Reoperative surgery after magnetic sphincter augmentation.

Reoperative surgery following magnetic sphincter augmentation (MSA) is rare. The clinical indications include the removal of MSA for dysphagia, the recurrence of reflux, or the issues of erosion. Diagnostic evaluation follows that of patients with recurrent reflux and dysphagia following surgical fundoplication. Procedures following the complications of MSA can be performed in a minimally invasive fashion, either endoscopically or robotic/laparoscopically, with good clinical outcomes.

Efficacy of oral antibiotics in children with post-operative abscess from perforated appendicitis.

BACKGROUND: Post-operative intra-abdominal abscess (PIAA) is the most common complication after appendectomy for perforated appendicitis (PA). Typically, intravenous antibiotics by a peripherally inserted venous catheter are utilized to treat the abscess. We sought to evaluate the role of oral antibiotics in this population. METHODS: This is a retrospective review conducted of children between January 2005 and September 2015 with a PIAA. Demographics, clinical course, complications, and follow-up were analyzed using descriptive statistics. Comparative analysis was performed on those who were treated with oral vs IV antibiotics after diagnosis of PIAA. RESULTS: 103 children were included. Days of symptoms prior to admission were 3.2 ± 2.3 days with a WBC of 17.9 ± 6.4. Median time to diagnosis of PIAA from appendectomy was 7 days (7, 10). Mean total length of stay was 10 ± 3.4 days. 42% were treated with oral antibiotics (n = 43) versus 58% IV antibiotics (n = 60) at the time of discharge. We found a significant increase in total length of hospital stay (9.1 vs 10.7, p = 0.02) and number of medical encounters required for treatment (3.4 vs 4.4, p ≤ 0.01) in the IV group. CONCLUSIONS: PIAA treatment after appendectomy for PA can be treated with oral antibiotics with equivalent outcomes as IV antibiotic treatment, but with shorter length of hospitalizations and less medical encounters required.

The relationship of eosinophilia with outcomes of Hirschsprung disease in children.

PURPOSE: It has been postulated that children with Hirschsprung disease (HD) and mucosal eosinophilia have been thought to have poorer outcome, but supporting evidence is lacking. The objective of our study was to review the outcomes of children with HD and mucosal eosinophilia. METHODS: A single center, retrospective review was conducted on all patients diagnosed with HD between 1999 and 2016. Pathology specimens were evaluated for mucosal eosinophilia. Demographics, complications, and outcomes were analyzed. RESULTS: A total of 100 patients were diagnosed with HD and 27 had mucosal eosinophilia. Median age at the time of surgery was 12 days (8, 30) and 82 were males. Comparing patients with HD with and without mucosal eosinophilia, there was no statistically significant difference in time to bowel function (2 days vs. 2 days; p = 0.85), time to start feeds (3 days vs. 3 days; p = 0.78) and time to goal feeds (5 days vs. 5 days; p = 0.47). There was no statistically significant difference in feeding issues (13% vs. 9%; p = 1.0) and stooling issues (60% vs. 50%; p = 0.38). There was no statistically significant difference in postoperative complications and readmissions rates (63% vs. 56%; p = 0.53). CONCLUSION: Hirschsprung-associated mucosal eosinophilia may not increase postoperative complications, and may not change feeding and bowel management. Further prospective studies are in process to evaluate long term follow-up outcomes for this patient population.

Maturation of effect size during enrollment of prospective randomized trials.

BACKGROUND: Randomized clinical trials are powered by calculating the minimum sample size required to achieve statistical significance, given an estimated effect size (ES). The ES is the raw difference between two treatment arms. ES quantifies the actual magnitude of clinical differences between cohorts and is usually reflective of the true meaning of the trial, regardless of statistical significance. Under a fixed protocol, we hypothesize that the ES may be attained at a smaller sample than predesigned. To investigate patterns of ES during enrollment, we analyzed completed trials that were completed at our institution. METHODS: Outcomes of 11 prospective randomized clinical trials from our institution were reviewed. ES was calculated at intervals throughout each trial to determine at which point a steady clinical difference was achieved between treatment cohorts. RESULTS: ES stabilized at a median of 64% enrollment. All patients were needed to meet the precise ES in our smallest study, indicating the need for full enrollment in smaller studies. Otherwise, 50% of our trials required between 48% and 76% of patient enrollment to meet ES. In comparing clinical outcomes, 9 of 12 found a final difference that was nearly identical to the difference that could have been determined much earlier. Categorical outcomes met stabilized ES at 51% enrollment and continuous outcomes at 68%. CONCLUSIONS: ES and final clinical outcomes were achieved before the completion of enrollment for most of our studies. This suggests that clinical differences detected by randomization may not necessarily require the robust sample size often needed to establish statistical significance. This is particularly relevant in fixed-protocol interventional trials of homogenous populations.

Utility of pediatric female fertility preservation discussions following pelvic radiation.

INTRODUCTION: While many childhood cancers are curable with therapy, adverse consequences in fertility exist. We sought to assess the number of female patients with pelvic tumors receiving radiation therapy, and the proportion that undergo measures for fertility preservation (FP). METHODS: A total of 53 female patients treated with pelvic tumors from 2000 to 2016 were retrospectively identified. RESULTS: 19 (34%) of these patients underwent pelvic radiation therapy (pXRT). Three of the patients received pXRT for palliative treatment. Of the 19 female patients receiving pXRT, six (31%) were prepubertal and 13 (68%) were postpubertal. Three patients (16%) had documentation of a discussion of FP measures prior to pXRT. One was prepubertal and the others were post-pubertal. Six patients (32%) were evaluated by endocrinology after radiation therapy, diagnosed with ovarian failure, and placed on hormone therapy. Current guidelines recommend discussion of FP in pre-and postpubertal patients with cancer. This 16-year retrospective review of female patients that underwent pXRT for pelvic tumors demonstrated < 17% of patients have documentation of a discussion of FP measures. CONCLUSION: Female pediatric patients who underwent chemotherapy and pXRT suffer a high rate of premature ovarian failure, high morbidity and mortality as well as low rates of documented FP discussions. Based on these findings we have established a multi-disciplinary fertility preservation team available for consultation and a protocol for discussing and documenting the impact of pXRT, along with other treatments, on fertility. LEVEL OF EVIDENCE: III.

Routine use of chest radiographs in the post-operative management of pectus bar removal: necessity or futility.

BACKGROUND: While there is literature on techniques for pectus bar removal, there are limited reports on post-operative management. This can include obtaining a postoperative chest radiograph (CXR) despite the minimal risk of associated intra-thoracic complications. This is a review of our experience with bar removal and lack of routine post-operative CXR. METHODS: A single institution retrospective chart review was performed from 2000 to 2015. Patients who underwent a pectus bar removal procedure were included. We assessed operative timing of bar placement and removal, procedure length, intra-operative and post-operative complications and post-operative CXR findings, specifically the rate of pneumothoraces. RESULTS: 450 patients were identified in this study. Median duration of bar placement prior to removal was 35 months (interquartile range 30 and 36 months). Sixtey-four patients obtained a post-operative CXR. Of these, only one (58%) film revealed a pneumothorax; this was not drained. A CXR was not obtained in 386 (86%) patients with no immediate or delayed complications from this practice. Median follow-up time for all patients was 11 months (interquartile range 7.5-17 months). DISCUSSION: The risk for a clinically relevant pneumothorax is minimal following bar removal. This suggests that not obtaining routine imaging following bar removal may be a safe practice.

The impact of developing a pectus center for chest wall deformities.

PURPOSE: In 2011, we established a dedicated center for patients with chest wall deformities. Here, we evaluate the center's effect on patient volume and management. METHODS: A retrospective review of 699 patients with chest wall anomalies was performed. Patients were compared, based on the date of initial consultation, before the pectus center opened (July 2009-June 2011, Group 1) versus after (July 2011-June 2013, Group 2). Analysis was performed utilizing Chi-square and Mann-Whitney U tests. RESULTS: 320 patients were in Group 1 and 379 in Group 2, an 18.4 % increase in patient volume. Excavatum patients increased from 172 (Group 1) to 189 (Group 2). Carinatum patients increased from 125 (Group 1) to 165 (Group 2). Patients undergoing operative repair of carinatum/mixed defects dropped significantly from 15 % (Group 1) to 1 % (Group 2) (p < 0.01), whereas those undergoing nonoperative bracing for carinatum/mixed defects rose significantly from 19 % (Group 1) to 63 % (Group 2) (p < 0.01). Patients traveled 3-1249 miles for a single visit. CONCLUSION: Initiating a dedicated pectus center increased patient volume and provided an effective transition to nonoperative bracing for carinatum patients. The concentrated focus of medical staff dedicated to chest wall deformities has allowed us to treat patients on a local and regional level.

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.

Ambulatory colectomy: a pathway for advancing the enhanced recovery protocol.

Enhanced recovery after surgery (ERAS) protocols employ multiple factors to decrease surgical stress and improve recovery (Lyon et al., World J Gastroenterol 18(40):5661-5663, 2012). These protocols use multimodal approaches to improve outcomes, including length of stay and morbidities (Lyon et al., World J Gastroenterol 18(40):5661-5663, 2012; Carmichael et al., Dis Colon Rectum 60:761-784, 2017). The ERAS guidelines have evolved since development; however, the question is posed of how to improve next (Lyon et al., World J Gastroenterol 18(40):5661-5663, 2012). With the success of ERAS, in combination with milestones made by minimally invasive surgery (MIS), it is our aim to describe the next step of same day discharge colectomy. Retrospective review was performed on all colectomies from February 2019 to January 2022. Same day discharge (SDD) was defined as admission less than 23 h and no overnight stay. Procedures were nonemergent and MIS. Patients were candidates SDD based on comorbidities, communication means, and social support. SDD candidacy continued if surgery was uncomplicated. Next, patients were required to achieve strict Post Anesthesia Care Unit (PACU) criteria for discharge. SDD patients were monitored via calls or messages until their first appointment. After analysis, 326 total colectomies were identified; based on inclusion and exclusion criteria, 115 patients underwent SDD, 35.3%. Of the 115 SDD, 5 patients returned to the emergency department, only 1 required readmission (0.9%). The most performed procedures were low anterior resection, 61 (53.0%), and right hemicolectomy, 25 (21.7%). Using ERAS protocols as a groundwork to improve upon, we identified several ways to advance select patients into SDD. Using strict patient selection, intraoperative regulations, and rigorous postoperative criteria, we found that SDD as an advancement of ERAS is a relatively safe procedure with minimal complications.

Pancreatic rest disguised as inflammatory bowel disease in young adult.

Pancreatic rest, otherwise known as aberrant, ectopic or heterotopic pancreas, occurs when the pancreatic tissue does not have an anatomical or vascular connection to the normal body of the pancreas. This rare congenital anomaly was first described in 1727 by Hunt and Bonesteel, and it is now known to be found predominantly within the stomach or proximal small bowel. Most of the time, pancreatic rest is asymptomatic and is found incidentally. When symptomatic, the most common presentations tend to be: abdominal pain, nausea, gastrointestinal bleeding, obstruction and symptoms of pancreatitis. We report a case of a 21-year-old female with symptomatic pancreatic rest noted in two locations: antrum of the stomach and the proximal jejunum just distal to the ligament of Treitz.

Ambulatory colectomy: A pilot protocol for same day discharge in minimally invasive colorectal surgery.

BACKGROUND: Since its inception colectomy has routinely been performed in the inpatient setting. The advent of Enhanced Recovery After Surgery (ERAS) protocols has led improved outcomes, including decreased length of stay (LOS). These improvements have introduced the possibility of ambulatory colectomy. However, indications, protocols, and limitations of ambulatory colectomy have not been extensively explored. METHODS: We conducted a retrospective review on ambulatory colectomies performed between February 2019 and August 2021. Patients were candidates for same day discharge (SDD) if they met rigorous preoperative criteria. Following an uncomplicated operation, strict postoperative parameters were required for safe discharge. If the patient underwent SDD following their operation, they were monitored closely via telehealth visits and/or patient communication messages until their one-week postoperative visit. RESULTS: From our review, we identified sixty-nine (n = 69) patients who underwent SDD after colectomy. Of the 69, only one patient was readmitted after discharge (1.4%). All procedures were performed via a robotic-assisted approach (Da Vinci Xi). None of the patients underwent conversion to an open procedure. The most frequently performed procedures included: low anterior resection (LAR) (n = 32, 46.4%) and right hemicolectomy (n = 11, 15.9%). CONCLUSION: Through proper patient education and strictly defined communication between the patient care teams, safe and effective care in the setting of SDD after colectomy can be provided. With recent technological advancements, enhanced mechanisms for patient education throughout all phases, and emerging means of patient-physician communication, via the data included herein the opportunity for same day discharge (SDD) after colectomy is a feasible and safe management plan in the proper patient.

Does Intravenous Acetaminophen Improve Postoperative Pain Control after Laparoscopic Appendectomy for Perforated Appendicitis? A Prospective Randomized Trial.

INTRODUCTION: The recent increased awareness of the dangers of opioids in the United States has highlighted the need to minimize narcotics and identify nonopioid options for pain control after surgery. With evidence suggesting that intravenous acetaminophen (IVA) can be an opioid sparing option, we conducted a prospective, randomized trial that evaluated the effect of IVA on the postoperative pain course of children with perforated appendicitis. MATERIALS AND METHODS: After IRB approval, children with perforated appendicitis were randomized to receive postoperative IVA with the standard patient/nurse-controlled analgesia (PCA) or to receive the PCA alone. All patients were treated according to an evidence-based treatment protocol. The primary outcome was duration of time on PCA. RESULTS: Eighty-two patients were analyzed from 7/14 to 11/15. There was no statistically significant difference in the time to transition from the PCA to oral pain medications for children given IVA compared with children not receiving IVA (76.4 ± 32.5 versus 86.7 ± 49.3 hours; p = 0.73). Children in the IVA group had no statistically significant difference in intravenous narcotics delivered and pain scores compared with the non-IVA group. There was no significant difference in the amount of oral narcotics between both groups (2.8 ± 2.4 versus 2.9 ± 2.5; p = 0.88). Patients who received IVA had higher medication charges ($3752.7 ± 1618.3 vs. $1198.19 ± 521.51; p < 0.01), but not total hospital charges ($53842.0 ± 19409.2 vs. $50501.03 ± 16223.32; p = 0.76). CONCLUSION: Children given IVA showed no difference in the transition time off the PCA and to oral pain medications after laparoscopic appendectomy for perforated appendicitis.

Primary Closure versus Bedside Silo and Delayed Closure for Gastroschisis: A Truncated Prospective Randomized Trial.

BACKGROUND: We report a prospective randomized trial comparing primary closure (PC) to bedside silo and delayed closure (DC) for babies with gastroschisis. MATERIALS AND METHODS: Patients were randomized to PC versus DC. We excluded those with atresia/necrosis, <34 weeks' gestation, or congenital anomalies. The primary outcome was length of stay (LOS). RESULTS: A total of 38 patients were included from August 2011 to August 2016; 18 patients underwent DC and 20 PC. There were no differences in gestational age or birth weight. Fifty percent of PC patients were successfully closed with the rest closed at a median of 4 days (interquartile range [IQR]: 2-4 days). DC patients were closed at a median of 4 days after silo placement (IQR: 2-5.8 days). None of the patients in this series developed abdominal compartment syndrome after closure. Median LOS, median time to enteral tolerance, and median time on ventilation were not statistically different. Two patients (one DC and one PC) had bowel ischemia and necrosis following silo placement requiring reoperation. Four patients (two DC and two PC) were noted to have small umbilical defects; none have yet required operative correction. CONCLUSION: There were no differences seen between PC and DC in LOS, time to enteral feeds, or ventilator times.

Success of Bolus Gastric Feeding After Fundoplication Among Children Who Require Preoperative Jejunal Feeding.

PURPOSE: Management of complicated reflux in infants and children is controversial. Jejunal feedings are used when reflux complications occur with gastric feeds. We sought to determine how successful fundoplication is to allow for return of physiologic gastric feeds in patients requiring jejunal feeds preoperatively. METHODS: A retrospective review of patients requiring jejunal feeds before fundoplication between 2010 and 2015 was conducted. RESULTS: Two hundred thirteen children underwent fundoplication during the study period. One hundred fourteen (49%) children required preoperative jejunal feeds. Median preoperative jejunal feeding trial was 15 days (interquartile range [IQR] 8-36). After fundoplication, gastric feeds were attempted in all patients. Ninety-one (80%) patients tolerated feeds postoperatively without return of preoperative symptoms. Twenty-one (18%) children developed gastric feeding intolerance and were treated with jejunal feeds at a mean of 8 months postoperatively (range 3-17). Ten (9%) children eventually tolerated intragastric bolus feeds, requiring jejunal feeds for a median duration of 2.3 months (IQR 1-5). There were no differences seen in those who were able to tolerate gastric early after the operation and those who did not. Of the patients who were unable to tolerate bolus gastric feeds during the study, a higher proportion had neurologic impairment and were on jejunal feeds for a longer period of time before fundoplication. CONCLUSION: In the majority of patients requiring continuous jejunal feeds to manage complications of reflux, fundoplication allows for transition to gastric bolus feeding.

Transabdominal Versus Subcuticular Sutures to Secure a Laparoscopic Gastrostomy.

PURPOSE: Traditional methods for securing a laparoscopic gastrostomy (LG) involve the placement of two monofilament transabdominal (TA) sutures to be removed after a short interval of 5 days. A modified technique employing an absorbable suture tunneled subcutaneously has been adopted by many surgeons. The aim of this study was to compare wound complications between these techniques. METHODS: A retrospective review of patients who underwent LG placement between 2010 and 2016 was conducted, dividing patients into two cohorts by securing stitch type, TA and subcutaneous (SC), and evaluating for complications. RESULTS: A total of 740 children underwent laparoscopic gastrostomy tube (GT) placement, of whom 554 (75%) patients had a TA stitch and the remaining 186 (25%) had a SC stitch. Demographic data were comparable in both groups. The most common wound complication was granulation tissue (22%), dislodgement (19%), external drainage (16%), cellulitis (10%), erosion (3%), and abscess formation (2%). Seven patients required operative revision for dislodgement; TA patients comprised the majority of these patients. Operative times were significantly longer in the SC group (22 minutes versus 28 minutes, P < .05). Rates of granulation, erosion, external and internal leakage, and dislodgement were equivalent between cohorts. There were higher rates of cellulitis (7.3% versus 19%, P < .05) and abscess (0.8% versus 7.6%, P < .05) noted in the SC group. Time to external leakage was significantly earlier in the SC group (P < .05); however, all other complications occurred at comparable times following initial operation. Persistent gastrocutaneous fistula requiring surgical closure occurred at equal rates with no difference in times to closure from GT discontinuation in both groups. CONCLUSION: While both techniques are feasible, there was a significant increase in infectious complications and operative times observed in the SC stitch patients, suggesting this may not be the optimal securing method.

Feeding Advancement and Simultaneous Transition to Discharge (FASTDischarge) after laparoscopic gastrostomy.

BACKGROUND: Laparoscopic gastrostomy (LG) is a common surgical procedure. However, there is little consensus on a postoperative feeding regimen. With prior nasogastric feed tolerance, there should be no delay in resumption of feeds and subsequent discharge to home. This is a report on a Feeding Advancement and Simultaneous Transition-Discharge (FAST-Discharge) pathway, which to date has not been reported in the literature. METHODS: A retrospective review of patients who underwent LG was performed from May 2010 to May 2015. All were outpatients who were on prior nasogastric feeds. The postoperative order set initiates feeds in 4 h to advance to goal as tolerated. Time to initial feed and goal nutrition, and overall length of stay (LOS) were evaluated. RESULTS: 122 patients were identified with 55% percent being male and with a median operative age of 15 months (IQR 8-27). 53% were started on bolus feeds. Initial feeds were started at a median of 2.8 h (IQR: 1.8-4.7). The median duration to goal nutrition was 6 h (IQR: 0-14). 97% reached full feeds within 24 h with no complications related to feed advancement. Median LOS was 26 h (IQR: 24-30). CONCLUSION: An expedited pathway with early feeding and discharge is possible after laparoscopic gastrostomy tube placement with a low risk for adverse events. LEVEL OF EVIDENCE: Level III.

A Single-Center Experience with Dynamic Compression Bracing for Children with Pectus Carinatum.

OBJECTIVE: Bracing for pectus carinatum (PC) has emerged as an alternative to surgical correction. However, predictive factors for bracing remain poorly understood, as much of the data have been reported from small series. MATERIALS AND METHODS: We reviewed a prospective dataset in patients with PC who underwent dynamic compression bracing (DCB) from July 2011 to July 2016. Bracing was initiated in patients > 10 years of age with a significant PC and desire for bracing. Data were analyzed for those observed two or more times after the brace was fitted to the patient. RESULTS: A total of 503 patients were evaluated for PC and 340 (68%) underwent DCB. Eighty-five percent were males with an average age of 14 ± 2 years. There was a positive correlation of age with pressure of initial correction (PIC, r = 0.2). One patient underwent operative correction as the initial therapy. Two hundred seventeen patients had two or more visits after the patient was fitted for the brace. The mean PIC in this cohort was 4 psi (range: 1.5-7.8), and the median duration of bracing in this group was 16 months (IQR: 7-23 months). One hundred three patients (47%) achieved complete correction after an average bracing time of 7.5 months and were then placed in the retainer mode. Thirty patients successfully completed bracing therapy and required an average of 23 months of therapy (2 months-4 years). No patient recurred after bracing was completed, but one failed bracing and required operative correction. Complications included mechanical problems (8%), skin complications (10%), complaints of tightness (3%), and pain (2%). CONCLUSION: DCB has both early and lasting effects in the correction of PC with minimal complications. Predictive factors for successful resolution of the PC include increased duration of DCB and lower initial PIC.

The role of 2-octyl cyanoacrylate in prevention of penile adhesions after circumcision: A prospective, randomized trial.

PURPOSE: Penile adhesions are the most common complication after circumcision, although strategies to decrease them are poorly studied. We conducted a prospective, randomized trial comparing the use of 2-octyl cyanoacrylate (glue) skin adhesive to hydrophobic ointment after circumcision. METHODS: Patients <7years old undergoing circumcision were randomized to glue around the sutures and corona of the penis or antibiotic ointment. The primary outcome variable was postoperative penile adhesions. Utilizing a power of 0.8 and an alpha of 0.05, 168 patients were calculated for each arm. Because of high attrition, we planned to include up to 500 patients. Presence/absence of adhesions was evaluated 2-4weeks postop. Parents subjectively scored happiness, comfort, distress, and concern on a Likert scale 1-5. RESULTS: From 11/2012 through 7/2016, 409 patients were enrolled. Adhesion data were available on 243 patients. There was no difference between glue (16.8%) and those with antibiotic ointment (15.2%) (p=0.88) or in parental satisfaction across all areas measured. 165 patients were lost to follow-up, evenly distributed between the two groups (38% vs. 42%, p=0.49). CONCLUSION: The placement of 2-octyl cyanoacrylate skin adhesive does not decrease the rate of postoperative penile adhesions after circumcision. Parent satisfaction outcomes are similar. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level II.

Are esophagocrural sutures needed during laparoscopic fundoplication: A prospective randomized trial.

PURPOSE: Historically, fundoplication has been performed with extensive dissection of the esophageal attachments to the diaphragm. Previously, we conducted a randomized trial demonstrating that minimal esophageal dissection and mobilization reduce the rate of wrap herniation and the need for reoperation. In that study, four esophagocrural (EC) sutures were placed in both groups to help obliterate the space between the esophagus and diaphragmatic crura. In this current study, we evaluate the need for these EC sutures. METHODS: Children less than age 7 undergoing laparoscopic fundoplication were randomized to receive four EC sutures or none. Exclusion criteria included an existing hiatal hernia. The primary outcome was transmigration of the fundoplication wrap through the esophageal hiatus into the mediastinum. A contrast study was performed around 1year postoperatively. Telephone follow-up was performed at a minimum of 1.5years. RESULTS: 120 patients were enrolled from 2/2010 to 2/2014, and 13 did not survive. One patient was excluded because a hiatal hernia was found at laparoscopy, leaving 52 patients with EC sutures (S) and 54 without EC sutures (NS). Operative time was 20min longer in the S group (P<0.01). Contrast studies were obtained in 62% of S and 68% of NS patients, and there were no wrap herniations in either group. There was one reoperation for wrap loosening in the NS group, none in the S group. Final telephone and clinic follow up was at a median of 4years (IQR 3-4.7). Reflux symptoms and medications were not different at one month, one year, and final follow-up. CONCLUSION: When minimal phrenoesophageal dissection is performed, EC sutures offer no advantages and increase operating time. LEVEL OF EVIDENCE: Level II.

Re-Tubularization of Highly-Ischemic Anti-Mesenteric Border (ReHAB): A Novel Bowel Preservation Technique in Complex Gastroschisis.

Complex gastroschisis with bowel necrosis poses an operative challenge. Surgeons must weigh the decision between resection versus preservation of ischemic bowel. As one of the leading causes of short bowel syndrome, aggressive resection in complicated gastroschisis subjects children to prolonged dependence on parenteral nutrition and its attendant complications. Herein, we describe a novel technique aimed towards bowel preservation in complex gastroschisis patients with severe bowel ischemia with the ultimate goal for enteral autonomy.