Testicular Workup for Ischemia and Suspected Torsion in Pediatric Patients and Resource Utilization.

BACKGROUND: Testicular torsion (TT) is a pediatric emergency requiring prompt diagnosis and management. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) scores patients on clinical symptoms and can predict TT. This study aimed to determine if the application of TWIST to children with acute scrotal pain could decrease the use of Doppler ultrasonography (DUS) and emergency department (ED) length of stay and ischemic time. MATERIALS AND METHODS: A retrospective cohort study applying TWIST to patients who presented to a pediatric ED with acute testicular pain from December 2017 to June 2019 was performed. Demographics, TWIST score, diagnosis, DUS, consults, and time to the operation were recorded. Patients were stratified into low (LR), intermediate (IR), and high (HR) risk groups for TT based on TWIST score. Descriptive and comparative analyses were performed. RESULTS: Seventy-seven patients were included in the study and had a mean age of 9.24 y ±5.24. All 9 HR patients (TWIST = 5-7) had TT, and none of the 57 LR patients (TWIST = 0-2) had TT. Use of TWIST could have reduced the number of DUS needed to diagnose TT from 69 to 11 (75.3% reduction in DUS). CONCLUSIONS: TWIST accurately predicts torsion in HR groups and excludes torsion in LR groups. Application of TWIST to HR patients may eliminate the need for DUS and decrease ischemic time and cost of care. Application of TWIST in LR patients may likewise eliminate the need for DUS and decrease ED length of stay and cost of care.

Should general surgery residents be taught laparoscopic pyloromyotomies? An ethical perspective.

OBJECTIVES: The authors examine the ethical implications of teaching general surgery residents laparoscopic pyloromyotomy. DESIGN/PARTICIPANTS: Using the authors' previously presented ethical framework, and examining survey data of pediatric surgeons in the United States and Canada, a rigorous ethical argument is constructed to examine the question: should general surgery residents be taught laparoscopic pyloromyotomies? RESULTS: A survey was constructed that contained 24 multiple-choice questions. The survey included questions pertaining to surgeon demographics, if pyloromyotomy was taught to general surgery and pediatric surgery residents, and management of complications encountered during pyloromyotomy. A total of 889 members of the American Pediatric Surgical Association and Canadian Association of Paediatric Surgeons were asked to participate. The response rate was 45% (401/889). The data were analyzed within the ethical model to address the question of whether general surgery residents should be taught laparoscopic pyloromyotomies. CONCLUSIONS: From an ethical perspective, appealing to the ethical model of a physician as a fiduciary, the answer is no. DEFINITIONS: We previously proposed an ethical model based on 2 fundamental ethical principles: the ethical concept of the physician as a fiduciary and the contractarian model of ethics. The fiduciary physician practices medicine competently with the patient's best interests in mind. The role of a fiduciary professional imposes ethical standards on all physicians, at the core of which is the virtue of integrity, which requires the physician to practice medicine to standards of intellectual and moral excellence. The American College of Surgeons recognizes the need for current and future surgeons to understand professionalism, which is one of the 6 core competencies specified by the Accreditation Council for Graduate Medical Education. Contracts are models of negotiation and ethically permissible compromise. Negotiated assent or consent is the core concept of contractarian bioethics. Nonnegotiable goods are goals for residency training that should never be sacrificed or negotiated away. Fiduciary responsibility to the patient, regardless of level of training, should never be compromised, because doing so violates the professional virtue of integrity. The education of the resident is paramount to afford him or her the opportunity to provide competent care without supervision to future patients. Such professional competence is the intellectual and clinical foundation of fiduciary responsibility, making achievement of educational goals during residency training another nonnegotiable good.

A warning: don't be stumped by stump appendicitis.

When an emergency medicine physician evaluates a child with abdominal pain and a history of appendectomy, appendicitis is often excluded from the differential. We present a case of a 16-year-old boy who developed stump appendicitis 3 years after laparoscopic appendectomy. Knowledge of this rare phenomenon in children can lead to timely diagnosis and avoid the significant additional morbidity associated with perforation of the stump.

Splenic conservation: variation between pediatric and adult trauma centers.

OBJECTIVES: Nonoperative management of hemodynamically stable children and adolescents with splenic injury regardless of grade has become standard; however, numerous studies have shown a wide variation in management. We compared the treatment and outcomes of adolescent splenic injuries in our region, which includes a pediatric level I trauma center (PTC) and an adult level I trauma center (ATC). METHODS: A retrospective review of the trauma registry was performed on patients 14 to 17 y old with blunt splenic injury admitted to either the local PTC or ATC from January 1999 through December 2010. Demographics, interventions, and hospital course were recorded and compared using Fisher exact, Student t-test, and multivariate analysis. RESULTS: Eighty-six adolescent patients presenting to the PTC and 65 patients presenting to the ATC met the criteria over the 12-y period. Although the ATC received more significantly injured and slightly older patients, logistic multivariate analysis demonstrated that the location of presentation was the only independent factor associated with splenectomy (P = 0.0015). A higher injury severity score was associated with a longer length of stay (LOS), but the nonoperative approach was not associated with a longer LOS (P = 0.96). CONCLUSIONS: Our study demonstrates that the location of presentation was independently associated with splenectomy while controlling for a higher injury severity score at the ATC. With the higher percentage of nonoperative management, treatment at the PTC was not associated with an increased LOS (total or intensive care unit).

Are facilities following best practices of pediatric abdominal CT scans?

BACKGROUND: Established guidelines for pediatric abdominal CT scans include reduced radiation dosage to minimize cancer risk and the use of intravenous (IV) contrast to obtain the highest-quality diagnostic images. We wish to determine if these practices are being used at nonpediatric facilities that transfer children to a pediatric facility. METHODS: Children transferred to a tertiary pediatric facility over a 16-mo period with abdominal CT scans performed for evaluation of possible appendicitis were retrospectively reviewed for demographics, diagnosis, radiation dosage, CT contrast use, and scan quality. If CT scans were repeated, the radiation dosage between facilities was compared using Student t-test. RESULTS: Ninety-one consecutive children transferred from 29 different facilities had retrievable CT scan images and clinical information. Half of CT scans from transferring institutions used IV contrast. Due to poor quality or inconclusive CT scans, 19 patients required a change in management. Children received significantly less radiation at our institution compared to the referring adult facility for the same body area scanned on the same child (9.7 mSv versus 19.9 mSv, P = 0.0079). CONCLUSION: Pediatric facilities may be using less radiation per CT scan due to a heightened awareness of radiation risks and specific pediatric CT scanning protocols. The benefits of IV contrast for the diagnostic yield of pediatric CT scans should be considered to obtain the best possible image and to prevent additional imaging. Every facility performing pediatric CT scans should minimize radiation exposure, and pediatric facilities should provide feedback and education to other facilities scanning children.

Computed tomography scanning in pediatric trauma: opportunities for performance improvement and radiation safety.

BACKGROUND: Recently, pediatric CT scanning protocols have reduced radiation exposure in children. Because evaluation with CT scan after trauma contributes to significant radiation exposure, we reviewed the CT scans in children at both initial presentation at a non-pediatric facility and subsequent transfer to a level I pediatric trauma center (PTC) to determine the number of scans, body area scanned, radiation dosage, and proportion of scans at each facility. METHODS: The trauma database was retrospectively reviewed for children aged 0 to 17 y initially evaluated for trauma at another facility and then transferred to our PTC for pediatric specialty care between January 2000 and December 2010. RESULTS: A total of 1562 patients with 1335 CT scans were reviewed over an 11-y period. The majority of CT scans occur at the referring facility compared to the PTC in a ratio of 7:3. CT of the head was the most frequent scan obtained (52%), and 17.9% of CT scans were repeated at the PTC. Less than 1% of CT scans performed at the non-pediatric centers contained radiation dosage information, precluding analysis of radiation exposure. CONCLUSIONS: The majority of CT scans for trauma occur at non-pediatric facilities, which demonstrates the need for referring facilities to perform optimal CT scans with the least amount of radiation exposure to the child. We believe this provides an opportunity for PTC performance improvement by facilitating the transfer of images and educating referring facilities about indications for CT scans, dosage amounts, and radiation reduction protocols.

Myositis ossificans requires multiple diagnostic modalities.

Myositis ossificans is a type of bone-forming lesion that arises in soft tissue and mimics malignancy. We present a case of myositis ossificans in a 16-year-old girl with anxiety disorder, Asperger syndrome, and no known history of trauma. A variety of diagnostic tools including magnetic resonance, ultrasound, and biopsy are used to make the diagnosis. The histologic and radiographic findings used to distinguish this disorder from malignant conditions are discussed.

Life-threatening hemorrhage from a congenital hemangioma caused by birth trauma.

Pediatric surgeons frequently diagnose and treat vascular malformations. We present the case of a boy born with a large congenital hemangioma of the flank that ruptured during birth, resulting in life-threatening hemorrhage, requiring emergent excision. Prenatal diagnosis may help to identify such lesions, and pediatric surgeons must be ready to treat emergent complications of vascular malformations.

Magnetic resonance as an aid in the diagnosis of a transverse vaginal septum.

Transverse vaginal septum is a rare, often overlooked congenital abnormality that is typically not diagnosed until adolescence. We present the case of a transverse vaginal septum and partial bicornuate uterus in a 16-year-old adolescent girl with developmental delay and cerebral palsy. Magnetic resonance is an excellent diagnostic tool to delineate the specific anatomy before surgery. The effects of delayed diagnosis and the utility of magnetic resonance in diagnosis will be discussed.

Laparoscopic diagnosis of magnetic malrotation with fistula and volvulus.

INTRODUCTION: Most foreign bodies that a child ingests pass harmlessly through the gastrointestinal tract. However, ingesting multiple magnets places a child at risk for serious viscus injury. CASE DESCRIPTION: A 16-y-old boy swallowed multiple magnets and presented with abdominal pain and emesis. Upon laparoscopy, the boy was found to have malrotation with volvulus caused by a cecal magnet attracted to a gastric magnet, resulting in a gastrocecal fistula. DISCUSSION: We review the management of magnet ingestion with an emphasis on a high index of suspicion and the use of laparoscopy for diagnosis, as well as the consequences of a coexisting rotational anomaly.

Laparoscopic assessment of a migrated ventriculoperitoneal shunt into an inguinal hernia.

Placement of a ventriculoperitoneal (VP) shunt may increase intraabdominal pressure and lead to an abdominal or genitourinary complication. We report on a 2-month-old boy with complex congenital neurologic and cardiac anomalies who had a VP shunt migrate into the left inguinal hernia. This report demonstrates how a laparoscopic approach can be successfully used to reposition the VP shunt, identify a contralateral inguinal hernia, and repair both without any additional incisions.

Laparoscopy for perforated Richter hernia with incarcerated foreign body.

Children often place nonedible objects into their mouths. Occasionally, these objects are inadvertently swallowed, and fortunately, the majority passes spontaneously without intervention. We present the case of a 10-month-old girl who presented with an incarcerated Richter hernia through an indirect inguinal defect containing a wall of sigmoid colon perforated by a swallowed lollipop stick. Although this is a rare case, we conclude that prompt laparoscopic abdominal exploration is an extremely valuable tool in making an accurate diagnosis in difficult-to-reduce or incarcerated hernia cases.

An alternative to open incision and drainage for community-acquired soft tissue abscesses in children.

BACKGROUND: The continually rising incidence of soft tissue abscesses in children has prompted us to seek an alternative to the traditional open incision and drainage (I&D) that would minimize the pain associated with packing during dressing changes and eliminate the need for home nursing care. STUDY DESIGN: A retrospective review of all patients with soft tissue abscesses from November 2007 to June 2008 was conducted after institutional review board approval. Patients who were treated with open I&D were compared to those treated with placement of subcutaneous drains through the abscess cavities. Both groups received equivalent antibiotic treatment, and all patients were followed in outpatient clinics until infection resolved. The demographics, presenting temperature, culture results, and outcomes were compared between these 2 groups. RESULTS: A total of 219 patients were identified; 134 of them underwent open I&D, whereas 85 were treated with subcutaneous drains. The demographics, anatomical location of the abscesses, and bacteriology were comparable between the 2 groups. There were equal number of patients in each group who presented with fever initially. Of those treated with open I&D, 4 had metachronous recurring abscesses within the same anatomical region and 1 patient required an additional procedure because of incomplete drainage. There were no recurrences or incomplete drainages in the subcutaneous drain group. The cosmetic appearance of the healed wound from subcutaneous drain placement during the immediate follow-up period is better than that of an open I&D. CONCLUSIONS: Placement of a subcutaneous drain for community-acquired soft tissue abscesses in children is a safe and equally effective alternative to the traditional I&D.

Outcome differences between gastroschisis repair methods.

BACKGROUND: Gastroschisis is a congenital abdominal wall defect that is repaired with either a primary closure or staged closure. The outcome of these infants may differ because of different closure techniques. In addition to the usual markers of parenteral nutrition (PN) use and length of stay (LOS) as outcome measures, we examined the duration of postoperative acidosis and positive fluid balance as markers for postoperative stress associated with these two techniques. METHODS: A retrospective review of newborns with gastroschisis was conducted at a free-standing children's hospital from 2002 to 2008. The demographic data, gestational age, birth weight, operative reports, days on PN, LOS, duration of postoperative acidosis and fluid balances were reviewed. Data were analyzed using the Fisher's exact test or unpaired t test. RESULTS: Thirty-two infants with gastroschisis were identified. One was excluded from analysis due to incomplete follow-up. The patients were classified as either primary closure (n = 8) or staged repair (n = 23). There was one death in our series. Patients who underwent primary closure had significantly older gestational age and higher birth weight. Primary closure is associated with significantly less duration of postoperative metabolic acidosis and fewer days with positive fluid balance. Patients who had primary repair also had less parenteral nutrition use and shorter length of hospitalization, though not statistically significant. Gastroschisis with associated intestinal atresia was more likely to be repaired with staged closures. CONCLUSIONS: There are physiologic advantages to primary repair of gastroschisis that can lead to better outcome, but the indications for the choices of closure technique remain unclear. Primary closure should be used when possible.

Preoperative bariatric screening and treatment of Helicobacter pylori.

BACKGROUND: A preoperative screening and treatment program for pre-existing H. pylori infections was hypothesized to reduce postoperative bariatric complications and associated morbidity as the role of H. pylori in gastrointestinal symptomatology and peptic ulcer disease is well established. METHODS: A single-institution, single-surgeon, IRB-approved, retrospective chart review was performed. It included 183 consecutive patients who underwent an initial laparoscopic gastric bypass over a 40-month period from December 2003 to April 2006. The patients were divided into a H. pylori untested group (125 patients) and a tested and treated if indicated group (58 patients). Patient demographics and incidence of hospital re-admissions, GI ulceration and bleeding, perforated viscus, esophagogastroduodenoscopy (EGD), and foregut symptoms were documented at routine follow-up and emergency room visits. Results were subjected to analysis with Fisher's exact test. RESULTS: Seven patients (12%) in the tested group were positive for H. pylori and treated. The number of GI ulcers and bleeding, EGDs, ER visits, and hospital re-admissions were not statistically different between groups; however, in the untested group, six patients (5%) presented with viscus perforation compared with none in the tested and treated group (p = 0.09). Demographics for both groups were similar and both had a large number of nonspecific foregut symptoms. CONCLUSION: Preoperative H. pylori screening should continue, especially in geographically high-prevalence areas, as data suggest that the incidence of viscus perforation may be reduced with preoperative treatment if indicated.

Stapled tapering coloplasty to manage colon interposition graft redundancy for long-gap esophageal atresia.

Long gap esophageal atresia continues to be a therapeutic challenge for the pediatric surgeon. Although numerous methods have been described to achieve esophageal continuity in infants with esophageal atresia, esophageal replacement is often required if these methods fail. A common method of esophageal replacement in children is the use of a colon graft. Complications include cervical anastomotic leak, stricture, redundant intrathoracic colon with stasis, and cologastric reflux. We present an 11-year-old male with swallowing difficulties because of redundancy of the colon after undergoing colon interposition for long gap atresia. The patient underwent a successful transhiatal mobilization of the intrathoracic colon and stapled tapering coloplasty. The patient currently remains symptom-free.

Metallic foreign body in the appendix of 3-year-old boy.

Foreign body-induced appendicitis is a rare but well-known entity. This condition was discovered during the first appendectomy performed almost 275 years ago. For the pediatric surgeon, evaluation of a patient for swallowed foreign bodies is common, and most foreign bodies traverse the gastrointestinal tract without incident. However, when the foreign body becomes incarcerated in the appendix, a prophylactic appendectomy is recommended to prevent appendicitis. We present the case of an asymptomatic 3-year-old boy with a metallic foreign body lodged in the appendix that was treated with a fluoroscopically assisted laparoscopic appendectomy and discuss treatment of sharp vs blunt foreign bodies of the appendix.

Laparoscopic excision of a newborn rectal duplication cyst.

Congenital rectal duplication cyst is a rare entity treated with surgical excision. Without treatment, a rectal duplication cyst may cause a variety of complications, most notably, transforming into a malignancy. We report on a 7-week-old girl who was found to have a rectal duplication cyst. The rectal duplication cyst was successfully excised laparoscopically. Rectal duplication cysts are rare alimentary tract anomalies generally discovered during childhood. Complications include symptoms arising from the cyst and the possibility of malignant degeneration. They are typically managed by surgical excision.