Implications of Foley catheterization in children with perforated appendicitis.

BACKGROUND: We treat patients after appendectomy for perforated appendicitis with patient controlled analgesia (PCA) using a background continuous dose. We usually place urinary catheters in these patients because of concerns of urinary retention. The objective of the present study was to determine the rate of urinary retention in this patient population when a catheter was not used or was removed before the continuous PCA infusion was discontinued. METHODS: We performed a retrospective review of all patients who had received PCA postoperatively for perforated appendicitis from December 2008 to May 2011. The demographics, need for replacement of a Foley catheter, number of recorded nursing calls to physicians, and the incidence of urinary tract infection was recorded. Patients who had received a urinary catheter intraoperatively were compared with those who had not. Subgroups were also created according to whether the patients with a Foley catheter had undergone removal of their catheter before or after cessation of the continuous PCA infusion. RESULTS: Of 242 patients, 20 (8.3%) did not have a catheter postoperatively, 1 of whom required a catheter because of retention. Of the 222 patients who started with a catheter, 2 required reinsertion for retention (P = 0.59). Age, gender, and body mass index were similar for patients with and without a catheter. In the subgroup analysis, of the patients with a catheter, 48 (21.6%) had their catheter removed before discontinuation of the continuous PCA infusion and none required Foley catheter replacement. Of the 174 patients whose catheters were removed after discontinuation of the continuous PCA dose, 2 required catheter replacement (P = 0.46). A significantly higher percentage of telephone calls was generated for patients with a catheter than for patients without a Foley catheter (41.4% versus 10%, P = 0.007). No patients with a catheter developed a urinary tract infection. CONCLUSIONS: Patients with a perforated appendicitis who receive a continuous PCA have a low rate of urinary retention whether or not a catheter has been placed intraoperatively.

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.

Accuracy of American College of Surgeons National Surgical Quality Improvement Program Pediatric for laparoscopic appendectomy at a single institution.

BACKGROUND: In October 2008, the American College of Surgeons revealed the National Surgical Quality Improvement Program (NSQIP) Pediatric in an effort to improve quality of surgical care in children. A 5% disagreement rate of data reported between institutions is accepted. The two goals of this study were to (1) determine if the random sampling performed with NSQIP data collection was representative of the population, and (2) verify that data captured in NSQIP was accurate. METHODS: For children undergoing laparoscopic appendectomy from April 2010-April 2011, demographic data, length of stay (LOS), and rates of surgical site infection (SSI) and postoperative abscess recorded in NSQIP (group 1) were compared with data from chart review (group 2). Secondarily, all NSQIP data were examined for accuracy by comparing relevant data points to existing databases. All disagreements were further examined with review of the medical chart. Unpaired t-test and χ(2) with Fisher's exact test were used in the statistical analysis. RESULTS: NSQIP Pediatric captured data from 126 children (group 1); group 2 had 525 children. There were no significant differences in age, body mass index, gender, race or LOS between the two groups. Rate of SSI was 1.6% in group 1 and 1.7% in group 2 (P = 0.92). Abscess rate was 1.6% in group 1 and 3.4% in group 2 (P = 0.28). There were six errors in the NSQIP database. One child was listed as having two SSI. One child with postoperative abscess was missed and another was not counted as they were not categorized correctly. Recorded LOS was incorrect for two children and the other had incorrect age. CONCLUSIONS: NSQIP Pediatric captured a representative sample of patients undergoing laparoscopic appendectomy. Errors were found in the reporting of outcomes for SSI and postoperative abscess in children undergoing laparoscopic appendectomy. Given the low incidence of these outcomes, there is little effect on percentages of complications reported.

Clinical outcomes following bowel resection versus reduction of intussusception.

BACKGROUND: Intussusception is most commonly managed with air-contrast reduction. However, when this fails, emergent operation with resection or manual reduction is indicated. It is not known if there are advantages to resection compared with manual reduction. METHODS: A retrospective review of all patients receiving operative care for intussusception from February 2000 to December 2011. Patients undergoing intestinal resection were compared with those treated with manual reduction alone. RESULTS: Of 111 patients, 49 underwent resection and 62 underwent manual reduction. Mean (±SD) time to oral intake favored manual reduction (2.1 ± 1.2 versus 2.6 ± 1.2 d, respectively, P=0.05). Manual reduction was associated with a greater need for repeat imaging (47% versus 18%, P=0.002) and the only recurrences were with manual reduction (8% versus 0%, P=0.1). Mean duration of stay was no different (P=0.36), nor was the need for reoperation (P=0.9). CONCLUSIONS: Patients undergoing manual reduction have an increased number of radiographic imaging procedures. The surgeon should have a low threshold for resection for intussusceptions requiring operative management.

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.

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.

New technique to prevent tilt during inferior vena cava filter placement.

PURPOSE: The risk of inferior vena cava (IVC) filter tilt during placement is significant and may limit filter retrieval. The purpose of the study was to determine if tilting of IVC filters on deployment is able to be reduced when using a femoral approach. METHODS: Under fluoroscopic guidance, Cook Celect IVC filters that are not in axis with the IVC prior to full deployment were straightened in the long IVC axis using a stiff guidewire prior to release. This guidewire helps to center the apex of the filter in the IVC and allow proper deployment. RESULTS: All 11 IVC filters deployed with this technique have been placed without tilt. No complications were encountered with this technique. CONCLUSIONS: IVC filter tilt may lessen their efficacy and ability to be easily retrieved. By using this technique, we have virtually eliminated IVC filter tilt in our patients.

Interval appendectomy after perforated appendicitis: what are the operative risks and luminal patency rates?

BACKGROUND: The need for interval appendectomy after nonoperative management of a perforated appendicitis is being questioned owing to recent studies that estimated recurrence rates as low as 5% because of obliteration of the appendiceal lumen. We review our experience with interval appendectomy in this subset of patients to determine the postoperative outcomes and luminal patency rates. METHODS: A retrospective review was conducted of all children treated nonoperatively for a perforated appendicitis followed by elective interval appendectomy during the past 10 years. The data collected included initial hospitalization, convalescence period, perioperative course, and luminal patency rates. RESULTS: A total of 128 patients were identified, of whom 55% were male. Their mean ± SD age was 9.1 ± 4.2 years. The mean interval from the initial presentation to appendectomy was 65.9 ± 20.3 d. All but 2 of the patients underwent laparoscopic appendectomy with 3 conversions to open surgery. The mean operative time was 43.6 ± 19.2 min. The complication rate was 9%, including 1 postoperative abscess, 1 reoperation for bleeding, and 1 readmission for Clostridium difficile infection. Six patients had a superficial wound infection, and 2 patients underwent outpatient procedures for suture granuloma. No risk factors for complications were identified. Of the specimens, 16% had obliterated lumens. CONCLUSIONS: Major postoperative morbidity for interval appendectomy after a perforated appendicitis is low and should not be a deterrent in offering interval appendectomy to this subset of patients.

When a Surgical Colleague Makes an Error.

Professionalism requires that doctors acknowledge their errors and figure out how to avoid making similar ones in the future. Over the last few decades, doctors have gotten better at acknowledging mistakes and apologizing to patients when a mistake happens. Such disclosure is especially complicated when one becomes aware of an error made by a colleague. We present a case in which consultant surgeons became aware that a colleague seemed to have made a serious error. Experts in surgery and bioethics comment on appropriate responses to this situation.

Metabolic cardioprotection by pyruvate: recent progress.

Pyruvate, a natural metabolic fuel and antioxidant in myocardium and other tissues, exerts a variety of cardioprotective actions when provided at supraphysiological concentrations. Pyruvate increases cardiac contractile performance and myocardial energy state, bolsters endogenous antioxidant systems, and protects myocardium from ischemia-reperfusion injury and oxidant stress. This article reviews and discusses basic and clinically oriented research conducted over the last several years that has yielded fundamental information on pyruvate's inotropic and cardioprotective mechanisms. Particular attention is placed on pyruvate's enhancement of sarcoplasmic reticular Ca2+ transport, its antioxidant properties, and its ability to mitigate reversible and irreversible myocardial injury. These research efforts are establishing the essential foundation for clinical application of pyruvate therapy in numerous settings including cardiopulmonary bypass surgery, cardiopulmonary resuscitation, myocardial stunning, and cardiac failure.

Pyruvate improves cardiac electromechanical and metabolic recovery from cardiopulmonary arrest and resuscitation.

Severe depletion of myocardial energy and antioxidant resources during cardiac arrest culminates in electromechanical dysfunction following recovery of spontaneous circulation (ROSC). A metabolic fuel and natural antioxidant, pyruvate augments myocardial energy and antioxidant redox states in parallel with its enhancement of contractile performance of stunned and oxidant-challenged hearts. This study tested whether pyruvate improves post-arrest cardiac function and metabolism. Beagles were subjected to 5 min cardiac arrest and 5 min open-chest cardiac compression (OCCC: 80 compressions min(-1); aortic pressure 60-70 mmHg), then epicardial dc countershocks (5-10 J) were applied to restore sinus rhythm. Pyruvate was infused i.v. throughout OCCC and the first 25 min ROSC to a steady-state arterial concentration of 3.6+/-0.2 mM. Control experiments received NaCl infusions. Phosphocreatine phosphorylation potential (approximately PCr) and glutathione/glutathione disulfide ratio (GSH/GSSG), measured in snap-frozen left ventricle, indexed energy and antioxidant redox states, respectively. In control experiments, left ventricular pressure development, dP/dt and carotid flow initially recovered upon defibrillation, but then fell 40-50% by 3 h ROSC. ST segment displacement in lead II ECG persisted throughout ROSC. Approximately PCr collapsed and GSH/GSSG fell 61% during arrest. Both variables recovered partially during OCCC and completely during ROSC. Pyruvate temporarily increased approximately PCr and GSH/GSSG during OCCC and the first 25 min ROSC and enhanced pressure development, dP/dt and carotid flow at 15-25 min ROSC. Contractile function stabilized and ECG normalized at 2-3 h ROSC, despite post-infusion pyruvate clearance and waning of its metabolic benefits. In conclusion, intravenous pyruvate therapy increases energy reserves and antioxidant defenses of resuscitated myocardium. These temporary metabolic improvements support post-arrest recovery of cardiac electromechanical performance.

Increased lymphatic flow in the thoracic duct during manipulative intervention.

The thoracic pump and the abdominal pump are osteopathic manipulative (OM) lymphatic pump techniques frequently used by osteopathic physicians to treat patients with infections (eg, pneumonia, otitis media). Although there is a widely accepted belief among the osteopathic medical profession that increasing lymphatic flow is beneficial, no measurements of lymph flow during osteopathic manipulative treatment have been reported. The authors surgically instrumented five mongrel dogs to record lymphatic flow in the thoracic duct (TDF) and cardiac variables during three intervention protocols. After recovery from surgery, canine subjects were placed in a standing-support sling, and TDF, cardiac output, mean aortic blood pressure, and heart rate were recorded during two randomized 30-second sessions of manipulative intervention using the osteopathic thoracic pump and abdominal pump techniques on two successive days. Lymph flow in the thoracic duct increased from 1.57+/-0.20 mL x min(-1) to a peak TDF of 4.80+/-1.73 mL x min(-1) during abdominal pump, and from 1.20+/-0.41 mL x min(-1) to 3.45+/-1.61 mL x min(-1) during thoracic pump. Lymph flow in the thoracic duct and cardiac variables were also recorded for canine subjects during physical activity (ie, treadmill exercise at 3 miles per hour at 0% incline). During physical activity, TDF increased from 1.47+/-0.33 mL x min(-1) to 5.81+/-1.30 mL x min(-1). Although cardiac variables did not change significantly during manipulative intervention with lymphatic pump techniques, cardiac output and heart rate did increase during physical activity. The authors conclude that physical activity and manipulative intervention using thoracic pump and abdominal pump techniques produced net increases in TDF (P<.05).

Two-center Analysis of Long-term Outcomes after High Ligation Inguinal Hernia Repair in Adolescents.

High ligation of the inguinal hernia sac is standard practice for many pediatric surgeons in postpubertal adolescents. Most adult surgeons do not use this technique to repair indirect inguinal hernias because of concerns for higher recurrence rates compared with mesh repairs. Therefore, we examined long-term outcomes of adolescent high ligation hernia repair performed by pediatric surgeons. Telephone surveys were conducted on children over 12 years old at the time of repair, and patients and/or their parents were contacted 18 months postrepair. Patients were identified from two institutions between 1998 and 2010. The incidences of reoperation, recurrence, presence of bulge, chronic pain, or numbness were determined. A total of 210 patients (40.7% response rate) were available for phone interviews at 18.6 to 159.5 months postrepair. Mean age was 14.6 ± 1.8 (range: 12.0-19.0 years). Fourteen patients had pain (6.7%) and five had numbness (2.4%). There were four (1.9%) patients with a second operation, two of which confirmed a recurrent hernia. Three patients expressed concern about possible recurrence. Two report a bulge, but have not been evaluated. Pediatric hernia repair with high sac ligation appears effective in patients anatomically similar to adults with low recurrence rate and low incidence of chronic symptoms. These data suggest that prospective trials on the adequacy of high ligation in adults are warranted.

Mortality of necrotizing enterocolitis and isolated ileal perforation at a single institution over the past 40 years.

PURPOSE: Controversy exists regarding differences in mortality between isolated ileal perforation (IIP) and necrotizing enterocolitis (NEC). We sought to identify risk factors and determine mortality rates for these two entities. METHODS: A retrospective review was conducted on all patients with NEC or IIP undergoing surgical management at our institution from May 1971 to December 2011. Demographics, birth history, management strategies, and mortality were recorded. Chi-square and unpaired t-test were used where appropriate. RESULTS: During the study period, 236 patients underwent operative management with 17.8% of those being for IIP. Patients with IIP had a lower estimated gestational age (27.8 ± 3.0 vs. 29.5 ± 4.2 weeks, p = 0.014), were more likely to be of multiple gestation (33.3 vs. 16.5%, p = 0.022), and were younger at diagnosis (8.7 ± 8.1 vs. 14.3 ± 11.1 days, p = 0.003) compared with those undergoing operation for NEC. Mortality was threefold lower with IIP (9.5 vs. 36.1%, p < 0.001). CONCLUSIONS: IIP carries a unique set of risk factors and has a significantly lower mortality rate when compared with NEC.

Burden of complications from needle penetration of plastic ports in children.

BACKGROUND: Complications of totally implanted venous access ports are well documented. A concerning mechanical complication we have encountered is posterior penetration of plastic ports with the access needle. The purpose of this study is to investigate the burden of posterior penetrations. METHODS: We performed a retrospective review of all ports placed between November 2007 and December 2011 at a single institution. RESULTS: There were 247 children who received a port. 117 children (47%) received a port with a plastic posterior wall, 95 children (38%) received a port with a metal posterior wall, and 35 children (14%) had ports that were unable to be identified as plastic or metal. Posterior port penetrations occurred 8 times (3.2% overall, 6.8% of plastic ports). All perforations occurred in plastic ports of a single brand and product code. Average time from port insertion to penetration was 11.2±21.3 months (range 0.3 to 63.4 months). Other complications included catheter malfunction (14), infection (9), pain (2), inability to draw/aspirate (4), leak (3), port migration (2), and malfunctioning not otherwise specified (15). CONCLUSIONS: There is an unacceptably high risk of needle penetration of the posterior wall of plastic ports. We recommend utilizing ports with metal backing to avoid this complication.

Patient and parental scar assessment after single incision versus standard 3-port laparoscopic appendectomy: long-term follow-up from a prospective randomized trial.

BACKGROUND: Single site laparoscopy for appendectomy is a technique with several case series suggesting a cosmetic advantage, but without prospective comparative data. We conducted a prospective, randomized trial comparing single site laparoscopic appendectomy to the standard 3-port approach, including scar assessment at early and long-term follow-up. METHODS: Enrolled patients over 12years old and parents of patients less than 12years old were asked to complete the validated Patient Scar Assessment Questionnaire (PSAQ) at early follow-up around 6weeks and by phone after 18months. The PSAQ consists of 4 scored subscales: Appearance, Consciousness, Appearance Satisfaction, and Symptom Satisfaction. Each subscale has a set of questions with a 4-point categorical response (1=most favorable, 4=least favorable). The sum of the scores quantifies each subscale. RESULTS: Early questionnaires were obtained from 98 3-port and 100 single-site patients with the single-site approach producing superior overall scar assessment (P=0.003). By telephone follow-up, questionnaires were completed by 49 3-port and 56 single-site patients at a median of 25 (18-32) months. In this longer-term follow-up, overall scar assessment was not significantly different between groups (P=0.06). CONCLUSION: Patients or parents express superior scar assessment with the single site approach at early follow-up, but this difference disappears in the long-term.

Evaluation of cardiac function during laparoscopic gastrostomy in pediatric patients with hypoplastic left heart syndrome using intraoperative transesophageal echocardiography.

INTRODUCTION: Patients with single ventricle physiology (SVP)--specifically, hypoplastic left heart syndrome (HLHS)--frequently need long-term enteral access; however, they are at an extremely high operative risk. Nothing has been published on the physiologic impact on single ventricle function during laparoscopy in this patient population. Therefore, we performed intraoperative transesophageal echocardiography (TEE) to study the physiologic effects of laparoscopic surgery in these patients. PATIENTS AND METHODS: After Internal Review Board approval, patients with SVP undergoing laparoscopic gastrostomy were studied with intraoperative TEE, and fractional shortening was determined. Patients were separated into those with HLHS and others with SVP. Data are reported as mean ± standard deviation values. Analysis of variance was used for continuous variables. RESULTS: From August 2011 to February 2013, in total, 11 patients with SVP underwent laparoscopic gastrostomy, including 6 with HLHS. One of the 6 HLHS patients and 1 of the SVP patients underwent concurrent fundoplication. All patients were post-first-stage palliation; two had completed post-second stage. Fractional shortening tended to decrease during insufflation and return to baseline after desufflation. There was no 30-day mortality. CONCLUSIONS: Pneumoperitoneum associated with laparoscopic gastrostomy tube placement results in a reversible decrease in fractional shortening in patients with HLHS and SVP. Overall, the children tolerated pneumoperitoneum. TEE allows for real-time assessment of ventricular function and volume and may improve safety during longer procedures.

Histologic analysis of the hernia sac: current practices based on a survey of IPEG members.

INTRODUCTION: Inguinal hernia repair is one of the most common operations performed by pediatric surgeons. Although the practice of sending the hernia sac for histologic examination after routine hernia repair is common, the indications and practice patterns for this have not been evaluated. The objective of this survey was to determine practice patterns and indications for histologic analysis of the pediatric inguinal hernia sac. MATERIALS AND METHODS: A 9-question online survey was sent to all members of the International Pediatric Endosurgery Group (IPEG). A Kruskal-Wallis test was used to determine whether practice patterns of sending the hernia sac for histologic evaluation were associated with respondent characteristics. The chi-squared test with Yates's correction was used where appropriate. RESULTS: The survey was completed by 315 IPEG members, for a response rate of 54.4%. Hernia sacs were sent for histologic evaluation always by 23.9%, often by 5.1%, rarely by 17.5%, and never by 53.5%. The respondent characteristics were not associated with whether or not specimens were sent for histology review. Of the 128 who reported sending the inguinal hernia sac, the most common reasons were hospital/state requirements (47.6%), followed by routine practice (25.7%) and concern for missed pathology (24.2%). CONCLUSIONS: The majority of IPEG respondents report never sending the inguinal hernia sac for histologic analysis. Of those that do, most are influenced by hospital/state requirements. The value of sending the hernia sac after routine inguinal hernia repair should be validated if it is to remain an institutional requirement.