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.

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.

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).

Operative findings in antenatal abdominal masses of unknown etiology in females.

BACKGROUND: Perinatal findings of abdominal masses pose a diagnostic challenge to clinicians. This study presents the operative findings of patients who underwent exploration for perinatally identified abdominal masses of unknown etiology. METHODS: Retrospective review of all patients with abdominal masses of unknown etiology identified in the antenatal period was conducted from January 1, 2000 to July 1, 2010. Patient demographics were collected. Preoperative radiographic studies, operative findings, and pathologic evaluation were reviewed. RESULTS: There were 17 patients identified within the study period. The median age was 30 d at the time of operation (range 0-287 d). The median height was 51 cm (range 45-77 cm), and the median weight was 4.0 kg (range 2.6-10.4 kg). All patients were asymptomatic. After birth, ultrasound identified abdominal masses in 14 patients, and computed tomography scan was used in four patients where one patient had both an ultrasound and a computed tomography scan. Mass resection was performed using laparoscopy in 15 patients, whereas two patients underwent open resection. At the time of surgery, 11 patients were diagnosed with ovarian cysts, four patients with ovarian torsion with an associated cyst, and two patients with an enteric duplication cyst. On final pathology, eight patients had benign ovarian cysts, seven patients had hemorrhagic ovarian necrosis, and two patients had duplication cysts. CONCLUSION: Females with antenatally identified abdominal masses of unknown etiology appear to be benign in nature. In this series, a benign ovarian cyst is the most common diagnosis, and these lesions can be approached laparoscopically.

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.

Treadmill injuries in the pediatric population.

BACKGROUND: Exercise equipment such as treadmills are becoming commonplace in residential homes, placing small children at risk for injury. These injuries can be severe and may require surgical intervention. While it is our clinical perception that these injuries are on the rise, they remain largely unreported in the literature. Therefore, we reviewed our experience to evaluate the incidence and outcomes of treadmill-associated injuries in children. METHODS: After receiving exempt IRB approval, we retrospectively reviewed all patients who sustained treadmill-related injuries that required evaluation by a surgeon from July 2005 to February 2010. Data collected included patient demographics, injury details, injury management, and outcomes. RESULTS: We identified 19 children who required treatment for treadmill-related injuries. Mean age at injury was 4.1 y (1.3-10.5 y), and 63% were male. The treadmill was in use by another person in 17 cases (89%). The hand was involved in 79%. All burns were <10% body surface area and 18 (90%) were <5 %. Admission was required in two cases, and four (21%) children required skin grafting. Healing was complicated by hypertrophic scarring in four patients (21%). Mean length of active therapy was 9.2 ± 7.0 d and involved a mean of 6.0 ± 3.5 healthcare visits. Mean hospital charges were $5700. CONCLUSION: Treadmill-related burn injuries in children are preventable injuries that can pose a substantial burden on patients and families. Supervision is paramount in prevention of these injuries, and strategies should include child safety features in equipment designs along with consumer awareness.

Neutropenic colitis in children.

BACKGROUND: Neutropenic colitis (NC) or typhlitis has an incidence of approximately 5% in patients receiving chemotherapy for malignancy. The precise cause is unknown, but almost all patients are neutropenic; most profoundly so. We reviewed our experience with neutropenic colitis over the past 10 y to assess the incidence, management, and outcome. MATERIALS AND METHODS: Hospital records were reviewed after obtaining IRB approval (# 10-10-184E). There were 1224 children treated for cancer at our institution over the study interval. Neutropenic colitis was strictly defined as the presence of both clinical and radiographic findings consistent with the diagnosis, since there are no definitive diagnostic criteria. Patients with confirmed appendicitis were excluded. Medical management consisted of bowel rest and/or decompression, broad-spectrum IV antibiotics and anti-fungal coverage, and serial clinical exams and radiographic studies. Clinical deterioration and free air were the primary indications for surgery. Demographic factors, signs, symptoms, clinical presentation, underlying disease process, white blood cell count (WBC), and absolute neutrophil count (ANC) prior to the onset of the disease, treatment, and outcome were analyzed. RESULTS: Neutropenic colitis was confirmed in 17 children (1.4% incidence). Three patients had more than one episode. Leukemia was the most common underlying diagnosis (53%). There was no gender predominance, and the mean age at diagnosis was 8.4 y. Mean WBC and ANC at onset were 670 and 164, respectively. A sharp decline in the ANC usually immediately preceded the onset of NC; 2/17 (12%) underwent operation, but both patients had only pneumatosis at exploration. Overall survival was 9/17 (53%), but no deaths were directly attributable to the colitis. CONCLUSION: Neutropenic colitis is an uncommon occurrence in children with neoplasia (1.4% in the current study). Leukemia is the most common cause. A precipitous decline in ANC usually occurs prior to the onset of NC. Most patients do not require operation and the overall mortality directly attributable to NC is low.

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.

The predictive value of Haller index in patients undergoing pectus bar repair for pectus excavatum.

BACKGROUND: The Haller index (HI) remains the standard metric to quantify the severity of pectus excavatum deformity. However, little data exist to determine how well this parameter correlates with the difficulty or early outcomes of repair. METHODS: The study population was comprised of all patients who underwent pectus bar repair for pectus excavatum on whom adequate preoperative images on computed tomography allowed for Haller index calculation, from December 1999 to February 2010. Patients with two bars placed for repair were excluded. All images were reviewed blinded to outcome and Haller index was calculated. Pearson's correlation was used to evaluate the relationship between age, length of operation, postoperative complications, and length of hospitalization. The correlations were performed on the entire population and then individual age groups analyzed: 5-11 y, 12-16 y, and over 17 y. Two-tailed P values were determined from the correlation coefficient and significance was defined as P ≤ 0.05. RESULTS: HI was available for 262 patients. There were 66 patients aged 5-11 y, 165 patients aged 12-16 years, and 30 patients over 17 y. The population was 80% male. In the entire population, there was a small correlation between postoperative pneumothorax and HI (R = 0.131, P = 0.05). There was no correlation between age, operative time, postoperative bar infection, or length of stay. No significant correlations existed in any of the individual age groups. CONCLUSION: The Haller index holds no correlation with age, operative time, postoperative bar infection, or length of stay.

Occurrence of Crohn's disease in children after total colectomy for ulcerative colitis.

BACKGROUND: Colectomy is the definitive treatment for ulcerative colitis (UC) to remove the inflammatory burden. Crohn's disease, however, can affect any portion of the bowel with a propensity to involve the terminal ileum. In some patients with fulminant colitis, distinction between the two is imperfect. Manifestations of Crohn's after colectomy can be devastating because the ileum is needed for restoration of continuity. There is currently little information in the pediatric literature addressing this concern. Therefore, we reviewed all of our patients who underwent colectomy for inflammatory bowel disease to evaluate the risk of subsequent Crohn's manifestations and to document the outcomes. METHODS: A two-center retrospective review of children who underwent colectomy for IBD from January 2000 to July 2010 was performed. Demographic, diagnostic, management, and outcome variables were recorded. RESULTS: We identified 70 patients who underwent colectomy for UC. The mean age at diagnosis was 12 y ± 7 y, and 59% were female. Clinical diagnosis prior to colectomy was UC in 90%, and indeterminate colitis in 10%. There was discordance between clinical and pathologic diagnosis in five patients, two patients were clinically diagnosed with UC but had an indeterminate biopsy, and three patients were clinically diagnosed as indeterminate colitis with a biopsy confirming UC. Indications for colectomy were refractory bleeding in 63%, failure of medical treatment in 28%, toxic megacolon in 6%, and perforation in 3%. A restorative pouch was created after colectomy in 46% using a two-stage approach while, 53% were managed with an initial colectomy and three-stage approach. In one patient, Crohn's was intraoperatively diagnosed from the operative colectomy specimen. This patient had a clinical diagnosis of UC with concordant biopsy prior to surgery. After total abdominal colectomy, 68 patients went on to ileal pouch anal anastomosis by either a two-stage or three-stage approach. In these patients, nine (13%) had a change in their diagnosis to Crohn's after reconstruction. Crohn's complications requiring an operation consisted of two patients with anastomotic dilations, four patients with fistulotomies, and one patient with perianal abscess drainage procedures. CONCLUSIONS: In the children studied, 13% had a diagnostic change to Crohn's disease, and 13% were diagnosed with Crohn's after ileal pouch-anal anastomosis (IPAA). In patients with IPAA and Crohn's, there were more operative interventions for perianal disease.

Treatment of appendicitis in neutropenic children.

BACKGROUND: Appendicitis in the neutropenic patient places the clinician in a precarious position; balancing the timing and risks of surgery and the risk of an uncontrolled infectious source in the abdomen. METHODS: Multi-center retrospective review from 2000 to 2010 of appendicitis occurring in patients with neutropenia secondary to chemotherapy. Patient demographics and surgical outcomes were tracked. RESULTS: There were 11 patients, mean age of 11 y (3-17 y); six were male. Mean weight was 46.9 kg (18.1-72.6 kg). Mean body mass index was 20.9 kg/m(2) (16.8-27.3 kg/m(2)). There were five acute lymphocytic leukemias, four acute myeloblastic leukemias, one T-Cell lymphoma, and one Ewing's sarcoma. Mean presenting white blood cell count was 1900 (0.2-4.4). Average absolute neutrophil count was 900 (0.00-2.6). Computed tomography scan was used in all patients. Appendectomy was performed within 24 h of presentation in all patients, three were perforated. Mean time to first feeding was 1 d (range, 0-5 d), goal feeds at 3 d (range, 1-6 d ). Mean length of stay from appendicitis was 4 d. CONCLUSION: Early appendectomy for appendicitis in neutropenic patients appears to be tolerated well with a low risk of surgical complications.

The lack of efficacy for oral contrast in the diagnosis of appendicitis by computed tomography.

BACKGROUND: Oral contrast is often used with computed tomography (CT) for the diagnosis of appendicitis. This adjunct adds time to evaluation, not all patients can tolerate enteric bolus, and the diagnostic advantages have not been well defined. Therefore, we reviewed our experience to evaluate the impact of oral contrast on diagnostic efficiency and its impact on the patient. METHODS: After obtaining IRB approval, a retrospective review was conducted on patients who underwent CT with oral contrast for the indication of appendicitis over the last 4 years. Data recorded included demographics, CT results, emergency room course, operative findings, and pathology interpretation. All images were reviewed to identify presence/absence of contrast at or beyond the terminal ileum. RESULTS: There were 1561 patients, of whom, 652 (41.8%) were diagnosed with appendicitis and 909 (58.2%) were not (non-appendicitis). Contrast was identified at least to the level of the terminal ileum in 72.4% of the entire population. The contrast was present in 76.2% of the non-appendicitis patients and 67.0% of the appendicitis patients (P = 0.01). Mean time from oral contrast administration to CT imaging was 105.5 min, which was longer in patients with appendicitis (112.2 min) compared with non-appendicitis patients (100.9 min) (P = 0.01). Emesis of the contrast occurred in 19.3% of those with appendicitis and 12.9% of those without appendicitis (P = 0.001). Nasogastric tubes were placed in 5.8% of those with appendicitis and 5.1% of those without (P = 0.37). Appendicitis was confirmed at operation in 94.3% of those with contrast in the area and 94.4% of those without (P = 1.0). Pathology confirmed appendicitis in 90.6% of those with contrast in the area and 94.0% of those without (P = 0.17). CONCLUSION: Nearly 30% of patients receiving oral contrast for the CT diagnosis of appendicitis do not have contrast in the point of interest at the expense of emesis, nasogastric tube placement, and diagnostic delay. These detriments are amplified in patients who have appendicitis. Further, there appears to be no diagnostic compromise in those without contrast in the terminal ileum.

Review of the evidence on the closure of abdominal wall defects.

Infants with congenital abdominal wall defects pose an interesting and challenging management issue for surgeons. We attempt to review the literature to define the current treatment modalities and their application in practice. In gastroschisis, the overall strategies for repair include immediate closure or delayed operative repair. The best level of data for gastroschisis is grade C and appears to support that there is no major difference in survival between immediate closure or delayed repair. In patients with omphalocele, the management techniques are more varied consisting of immediate closure, staged closure or delayed closure after epithelialization. The literature is less clear on when to use one technique over the other, consisting of mostly grade D and E data. In patients with omphalocele, a registry to collect information on patients with larger defects may help determine which of the management strategies is optimal.

Diagnosis of gastroesophageal reflux disease in infants.

Gastroesophageal reflux is commonly encountered in the infant population. Most children will outgrow their reflux but some develop pervasive disease and require medical or surgical treatment. Many tools exist for use in the workup of pediatric gastroesophageal reflux disease; however, the most effective method of diagnosis is not clear. Delineating which patients will benefit from more definitive therapy is a remarkable challenge in this group, often borrowing tools and principles from the adult patient population. Therefore, we reviewed the available literature to critically evaluate the merits and limitations of the current diagnostic modalities available for the evaluation of infantile gastroesophageal reflux.

Predictors of radiolucent foreign body aspiration.

BACKGROUND: Children frequently present for suspected foreign body aspiration, many have mild symptoms and/or negative radiographs raising the question of a radiolucent foreign body aspiration. METHOD: Retrospective review of patients having bronchoscopy for suspected radiolucent foreign body aspiration from 2000 to 2010 collecting demographics, history, hospital presentation, radiographic, and operative details. Pearson's correlation was used between event history, presentation, radiographic details and bronchoscopically identified foreign body with P value <0.01. RESULTS: 138 patients, mean age 2.6 years, mean weight 15.6 kg, 68% male. Event symptoms: 81% witnessed events, 64% wheezing, 43% coughing, 39% choking, 6% stridor, and 0.7% lethargy. Hospital presentation: 70% persistent symptoms, wheezing 56%, coughing 15%, desaturations 11%, stridor 7%, choking 4%, and lethargy 1%. 92% of patients had a chest x-ray; air trapping found in 38%, and lung collapse in 21%. 2 patients received CT scans; 1 had lung collapse. Bronchoscopy identified foreign bodies in 93% of patients: food 68%, plastic 18%, non-descript 11%, rocks 3%. No correlations between event symptoms, hospital presentation, radiographs and foreign body presence. CONCLUSION: Event history, hospital presentation, and radiographs are insufficient in proving the absence of a radiolucent foreign body. Patients with suspected radiolucent foreign body aspiration should undergo diagnostic bronchoscopy prior to discharge.

Predictors of failed enema reduction in childhood intussusception.

BACKGROUND: Initial management of intussusception is enema reduction. Data are scarce on predicting which patients are unlikely to have a successful reduction. Therefore, we reviewed our experience to identify factors predictive of enema failure. METHODS: A retrospective review of all episodes of intussusception over the past 10 years was conducted. Demographics, presentation variables, colonic extent of intussusceptions, and hospital course were collected. Extent of intussusception was classified as right, transverse, descending, and rectosigmoid. Episodes were grouped as success or failure of enema reduction and compared using the Student t test for continuous variables and χ(2) test for dichotomous variables. Significance was P less than .05. RESULTS: We identified 405 episodes of intussusception and 371 attempts at enema reduction. There were 285 successful enema reductions. There was no difference between groups in age; sex; or the presence of emesis, fever, or abdominal mass. The failed enema group was more likely to have had symptoms over 24 hours before presentation (P = .006), bloody diarrhea (P < .001), and lethargy (P < .001). The chance of success diminished with colonic extent (right, 88%; transverse, 73%; left, 43%; colorectal, 29%; P < .001). CONCLUSION: Predictors of failed enema reduction of intussusception include presence of symptoms over 24 hours, diarrhea, lethargy, and distal extent of intussusception.

Utility of pH/multichannel intraluminal impedance probe in identifying operative patients in infants with gastroesophageal reflux disease.

INTRODUCTION: Gastroesophageal reflux is a common clinical problem in infants, but identifying which infants may benefit from a fundoplication remains a conundrum. Esophageal pH and multichannel intraluminal impedance (MII) measurements are useful diagnostic tools in adults and older children, but their diagnostic efficacy in infants is unclear. Therefore, we reviewed our experience with the combined pH/MII probe in this population. SUBJECTS AND METHODS: A retrospective review of patients ≤ 6 months of age who were studied with the pH/MII probe from 2006 to 2010 was performed. Test results, interventions, and outcomes were reviewed. Patients were divided into operative and nonoperative groups, and pH probe and MII results were compared. RESULTS: Fifty-seven patients (53% male) were identified. Mean age at the time of pH/MII probe was 3.1 months. Regarding the operative group (n = 33), 21% had an abnormal pH probe, and 100% had an abnormal MII; 97% had symptom improvement at a mean follow-up of 16 months (range, 0.4-38 months). In the nonoperative group (n = 24), 29% had an abnormal pH probe, and 100% had an abnormal MII. There was no significant difference in reflux index, Boix-Ochoa score, or percentage of acid and non-acid reflux between the two groups. CONCLUSIONS: The pH and MII studies are poor indicators of pathologic reflux in infants and do not adequately discern which patients will benefit from fundoplication.

Experience with a simple technique for pectus bar removal.

BACKGROUND: There have been numerous reports of techniques used for pectus bar removal after correction of pectus excavatum. We use 2 operating tables positioned perpendicular to each other in a T-shaped configuration with the patients thorax circumferentially exposed so the bar is removed in 1 motion without bending the bar. In this study, we report the results of this procedure. METHODS: A retrospective chart review of patients undergoing bar removal after repair of pectus excavatum at our institution from August 2000 to March 2010 was performed. RESULTS: There were 230 patients with a mean age of 16.7 years (range, 7.8-25.3 years) at bar removal. Mean operative time for bar removal was 28.6 minutes, and average estimated blood loss (EBL) was 9.5 mL (range, 5-400 mL). One patient demonstrated significant hemorrhage from the bar tract after bar removal, which was controlled with circumferential compression wrap. Calcification was noted in 11 patients, and chondroma, in 8 patients. Wound infection after bar removal occurred in 3% of patients. No patient required the bar to be bent into a straight configuration for removal. CONCLUSIONS: Removal of pectus bars using this 2-table T-configuration technique is safe, is time efficient, and obviates the need for bending the bar.

The use of high-frequency oscillating ventilation to facilitate stability during neonatal thoracoscopic operations.

BACKGROUND: Thoracoscopy has become a surgical option for the repair of esophageal atresia (EA) and congenital diaphragmatic hernia (CDH). Insufflation of carbon dioxide combined with one lung ventilation creates an anesthetic challenge to control acidosis and maintain oxygenation while allowing optimal operative exposure. We have overcome these issues by utilizing the high-frequency oscillating ventilator (HFOV) and report our early experience. METHODS: A retrospective review from 2007 to 2010 on neonates who underwent thoracoscopic operation utilizing HFOV. Patient demographics and intraoperative course were reviewed. RESULTS: Seventeen neonates were identified, 12 with EA and 5 with posterolateral CDH. The median age at operation was 4 days (range 1-166 days), with a median weight of 2.9 ± 1.0 kg. Median gestational age was 38 ± 3 weeks. Before surgery, 6 patients (35%) were on conventional mechanical ventilation, and no patient was on high-frequency oscillating ventilation. Median American Society of Anesthesiologist's score was 3 (range 3-4). There were no intraoperative complications and median operative time was 208 ± 72 minutes. Review of the operative reports identified no significant difficulties with exposure of the operative field in all patients. Median ventilator manipulations needed were 3 per case. Mean intraoperative pulse oximetry was 97% ± 2%. Sixteen patients had intraoperative arterial blood gases; 1 had venous sampling. Patients with arterial blood gases had a mean pH of 7.36 (range 7.18-7.47), mean pCO2 was 41 mmHg (range 25-63 mmHg), and mean pO2 was 156 mm Hg (range 41-426 mmHg). CONCLUSION: Usage of HFOV allows for good intraoperative exposure with excellent oxygenation and elimination of carbon dioxide to prevent acidosis.