception of enrollment (NCT00981136).

Experience with pilonidal disease in children.

BACKGROUND: Controversy exists regarding the optimum treatment for pediatric pilonidal disease. It is a complex disease process with a high rate of recurrence. A spectrum of surgical strategies exists, including drainage, cyst marsupialization, complete cyst and sinus tract excision with primary versus secondary closure, and excision utilizing flap closure. There is little published in the pediatric literature; therefore, we reviewed our experience in an attempt to document how various interventions affect the natural history. METHODS: A retrospective review was conducted in which all patients who underwent surgical intervention for pilonidal disease at our institution from January 2000 to June 2010 were identified. Data collection included demographics, surgical procedure performed, presence of wound breakdown, presence of infection, recurrence, total procedures performed, number of follow-up visits, and total hospital days. RESULTS: In the study period, 120 patients were identified, and 58% were female. Mean age was 14.9 y old (1-19 y). These patients were then subdivided into closed versus open groups based on the status of their operative wound. In the closed group, 74 patients underwent excision with midline closure and 18 underwent excision with flap closure. There were 28 patients left open after excision. In the closed group, wound breakdown occurred in a total of 41 patients (45%). There was no difference in breakdown between midline and flap closure. Postoperative wound infection occurred in 15% of all patients. The midline closure group had a higher infection rate (20%) compared with those with flap closures (11%), which was not significant (P = 0.30). There was no difference in recurrence rate between patients who were primarily closed and patients who were left open (20.6% versus 25%, P = 0.51). There was also no difference in their hospital length of stay (0.44 ± 2.53 d versus 1.18 ± 2.9 d, P = 0.18). Conversely, the patients who were left open had more follow-up visits (6.48 ± 7.6 versus 4.18 ± 3.3, P = 0.02) and subsequently required more operative procedures (1.71 ± 1.12 versus 1.25 ± 0.49, P = 0.002). CONCLUSION: Management of pilonidal disease remains a complex problem, and operative intervention is fraught with complications, including wound breakdown, infection, and cyst recurrence. Primary closure appears to have better outcomes compared with healing by secondary intention. There does not appear to be a clear advantage of primary closure utilizing flaps over primary closure based on our early experience with flap closures.

The impact of postoperative abscess formation in perforated appendicitis.

BACKGROUND: Abscess after appendectomy for perforated appendicitis is the most common complication. We have completed three prospective trials and are conducting a fourth in which the included patients had either a hole in the appendix or a fecalith in the abdomen identified at the time of operation. The abscess rate in each of these trials was 20%. Multiple publications have focused on prevention and management of this postoperative complication but the total impact of an abscess on the hospital course has not been well documented. Therefore, we reviewed our experience with patients who developed a postoperative abscess to evaluate the total care received compared with those who recovered uneventfully. METHODS: Data from patients with abscess who have been enrolled in our prospective trials from April 2005 to December 2009 were utilized. Patients who recovered without complications in the most recent trial served as a comparison group, as this protocol offers the minimal length of stay without a predetermined length of stay. Data comparison included patient demographics, admission lab values, hospital length of stay, and hospital charges. RESULTS: There were 63 patients with a postoperative abscess and 61 patients without an abscess identified. Patients with an abscess were older (11.0 versus 9.7 y, P = 0.04) and had a higher mean body mass index (22.4 versus 19.5, P = 0.03). Total hospital length of stay was significantly longer in the abscess group (11.6 d versus 5.1 d, P ≤ 0.001). Total hospital charges doubled for patients who developed an abscess ($82,000 versus $40,000 P < 0.001). CONCLUSION: A postoperative abscess after appendectomy for perforated appendicitis translates into an average of an extra week in hospital care with double the total hospital cost.