Hepatic artery thrombosis and use of anticoagulants and antiplatelet agents in pediatric liver transplantation.

BACKGROUND: Hepatic artery thrombosis (HAT) is a reported complication of 5%-10% of pediatric liver transplantations, rates 3-4 times that seen in adults. Early HAT (seen within 14 days after transplant) can lead to severe allograft damage and possible urgent re-transplantation. In this report, we present our analysis of HAT in pediatric liver transplant from a national clinical database and examine the association of HAT with anticoagulant or antiplatelet medication administered in the post-operative period. METHODS: Data were obtained from the Pediatric Health Information System database maintained by the Children's Hospital Association. For each liver transplant recipient identified in a 10-year period, diagnosis, demographic, and medication data were collected and analyzed. RESULTS: Our findings showed an average rate of HAT of 6.3% across 31 centers. Anticoagulant and antiplatelet medication strategies varied distinctly among and even within centers, likely due to the fact there are no consensus guidelines. Notably, in centers with similar medication usage, HAT rates continue to vary. At the patient level, use of aspirin within the first 72 h of transplantation was associated with a decreased risk of HAT, consistent with other reports in the literature. CONCLUSION: We suggest that concerted efforts to standardize anticoagulation approaches in pediatric liver transplant may be of benefit in the prevention of HAT. A prospective multi-institutional study of regimen-possibly including aspirin-following transplantation could have significant value.

Outpatient Botulinum Injections for Early Obstructive Symptoms in Patients with Hirschsprung Disease.

INTRODUCTION: Botulinum toxin (BT) injections may play a role in preventing Hirschsprung associated enterocolitis (HAEC) episodes related to internal anal sphincter (IAS dysfunction). Our aim was to determine the association of outpatient BT injections for early obstructive symptoms on the development of HAEC. METHODS: A retrospective review of children who underwent definitive surgery for Hirschsprung disease (HSCR) from July 2010 - July 2020 was performed. The timing from pull-through to first HAEC episode and to first BT injection was recorded. Primary analysis focused on the rate of HAEC episodes and timing between episodes in patients who did and did not receive BT injections. RESULTS: Eighty patients were included. Sixty patients (75%) were male, 15 (19%) were diagnosed with trisomy 21, and 58 (72.5%) had short-segment disease. The median time to pull-through was 150 days (IQR 16, 132). Eight patients (10%) had neither an episode of HAEC or BT injections and were not included in further analysis. Forty-six patients (64%) experienced at least one episode of HAEC, while 64 patients (89%) had at least one outpatient BT injection. Compared to patients who never received BT injections (n = 9) and those who developed HAEC prior to BT injections (n = 35), significantly fewer patients who received BT injections first (n = 28) developed enterocolitis (P < 0.001), with no patient developing more than one HAEC episode. CONCLUSION: Outpatient BT is associated with decreased episodes of HAEC and increased interval between HAEC episodes requiring inpatient treatment. Scheduling outpatient BT injections to manage obstructive symptoms may be beneficial after pull-through for HSCR.

Behind the mask: extended use of surgical masks is not associated with increased risk of surgical site infection.

PURPOSE: COVID-19 has prompted significant policy change, with critical attention to the conservation of personal protective equipment (PPE). An extended surgical mask use policy was implemented at our institution, allowing use of one disposable mask per each individual, per day, for all the cases. We investigate the clinical impact of this policy change and its effect on the rate of 30-day surgical site infection (SSI). METHODS: A single-institution retrospective review was performed for all the elective pediatric general surgery cases performed pre-COVID from August 2019 to October 2019 and under the extended mask use policy from August 2020 to October 2020. Procedure type, SSI within 30 days, and postoperative interventions were recorded. RESULTS: Four hundred and eighty-eight cases were reviewed: 240 in the pre-COVID-19 cohort and 248 in the extended surgical mask use cohort. Three SSIs were identified in the 2019 cohort, and two in the 2020 cohort. All postoperative infections were superficial and resolved within 1 month of diagnosis with oral antibiotics. There were no deep space infections, readmissions, or infections requiring re-operation. CONCLUSION: Extended surgical mask use was not associated with increased SSI in this series of pediatric general surgery cases and may be considered an effective and safe strategy for resource conservation with minimal clinical impact.

The impact of botulinum injection for hospitalized children with Hirschsprung-associated enterocolitis.

INTRODUCTION: Stasis from obstruction at the level of the internal anal sphincter (IAS) can lead to Hirschsprung-associated enterocolitis (HAEC) and may be improved by botulinum toxin (BT) injections. Our aim was to determine if BT injection during HAEC episodes decreased the number of recurrent HAEC episodes and/or increased the interval between readmissions. METHODS: A retrospective review was performed of patients admitted for HAEC from January 2010 to December 2019. Demographics and outcomes of patients who received BT were compared to patients who did not receive BT during their hospital stay. RESULTS: A total of 120 episodes of HAEC occurred in 40 patients; 30 patients (75%) were male, 7 (18%) had Trisomy 21 and 10 (25%) had long-segment disease. On multivariate analysis, patients who received BT during their inpatient HAEC episode had a longer median time between readmissions (p = 0.04) and trending toward an association with fewer readmissions prior to a follow-up clinic visit (p = 0.08). CONCLUSION: The use of BT in HD patients hospitalized for HAEC is associated with an increased time between recurrent HAEC episodes and trended toward fewer recurrent episodes. The use of BT should be considered in the management of patients admitted with HAEC.

Complications of Cryptosporidium infection after pediatric liver transplantation: Diarrhea, rejection, and biliary disease.

BACKGROUND: Cryptosporidium enteritis can be devastating in the immunocompromised host. In pediatric liver transplant recipients, infection may be complicated by prolonged carriage of the parasite, rejection, and biliary tree damage and fibrosis. Herein, we report on six patients and their long-term outcomes following cryptosporidiosis. METHODS: We reviewed all cases of cryptosporidiosis in a pediatric liver transplant population over a 17-year period at a single center. Six patients with infection were identified, and their outcomes were analyzed. RESULTS: Infection was associated with significant diarrhea and dehydration in all cases, and led to hospitalization in one-half of patients. Four of the six patients developed biopsy-proven rejection following infection, with three of those patients developing rejection that was recalcitrant to intravenous steroid treatment. Additionally, three patients developed biliary tree abnormalities with similarity to sclerosing cholangitis. In one patient, those biliary changes led to repeated need for biliary drain placement and advancing fibrotic liver allograft changes. CONCLUSIONS: Cryptosporidiosis in pediatric liver transplant recipients may lead to significant complications, including recalcitrant episodes of rejection and detrimental biliary tree changes. We advocate for increased awareness of this cause of diarrheal disease and the allograft injuries that may accompany infection.

Inpatient management of Hirschsprung's associated enterocolitis treatment: the benefits of standardized care.

INTRODUCTION: Patients with Hirschsprung's disease (HSCR) remain at risk of developing Hirschsprung-associated enterocolitis (HAEC) after surgical intervention. As inpatient management remains variable, our institution implemented an algorithm directed at standardizing treatment practices. This study aimed to compare the outcomes of patients pre- and post-algorithm. METHODS: A retrospective review of patients admitted for HAEC was performed; January 2017-June 2018 encompassed the pre-implementation period, and October 2018-October 2019 was the post-implementation period. Demographics and outcomes were compared between the two groups. RESULTS: Sixty-two episodes of HAEC occurred in 27 patients during the entire study period. Sixteen patients (59%) had more than one episode. The most common levels of the transition zone were the rectosigmoid (50%) and descending colon (27%). Following algorithm implementation, the median length of stay (2 vs. 7 days, p < 0.001), TPN duration (0 vs. 5.5 days, p < 0.001), and days to full enteral diet (6 days vs. 2 days, p < 0.001) decreased significantly. Readmission rates for recurrent enterocolitis were similar pre- and post-algorithm implementation. CONCLUSION: The use of a standardized algorithm significantly decreases the length of stay and duration of intravenous antibiotic administration without increasing readmission rates, while still providing appropriate treatment for HAEC. LEVEL OF EVIDENCE: III level. TYPE OF STUDY: Retrospective comparative study.

Safety of Laparoscopic Gastrostomy in Children Receiving Peritoneal Dialysis.

BACKGROUND: The preferred method of dialysis for children is chronic peritoneal dialysis (CPD), and these children may require delayed gastrostomy tube (GT) placement. Investigators have reported a high risk of fungal peritonitis, early bacterial peritonitis, and catheter loss when percutaneous endoscopic gastrostomy is performed in children already undergoing CPD. Current International Society for Peritoneal Dialysis guidelines recommend only open GT for these patients. We sought to report the safety of laparoscopic gastrostomy (LG) among children already receiving PD. MATERIALS AND METHODS: We conducted a retrospective chart review of children who had initiated CPD before GT placement between 2010 and 2017 at our pediatric hospital. Demographic data, clinical details, and peritonitis rates were recorded. Peritonitis was defined as peritoneal WBC count >100/mm3 and >50% neutrophils, with or without a positive peritoneal culture. RESULTS: Twenty-three subjects had both undergone CPD and had a GT placed in the study period. Of these, 13 had a GT placed after CPD had been initiated. One of these was excluded for open technique and another excluded because of no overlap of GT and PD catheter, leaving 11 for analysis. Median age at the time of LG was 1.32 y and median weight-for-age z-score was -1.86 (IQR -2.9, -1.3). Median days to PD catheter and GT use after LG were 2 (range 0-4) and 1 (range 0-2). Median weight z-score change at 90 d was +0.5 (IQR -0.1, +0.9). All patients received antifungal and antibiotic coverage at time of GT placement. No subjects developed fungal peritonitis or early bacterial peritonitis, although one developed bacterial peritonitis within 30 d. The overall rate of peritonitis after laparoscopic gastrostomy tube was 0.35 episodes/patient-year. This was similar to a rate of 0.45 episodes/patient-year during PD but before laparoscopic gastrostomy tube in the same patients (P = 0.679). Four subjects required periods of hemodialysis, two of which were because of PD catheter removal due to infection. One of the latter was due to a relapse of pre-LG peritonitis and the patient later resumed PD. The other was due to remote post-LG peritonitis and the patient continued hemodialysis until renal transplant, both after 6 mo. CONCLUSIONS: We found that, in children already receiving PD, LG is similar in safety profile, efficacy, and technical principle to open gastrostomy. LG is therefore an appropriate and safe alternative to open gastrostomy in this setting.

Indications and efficacy of conversion from tacrolimus- to sirolimus-based immunosuppression in pediatric patients who underwent liver transplantation for unresectable hepatoblastoma.

SRL-based immunosuppressive strategies in pediatric liver transplantation are not clearly defined, especially within the first year after liver transplant. TAC is the more common, traditional immunosuppressant used. However, SRL may modulate TAC-associated kidney injury and may also have antiproliferative properties that are valuable in the management of patients following liver transplantation for HB. We sought to determine whether early conversion from TAC to SRL was safe, effective, and beneficial in a subset of liver transplant recipients with unresectable HB exposed to CDDP-based chemotherapy. Between 2008 and 2013, six patients were transplanted for unresectable HB. All patients received at least one cycle of CDDP-based chemotherapy prior to transplant. All patients were switched from TAC- to SRL-based immunosuppression within 1 year of transplant. Five patients had improvement in their mGFR, while one patient had a slight decline. The improvement in mGFR was statistically significant. No adverse events were identified. Three patients had BPAR that responded to pulsed steroids. Historical controls showed similar rates of BPAR within the first year after transplant. There were no identified HB recurrences in the follow-up time period. Conversion from TAC to SRL appears to be safe and effective in this selected group of pediatric liver transplant recipients without adverse reaction or HB recurrences.

Elective laparoscopic gastrostomy in children: potential for an enhanced recovery protocol.

PURPOSE: Gastrostomy tube placement is one of the most commonly performed pediatric surgical procedures and discharge is possible as early as the first postoperative day with early initiation of feeds postoperatively. We examined a national database to determine hospital length of stay (LOS) after elective laparoscopic gastrostomy in children. METHODS: We queried the 2012-2013 National Surgical Quality Improvement Program Pediatric (NSQIP-P) database, including all patients who underwent elective laparoscopic gastrostomy tube placement for failure to thrive or feeding difficulties. Demographic data, admission status, disposition at discharge, surgical subspecialty data and hospital LOS were extracted. RESULTS: A total of 599 patients underwent gastrostomy tube placement for failure to thrive or feeding intolerance. The majority, 52%, was male and 69.3% were White. The median age was 2.2 years (IQR 0.9-6.3). Of the total, 28.7% were infants. The median total hospital LOS was 2 days (IQR 1-2), with only 39% discharged in a day or less. CONCLUSION: Pediatric patients undergoing elective laparoscopic gastrostomy have a median hospital length of stay of 2 days, despite evidence that early feeding and discharge within 24 h is both feasible and safe. There is potential for the implementation of an enhanced recovery protocol as a quality metric for this procedure.

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.

The impact of thromboelastography on resuscitation in pediatric liver transplantation.

Although TEG directs effective resuscitation in adult surgical patients, pediatric data are lacking. We performed a retrospective comparative review of the effect of TEG on blood product utilization and outcomes following pediatric liver transplantation in 38 patients between 2008 and 2014. Diagnoses, laboratory values, fluid and blood product use, and outcomes were examined. Nineteen patients underwent liver transplantation prior to the implementation of TEG, and 19 had perioperative TEG. The most common indications for transplant were BA (n = 14), HB (n = 7), and metabolic disorders (n = 7). Intraoperative blood loss, urine output, fluid and blood product use were similar between groups. However, the use of fresh frozen plasma decreased significantly in TEG patients within the first 24 hours (29 vs 0 mL/kg, P < .01), and between 24 and 48 hours (12 vs 0 mL/kg, P = .01) post-operatively. The total use of fresh frozen plasma during hospitalization was markedly reduced (111 vs 17 mL/kg, P < .01). Four patients in the TEG group had thromboembolic graft complications, including portal vein or hepatic artery thrombosis, and underwent retransplantation. The decreased use of fresh frozen plasma since implementation of TEG is an important finding for resource utilization and patient safety. However, the increased incidence of thromboembolic complications requires further investigation.

Antibiotic Prophylaxis for Pyloromyotomy in Children: An Opportunity for Better Stewardship.

INTRODUCTION: Surgical site infection is very uncommon after pyloromyotomy in children, and it is considered a "clean" procedure under the traditional wound classification system. This study aims to investigate prophylactic antibiotic administration for pyloromyotomy among children's hospitals in the USA. METHODS: The Pediatric Health Information System (PHIS) database was retrospectively reviewed from 2014 to 2015 including all patients less than 1 year old who had a principal diagnosis of pyloric stenosis and underwent pyloromyotomy. Patient demographics, hospital length of stay, and perioperative antibiotic administration were extracted. RESULTS: A total of 4206 patients met study criteria. Most patients were male (84%) and Caucasian (70%). The median age at admission was 32 days (IQR 24-44 days), and median length of stay was 2 days (IQR 1-2 days). Antibiotics were administered perioperatively in 2153 (51%) patients with marked variation among children's hospitals. Antibiotics were given to more than 10% of patients in more than 90% of hospitals, and only two of 49 hospitals gave no antibiotic prophylaxis. CONCLUSIONS: This study has shown that at several tertiary-level children's hospitals in the USA, antibiotic prophylaxis is administered for pyloromyotomy, a "clean" procedure. This highlights the need for standardization of care and more effective antibiotic stewardship in pediatric surgery.

Enteric duplication in children.

INTRODUCTION: Enteric duplication is a congenital anomaly with varied clinical presentation that requires surgical resection for definitive treatment. This had been approached with laparotomy for resection, but has changed with minimally invasive technique. The purpose of our study was to determine the demographics, natural history, operative interventions, and outcomes of pediatric enteric duplication cysts in a contemporary cohort. METHODS: With IRB approval, we performed a retrospective chart review of all patients less than 18 years old treated for enteric duplication between January 2006 and August 2016. Demographics, patient presentation, operative technique, intraoperative findings, hospital course, and follow-up were evaluated. Descriptive statistical analysis was performed; all medians were reported with interquartile range (IQR). RESULTS: Thirty-five patients underwent surgery for enteric duplication, with a median age at surgery of 7 months (2.5-54). Median weight was 7.2 kg (6-20). Most common patient presentations included prenatal diagnosis 37% (n = 13). Thirty-four patients (97%) had their cyst approached via minimally invasive technique (thoracoscopy or laparoscopy) with only three (8%) requiring conversion to an open operation. Median operative time was 85 min (54-133) with 27 (77%) patients requiring bowel resection. Median length of bowel resected was 4.5 cm (3-7). Most common site of duplication was ileocecal (n = 15, 42%). Postoperative median hospital length of stay was 3 days (2-5) and median number of days to regular diet was 3 (1-4). No patients required re-operation during their hospital stay. Median follow-up was 25 days (20-38). CONCLUSION: In our series, most enteric duplication cysts were diagnosed prenatally. These can be managed via minimally invasive technique with minimal short-term complications, even in neonates and infants.

Right trisegmentectomy after portal vein embolization in a high-risk toddler with hepatoblastoma.

Portal vein embolization (PVE) is a pre-operative treatment modality in adults undergoing hepatectomy with concerns of post-operative liver failure from insufficient future liver remnant (FLR). PVE induces growth in the FLR. The success of this technique is well described in adults, but not in young children with hepatoblastoma.

A safe and efficacious preventive strategy in the high-risk surgical neonate: cycled total parenteral nutrition.

INTRODUCTION: Hepatic dysfunction in patients reliant on total parenteral nutrition (TPN) may benefit from cycled TPN. A concern for neonatal hypoglycemia has limited the use of cycled TPN in neonates less than 1 week of age. We sought to determine both the safety and efficacy of cycled TPN in surgical neonates less than 1 week of age. METHODS: A retrospective chart review was conducted on surgical neonates placed on prophylactic and therapeutic cycled TPN from January 2013 to March 2016. Specific emphasis was placed on identifying incidence of direct hyperbilirubinemia and hypoglycemic episodes. RESULTS: Fourteen neonates were placed on cycled TPN; 8 were prophylactically cycled and 6 were therapeutically cycled. Median gestational age was 36 weeks (34, 37). Sixty-four percent (n = 9) had gastroschisis. There was no difference between the prophylactic and therapeutic groups in incidence of hyperbilirubinemia > 2 mg/dL (3 (37%) vs 5 (83%), p = 0.08) or the length of time to development of hyperbilirubinemia [24 days (4, 26) vs 27 days (25, 67), p = 0.17]. Time on cycling was similar though patients who were prophylactically cycled had a shorter overall time on TPN. Three (21%) infants had documented hypoglycemia, but only one infant became clinically symptomatic. CONCLUSION: Prophylactic TPN cycling is a safe and efficacious nutritional management strategy in surgical neonates less than 1 week of age with low rates of hypoglycemia and a shorter total course of TPN; however, hepatic dysfunction did not appear to be improved compared to therapeutic cycling.

Do-not-resuscitate orders and high-risk pediatric surgery: professional nuisance or medical necessity?

BACKGROUND: There is a paucity of data in the literature regarding end-of-life care and do-not-resuscitate (DNR) status of the pediatric surgical patient, although invasive procedures are frequently performed in very high risk and critically ill children. Despite significant efforts in adult medicine to enhance discussions around end-of-life care, little is known about similar endeavors in the pediatric population. METHODS: A retrospective review of the National Surgical Quality Improvement Program Pediatric database was performed. Patients aged <18 y with American Society of Anesthesiologists class 3 or greater who underwent elective surgical procedure in 2012-2013 were included. Demographic factors, principal diagnosis, associated conditions, DNR status, and mortality were extracted. Descriptive analysis was performed. RESULTS: A total of 20,164 patients met the inclusion criteria. Only 36 (0.2%) patients had a signed DNR order before surgical procedure. Of severely ill American Society of Anesthesiologists four patients, only 1% had DNR status. There were no differences in gender, race, ethnicity, or surgical specialty by the presence of a DNR order. Notably, 17.1% of children who died within this period had multiple surgical procedures performed before expiring. CONCLUSIONS: The rate of documented DNR status is extremely low in the high-risk pediatric surgical population undergoing elective surgery, even among severely ill children. Well-informed end-of-life care discussions in a patient-focused approach are essential in the surgical care of children with complex medical conditions and critical illness. Better documentation of DNR discussion will also allow better tracking and benchmarking.

Review of surgical and anesthetic management for esophageal atresia with tracheoesophageal fistula, unilateral pulmonary agenesis and dextrocardia.

Association of unilateral severe pulmonary atresia or agenesis and esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) and dextrocardia is a rare and highly lethal combination. We report a case of a full-term female infant who had EA with TEF, right lung agenesis, and dextrocardia. Repair of the fistula took place on day of life 3. We describe anesthetic and surgical concerns of this patient's case which are keys to a good operative outcome as well as follow-up for the patient.

Exchange of Extracorporeal Membrane Oxygenation Cannulas for Hemodialysis Catheters in Children Requiring Renal Replacement Therapy.

BACKGROUND: Pediatric patients requiring extracorporeal membrane oxygenation (ECMO) may require renal replacement therapy even after decannulation. However, data regarding transition from ECMO cannulation to a hemodialysis catheter in pediatric patients is not currently available. METHODS: Patients <18 years old who had an ECMO cannula exchanged for a hemodialysis catheter during decannulation at a tertiary care children's center from January 2011 to September 2022 were identified. Data was collected from the electronic medical record. RESULTS: A total of 10 patients were included. The cohort was predominantly male (80.0%, n = 8) with a median age of 1 day (IQR 1.0, 24.0). All ECMO cannulations were veno-arterial in the right common carotid artery and internal jugular vein. The median time on ECMO was 8.5 days (IQR 6.0, 15.0). One patient had the venous cannula exchanged for a tunneled hemodialysis catheter during decannulation, two were transitioned to peritoneal dialysis, and seven had the temporary hemodialysis catheter converted to a tunneled catheter by Interventional Radiology (when permanent access was required) at a median time of 10 days (IQR 8.0, 12.5). Of these 7 patients, 28.6% (n = 2) developed catheter-associated infection within 30 days of replacement, with one requiring catheter replacement. Transient bloodstream infection occurred in 10.0% (n = 1) within 30 days of ECMO cannula exchange. CONCLUSION: Venous ECMO cannula exchange for a hemodialysis catheter in children requiring renal replacement therapy after decannulation is possible as a bridge to a permanent hemodialysis or peritoneal catheter if renal function does not recover, while supporting vein preservation.

Hypertrophic Pyloric Stenosis Protocol: A Single Center Study.

BACKGROUND: Initial treatment of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Our aim was to describe the protocol and subsequent outcomes. METHODS: We conducted a single-center retrospective review of patients diagnosed with HPS from 2016 to 2023. All patients were given ad libitum feeds postoperatively and discharged home after tolerating three consecutive feeds. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the number of preoperative labs drawn, time from arrival to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate. RESULTS: The study included 333 patients. A total of 142 patients (42.6%) had electrolytic disturbances that required fluid boluses in addition to 1.5x maintenance fluids. The median number of lab draws was 1 (IQR 1,2), with a median time from arrival to surgery of 19.5 hours (IQR 15.3,24.9). The median time from surgery to first and full feed was 1.9 hours (IQR 1.2,2.7) and 11.2 hours (IQR 6.4,18.3), respectively. Patients had a median postoperative LOS of 21.8 hours (IQR 9.7,28.9). Re-admission rate within the first 30 postoperative days was 3.6% (n = 12) with 2.7% of re-admissions occurring within 72 hours of discharge. One patient required re-operation due to an incomplete pyloromyotomy. DISCUSSION: This protocol is a valuable tool for perioperative and postoperative management of patients with HPS while minimizing uncomfortable intervention.

Duodenal Atresia Repair: A Single-Center Comparative Study.

BACKGROUND: The use of laparoscopy in the repair of duodenal atresia has been increasing. However, there is no consensus regarding which surgical approach has better outcomes. We aimed to compare the different surgical approaches and types of anastomoses for duodenal atresia repair. METHODS: Patients who underwent duodenal atresia repair at a single pediatric center were identified between January 2006 and June 2022. Those with concomitant gastrointestinal anomalies or who required other simultaneous operations were excluded. The primary outcome was rate of complications, defined as rate of leak, stricture, and re-operation by surgical approach and technique of anastomosis. RESULTS: A total of 78 patients were included. The majority were female (51.3%, n = 40), with a median age of 4 days (IQR 3.0,8.0) and a median weight of 2.7 kg (IQR 2.2,3.3) at repair. The re-operation rate was 7.7% (n = 6), of which two were anastomotic leaks, and four were anastomotic strictures. The leak rate was 5.6% (n = 1/18) for the open handsewn and 4.8% (n = 1/21) for the laparoscopic handsewn technique. The stricture rate was 12.5% (n = 1/8) for the laparoscopic-assisted handsewn, 9.1% (n = 2/22) for the laparoscopic U-clip, 4.8% (n = 1/21) for the laparoscopic handsewn, and none with laparoscopic stapled and laparoscopic converted to open handsewn techniques. No differences were found in complication rate when controlling for surgical approach. CONCLUSION: The method of surgical approach did not affect the outcomes or complications in the repair of duodenal atresia.