The Minimally Invasive Repair of Pectus Excavatum Using a Subxiphoid Incision.

Purpose Several surgeons have documented outcomes following the Nuss operation. Most reports have described the use of thoracoscopy to avoid cardiac injury. Since 1999, our group has utilized a subxiphoid incision, allowing insertion of the surgeon's finger into the substernal space to help guide the bar across the mediastinum. Our initial experience has been reported and we are now reporting our entire experience to date. Methods A retrospective review was conducted on all patients who underwent pectus excavatum repair using a subxiphoid incision from December, 1999 to September, 2015. Results During the study period, 554 repairs were performed. A total of 80% of the patients were male. The mean age was 14.3 years ± 3.1, the mean operating time was 52 minutes ± 17.4, the mean length of stay was 4.2 days ± 1.1, and the mean time to bar removal was 2.7 years ± 0.7. A total of 20 patients (3.6%) received two bars. No patients sustained cardiac injury or evidence of pericarditis. Postoperatively, 22 patients (4%) developed an infection, either cellulitis or a local abscess requiring incision and drainage and/or antibiotics. In four of these 22 patients, the wound infection developed after the bar had been removed. Only one patient required bar removal before 2 years due to an infection. A total of 12 patients required either repositioning of the bar due to rotation (4) or removal of a stabilizer due to chronic discomfort (8), 2 required early bar removal for chronic pain, and 1 patient developed a tension pneumothorax in the operating room. A recurrence has developed in two patients but neither patient has desired correction. Conclusion In this relatively large series of patients, the addition of a subxiphoid incision to the technique has allowed for safe passage of the bar across the mediastinum to avoid cardiac injury during the Nuss operation.

The risk of developing a symptomatic inguinal hernia in children with an asymptomatic patent processus vaginalis.

BACKGROUND: Children with a symptomatic indirect inguinal hernia have a patent processus vaginalis (PPV). However, the reverse is unknown, as the natural history of PPV is unclear. Currently, there are little data regarding the incidence and time frame for developing a symptomatic hernia with a known asymptomatic PPV. METHODS: A retrospective chart review was conducted in children who were evaluated for a PPV during nonhernia laparoscopic surgery by a single pediatric surgeon (GWH) from 2000 to 2014. Those patients with intraoperative findings of PPV were followed up by chart review and phone inquiry. RESULTS: 1548 children underwent a laparoscopic operation, with 308 having an asymptomatic PPV. Phone contact was successful in 125 (43%) of these patients at a median of 8.1years (range 4.8-12.7) after the initial laparoscopic operation. Nineteen (13%) patients returned with a symptomatic hernia at a median age of 17months (range: 5-74) and a median presentation of 9months (range: 1-66) after the initial laparoscopy. Ten hernia repairs were unilateral and 9 bilateral. None of those who were contacted via phone inquiry reported hernia symptoms or hernia repair. CONCLUSIONS: These data suggest that the risk of developing a symptomatic hernia during childhood in the presence of a known PPV is relatively low. LEVEL OF EVIDENCE: Level 3; type of study: retrospective study.

Contemporary Management of Achalasia by Pediatric Surgeons: A Survey of the International Pediatric Endosurgical Group.

INTRODUCTION: Achalasia is a rare neurodegenerative disorder of the esophagus. Surgical repair consists of esophagomyotomy, often in conjunction with an antireflux procedure. We sought to determine practice patterns in surgical treatment of pediatric achalasia. METHODS: Data regarding preferences were collected as part of a comprehensive online-based survey sent to members of the International Pediatric Endosurgery Group (IPEG) completed by 191 surgeons of which 141 performed esophagomyotomies for achalasia. RESULTS: Procedures performed per surgeon were 1-2 (n = 21, 15%); 3-5 (n = 49, 34%); 6-10 (n = 39, 28%); 11-20 (n = 21, 15%); >20 (n = 11, 8%). Most approached the operation laparoscopically (n = 127, 90%). Workup before esophageal myotomy consisted of a diagnostic esophagram (n = 133, 94%) or manometry (n = 102, 73%). Only 60% of surgeons (n = 84) required an EGD. No preference observed in division location of the phrenoesophageal ligament for mobilization of the esophagus. There was a predominant preference for hook cautery (n = 82, 58%) over harmonic shears (n = 30, 21%), heated sealing device LigaSure™ (n = 18, 13%), and other devices (n = 11, 8%) for muscle division. Intraoperatively, 57% (n = 80) had endoscopy and 50% (n = 71) had postoperative esophagram before initiation of enteral feeding. For antireflux procedure, Thal/Dor approach was performed most frequently (n = 111, 79%) followed by the Toupet (n = 18, 13%) and Nissen (n = 4, 3%) and none (n = 7, 5%). Diet restrictions were provided in 76% (n = 107) of postoperative patients. CONCLUSION: Given the infrequency of achalasia in children, there are a range of treatment plans among pediatric surgeons. We have identified current practices as a first step in developing more standard treatment pathways.

Same day discharge protocol implementation trends in laparoscopic cholecystectomy in pediatric patients.

PURPOSE: After investigating barriers for same day discharge (SDD) after laparoscopic cholecystectomy (LC), we employed a protocol which we have followed with a prospective, observational study. METHODS: A single institution, prospective observational study was performed from July 2014 to 2015 (2nd period). These data were compared to our initial experience with an SDD protocol from January 2013 to July 2014 (1st period). RESULTS: A total of 191 LCs were analyzed, 116 in the 1st period and 75 in the second period. In the 1st period, 47% were discharged the same day compared to 78% in the 2nd period (P<0.001). There was no difference in postoperative complications or readmissions between those discharged and those who spent the night. Additionally, there was no difference between admitted and SDD patients in age, BMI, or gender. Reasons for admission included pain (12%) and emesis (12%), and 1 patient had a syncopal event. However, the majority stayed with no identifiable patient factor. CONCLUSION: SDD after LC is safe and effective and implementing and revising a standardized clinical protocol can substantially improve the success of SDD. LEVEL OF EVIDENCE: Retrospective comparative study, level III.

The effectiveness of costal cartilage excision in children for slipping rib syndrome.

PURPOSE: Slipping rib syndrome (SRS) is an elusive diagnosis. Previous reports have been single cases or small series. We previously reported a small multicenter review with encouraging early results. We now describe our matured experience. METHODS: This is a follow-up study of patients with SRS from 2006 to 2015. Included are 5 previously analyzed patients and 25 new patients. Patients were called to review current symptoms, course, and satisfaction. RESULTS: From 2006 to 2015, 30 patients underwent 38 operations. Eight underwent re-operation. All had reproducible pain localized to the costal margin, 60% had a popping sensation, and 23% were bilateral. 86% were female. Median age of symptom onset was 14 (IQR 13.75-15) years, while median age at diagnosis was 16 (IQR 15-17). Contact was possible with 18/30 patients, and mean follow up time was 1.3years. 72% of those felt they were cured, and 44% rated satisfaction a 10/10 (mean 7.84). Of those not cured, all reported significant improvement. CONCLUSIONS: Costal cartilage excision is an effective treatment for SRS and should be considered early in the workup of costal margin pain in a normally active population. Case Series with no Comparison Group - Level IV.