Percutaneous endoscopic gastrostomy tube placement via the introducer technique is safe and effective in children when compared to the laparoscopic technique.

PURPOSE: We compare our experience of percutaneous endoscopic gastrostomy, introducer technique (PEG) and laparoscopic technique (LapGT) at a tertiary care pediatric hospital. METHODS: Isolated PEGs and LapGTs placements were reviewed at our institution from August 2016 through January 2018. Demographics, procedure time, operative charges, and 30-day complications were reviewed. Means of quantitative values were compared using the student's t test. Categorical values were compared using the X2 test. RESULTS: Ninety-three isolated gastrostomy tubes were placed in children aged 2 weeks to 19 years. There were 56 PEGs (60%) and 37 LapGTs (40%), based on surgeon preference. There was no significant difference in demographics between the two groups. Mean operative time for PEG was 59% shorter (14 vs. 33 min, p < 0.001). Operating room charges averaged $4500 less in the PEG group ($11,400 vs. $15,900, p < 0.001). Neither group had complications that required a return to the operating room within 30 days postoperatively. There was no difference in the rate of fundoplication after gastrostomy tube placement. In two cases PEGs were converted to LapGTs after safety criteria for PEG were not met. CONCLUSION: The PEG introducer technique, when used with clearly defined safety criteria, decreased operative time and cost without compromising safety. LEVEL OF EVIDENCE: III.

Transanal endorectal approach for the treatment of idiopathic rectal prolapse in children: Experience with the modified Delorme's procedure.

BACKGROUND: Persistent or recurrent idiopathic rectal prolapse in children requires surgical intervention. Several techniques have been used to repair this problem. However, recurrence and complications continue to be a challenge in the management of this condition. Here we report our experience in using the modified Delorme's procedure to treat such patients. METHODS: We conducted a retrospective observational study of patients with idiopathic rectal prolapse who underwent the modified Delorme's procedure during 2013-2017. We analyzed the clinical characteristics of the patients and the recurrence and complication rates during a follow-up of 15-68 months. RESULTS: We included 14 patients. The age at operation ranged from 2 to 17 years, and the length of the prolapse was 3-15 cm. There were no intraoperative or postoperative complications. All patients achieved postoperative fecal control, and there were no recurrences. CONCLUSION: The modified Delorme's procedure was effective for the treatment of idiopathic rectal prolapse. There were no recurrences or complications. Because it is a perineal technique, the procedure avoids the risk of nerve injury that exists for transabdominal methods.

A large single-institution review of tracheoesophageal fistulae with evaluation of the use of transanastomotic feeding tubes.

INTRODUCTION: Transanastomatic feeding tube (TAT) use in the repair of tracheoesophageal fistulas (TEF) with or without esophageal atresia (EA) and EA with or without TEF allows for earlier enteral feedings, however, may predispose to esophageal stricture. METHODS: We review our institutional experience with esophageal atresia repair over a 15-year period from 2000 to 2015 and report on our observed complication rate with emphasis on the surgical approach and use of TATs. RESULTS: We identified 110 TEF repairs. Ninety-six were Type C, 7 were Type A, 4 were Type D, and 3 were Type E (H-Type). TATs were used in 74% of patients. The stricture rate with the TAT approached 56% versus 17% without a TAT (p<0.0005). There was no difference in leak rate (p=0.27). Ninety-four TEF repairs were performed via open thoracotomy, and 16 were initially approached thoracoscopically. Six out of 16 that were started thoracoscopically were completed with the minimally invasive approach. Whether the case was started thoracoscopically, completed thoracoscopically, or performed open made no difference in the rate of stricture or anastomotic leak, but we did observe an increase in musculoskeletal complications in the open thoracotomy group (28% vs. 0). CONCLUSION: Our data suggests that the use of TATs does not protect against anastomotic leak, but may increase stricture rate. Further, the thoracoscopic group showed no difference in the leak or stricture rate and demonstrated less musculoskeletal complications. Confirmation of these findings will require a prospective study. LEVEL OF EVIDENCE: III.

Vaginal agenesis and rectovestibular fistula. Experience utilizing distal ileum for the vaginal replacement in these patients, preserving the natural fecal reservoir.

BACKGROUND: The association of rectovestibular fistula (RVF) and vaginal agenesis (VA) presents a diagnostic and management challenge. The vaginal replacement is usually performed with rectum or sigmoid, which are the natural fecal reservoirs; thus, the fecal control could be affected. We present our experience utilizing ileum to preserve the rectum and sigmoid. METHODS: We performed a retrospective study of eight patients with RVF and VA treated from May 2011 to June 2015 at two colorectal centers, at Pittsburgh and Mexico. We recorded the age at diagnosis of VA, treatment, presence of other associated malformations and outcome. RESULTS: Eight of forty-nine girls with RVF had an associated VA (16.3%). Three patients had a timely diagnosis and five a delayed diagnosis. Six patients were submitted to a vaginal replacement with ileum and achieved fecal control. Two are waiting for surgery. CONCLUSIONS: A high index of suspicion of vaginal agenesis helps in a timely diagnosis in girls with RVF. The use of ileum allows for preservation of the fecal reservoirs, thus optimizing the chance for fecal control in patients with anorectal malformations.