Probiotic fortified diet reduces bacterial colonization and translocation in a long-term neonatal rabbit model.

BACKGROUND: Probiotic fortified diet reduces bacterial colonization and translocation in a short-term neonatal rabbit model when continuously challenged with pathogen. The purpose of this study was to determine if live probiotic diet could remain effective at decreasing colonization/translocation of pathogens in a long-term neonatal rabbit model without ill effects of the probiotic outside the gastrointestinal (GI) tract. METHODS: Rabbit pups were born via cesarean delivery 1 day preterm and assigned to 2 diets: a newly formulated diet (controls) vs the same diet fortified with the live probiotic Lactoccocus lactis. Enterobacter cloacae was added to both preparations before each feed. Pups were gavage fed twice daily, and weights were recorded. Rabbits were sacrificed on day 7, and organs were harvested and cultured for target organism growth. RESULTS: The probiotic fortified diet resulted in a significant decrease in Enterobacter translocation to the liver and decreased colonization in the stomach and lungs. There was no evidence of Lactococccus translocation or colonization outside of the GI tract. CONCLUSION: This probiotic fortified diet was effective at decreasing pathogenic bacteria colonization and translocation in a long-term neonatal model. The addition of L lactis to the diet resulted in appropriate growth without any colonization or translocation of the probiotic outside of the GI tract.

Surgeon-performed ultrasound for diagnosis of pyloric stenosis is accurate, reproducible, and clinically valuable.

PURPOSE: We will demonstrate that a surgical resident with proven accuracy in the diagnosis of hypertrophic pyloric stenosis (HPS) can teach other surgeons to diagnose HPS with reproducible accuracy. METHODS: A surgical resident with proven sonographic accuracy in diagnosing HPS instructed 5 other surgical residents in the technique. Consecutive patients referred to pediatric surgery with a presumed clinical diagnosis of HPS were examined, and measurements of residents were compared with formal radiology studies. Each surgeon was proctored for 5 examinations before independent evaluation and was blinded to results from both radiologists and other residents. Results were evaluated using Student's t test; P less than .05 was considered significant. RESULTS: Seventy-one patients were evaluated by 5 surgical residents. Residents were diagnostically accurate in all cases. There was no statistically significant difference between pyloric muscle thickness or channel length measurements obtained by radiology and any of the residents. CONCLUSION: Surgeon-performed ultrasound examination for the diagnosis of HPS is accurate and reproducible through surgeon-to-surgeon instruction on appropriate technique. This skill is a valuable asset in the initial surgical evaluation of any patient with suspected HPS, expediting appropriate management.

Throwing out the "grade" book: management of isolated spleen and liver injury based on hemodynamic status.

PURPOSE: Current organizational guidelines for the management of isolated spleen and liver injuries are based on injury grade. We propose that management based on hemodynamic status is safe in children and results in decreased length of stay (LOS) and resource use compared to current grade-based guidelines. METHODS: Patients with spleen or liver injuries for a 5-year period were identified using our institutional trauma registry. All patients were managed using a pathway based on hemodynamic status. Charts were reviewed for demographics, mechanism, hematrocrit values, transfusion requirement, imaging, injury grade, LOS, and outcome. Exclusion criteria included penetrating mechanism, associated injuries altering LOS or ambulation status, combined spleen/liver injury, initial operative management or death. Statistical comparison was performed using Student's t test; P < .05 is significant. RESULTS: One hundred one patients (50 spleen, 51 liver) meeting inclusion criteria were identified. Average actual LOS for all patients was 1.9 days vs 3.2 projected days based on American Pediatric Surgical Association guidelines (P < .0001). Actual vs projected LOS for grades III to V was 2.5 vs 4.3 days (P < .0001). All patients returned to full activity without complication. CONCLUSIONS: Isolated blunt spleen and liver injuries, regardless of grade, can be safely managed using a pathway based on hemodynamic status, resulting in decreased LOS and resource use compared to current guidelines.

Formula fortified with live probiotic culture reduces pulmonary and gastrointestinal bacterial colonization and translocation in a newborn animal model.

BACKGROUND/PURPOSE: Acidified diets are protective against intestinal bacterial colonization and translocation. Probiotic diets are designed to modulate the intestinal flora to enhance mucosal immunity. This study was designed to determine if formula acidified with live probiotic decreases bacterial gut colonization and translocation, and is equally tolerated as other acidified diets. METHODS: One hundred twenty-eight rabbit pups delivered via cesarean section [cesarean delivery, cesarean birth, abdominal delivery] were randomly assigned to 4 feeding groups: NAN Nestle (control, pH 7.0), NAN acidified with citric acid (pH 4.55), biologically acidified Pelargon (pH 4.55), and NAN with live Lactococcus lactis culture (pH 4.2). Pups were gavage fed every 12 hours with Enterobacter cloacae challenges of 10 colony-forming units/mL per feed and killed on day of life 3. Lungs, liver, spleen, mesenteric lymph nodes (MLNs), stomach, and cecum were cultured and quantitatively analyzed for target organism growth. Results were analyzed using chi(2) tests. RESULTS: NAN with live probiotic culture, when compared with Pelargon, acidified NAN, and NAN, significantly reduced the incidence of Enterobacter pulmonary colonization (P < .01), bacterial translocation (liver, P < .025; spleen and MLN, P < .05), and gastric and intestinal colonization (P < .001 for both). CONCLUSION: Probiotic-fortified formula provides superior protection against pulmonary and gastrointestinal bacterial colonization and translocation compared with neutral and acidified formulas, and is equally tolerated.

Postoperative follow-up: is a phone call enough?

BACKGROUND/PURPOSE: At our institution, patients undergoing selected operative procedures are referred to a protocol for telephone follow-up by surgical specialty nurses. Our objective was to review our experience with this protocol to determine if telephone follow-up is a safe and preferred alternative to the traditional postoperative clinic visit. METHODS: Records of patients followed up by telephone over 6 months were evaluated for information regarding each patient's postoperative course. Records included telephone follow-up forms, clinic notes, and emergency department records. RESULTS: A total of 563 patients underwent a total of 601 procedures. Seventy-six percent (n = 427) were successfully contacted postoperatively; 24% (n = 136) did not respond to multiple contact attempts. Forty-five requests for clinic follow-up resulted in 27 actual visits, 10 from families not satisfied with telephone contact alone. Most families contacted (382/427, 90%) were satisfied and did not request an appointment. A total of 43 postoperative clinic or emergency department evaluations resulted in 9 interventions (1.6% complication rate). CONCLUSION: Postoperative follow-up by telephone using a structured protocol is a safe alternative to routine clinic follow-up for patients undergoing selected procedures and is preferred by patients' families.

Ultrasound as a diagnostic tool used by surgeons in pyloric stenosis.

PURPOSE: The purpose of the study was to validate surgeon-performed abdominal ultrasound in the diagnosis of pyloric stenosis, thus expediting diagnosis and management and increasing overall cost-effectiveness. METHODS: A surgical resident, after completing ultrasound courses offered by the American College of Surgeons, Chicago, IL, examined 30 consecutive patients with a suspected diagnosis of hypertrophic pyloric stenosis (HPS). Blinded regarding both clinical and radiographic findings, the resident scanned the pylorus in longitudinal and transverse axes. Positive ultrasonographic evidence of HPS was defined as muscle thickness of at least 4 mm and/or channel length of at least 16 mm. Surgeon and radiology measurements were compared using descriptive analyses and Student t test. RESULTS: There were 25 boys and 5 girls examined. Twenty-eight of 30 patients were found to have HPS. When ultrasound performed by the surgeon was compared with that of radiology, no false-negative or false-positive results were noted. The surgeon was diagnostically accurate in all cases, and there was no statistically significant difference between surgeon and radiology measurements with regard to pyloric muscle thickness (P = .825, mean deviation = 0.4 mm) or channel length (P = .74, mean deviation = 2.2 mm). CONCLUSION: A surgeon with appropriate training in abdominal ultrasound can diagnose HPS with the same degree of accuracy as radiologists.

Ghosts in the machine: a multi-institutional comparison of laparoscopic and open pyloromyotomy.

INTRODUCTION: The purpose of this study was to compare laparoscopic and open pyloromyotomy using data from multiple centers in the United States. METHODS: Children's hospitals that have a predominant surgical approach to pyloromyotomy were identified in the Pediatric Health Information System database. Using 2005 data, institutions were stratified into open (OPEN) and laparoscopic (LAP) groups. Patients with significant comorbid conditions were excluded. Group differences were compared using t tests and Mann-Whitney nonparametric tests for continuous variables and exact tests for categorical variables. RESULTS: A total of 3 hospitals were in the LAP group (n = 207), and 4 hospitals were in the OPEN group (n = 357). The LAP group had a longer mean length of stay (LAP = 2.5 +/- 1.7, OPEN = 2.1 +/- 1.4 days; P = .02). Mean total hospital charges were similar in both groups (LAP = $11307 +/- 9499, OPEN = $11245 +/- 4841; P = .93), but there was significant skewness of the distribution for the LAP group. Nonparametric analysis demonstrated a statistically significant difference in charges (LAP median = $9727, min = $5075, max = $94323, OPEN median = $10001, min = $1614, max = $46461; P = .004). Four patients in the LAP group had charges ranging from approximately $56000 to $94000, which may have resulted from surgical complications. CONCLUSION: Prolonged length of stay and skewed hospital charge data in patients undergoing laparoscopic pyloromyotomy may be the result of rare but serious complications associated with the laparoscopic approach.

Jack Barney Award. The changing spectrum of intestinal malrotation: diagnosis and management.

BACKGROUND: Management of typical malrotation is universally accepted, but management of atypical malrotation is less well defined in both children and adults. METHODS: Records of patients with malrotation diagnosed over 6 years were reviewed. Patients were grouped into typical or atypical based on ligament of Treitz location. Outcomes were evaluated using chi-square analysis. RESULTS: Of 275 patients, 148 diagnosed with typical malrotation underwent Ladd's procedure. Based on symptoms, 91 of 127 patients with atypical malrotation were managed operatively. The remaining 36 patients were asymptomatic or had reflux symptoms only and were observed. Six of 36 subsequently required surgery due to symptoms, but 30 remain asymptomatic. No observed patients developed acute midgut volvulus. The overall postoperative complication rates were higher for atypical versus typical malrotation, 27% versus 16% (P < .05). CONCLUSIONS: Close observation with repeat contrast study is an acceptable management option for patients with atypical malrotation who are asymptomatic or exhibit only reflux symptoms.

Surgical management of lipoblastoma.

BACKGROUND/PURPOSE: Lipoblastoma/lipoblastomatosis, a rare benign pediatric tumor composed of embryonic fat, most often presents as a rapidly growing mass in children younger than 3 years. This benign tumor locally recurs up to 25% of the time. This retrospective review was done to emphasize problems with diagnosis, management, and the approach to follow-up care. METHODS: Sixteen cases of pathologically proven lipoblastoma presenting to a single institution over a 16-year period (1988-2004) were reviewed retrospectively for clinical features and outcome. RESULTS: There were 11 males and 5 females ranging in age from 18 days to 12.75 years. Preoperative diagnoses were accurate in only 3 cases. Two lesions recurred locally over a period of 10 months and 5 years. One lesion presented with local infiltration. Six lesions were right-sided, 5 were left-sided, and 5 were midline. CONCLUSIONS: It is important to consider lipoblastoma in the diagnosis of a rapidly enlarging fatty mass in children. Complete resection is the only definitive treatment and should not be delayed when impingement on surrounding structures is imminent. There is a tendency for these lesions to recur despite presumed complete excision. Therefore, follow-up for a minimum of 5 years is recommended.