Population Density and Triage of Pediatric Firearm Injuries in a Rural Trauma System.

BACKGROUND: Rural pediatric firearm injuries require regional pediatric and trauma expertise. We evaluated county-level population density associations with transport, hospital interventions, and patient outcomes at a Level I pediatric trauma center serving a rural, statewide catchment area. MATERIAL AND METHODS: The trauma registry of the only in-state pediatric trauma center was reviewed for firearm injuries in patients < 18 between 1/2013 and 3/2020. County-level population density was classified according to the United States Office of Management and Budget definitions for rural, micropolitan, and metropolitan areas. RESULTS: 364 patients were identified, including 7 patients who were re-injured. Mean age was 11.3 ± 4.5 y and patients were 79.4% male. 59.3% were transferred from a referring hospital. Median injury severity score was 5 (IQR 1-10); 88.0% required trauma center admission, and 48.2% required operative intervention. 7.4% were injured in a rural county, 46.4% in a micropolitan county, and 46.2% in a metropolitan county. Patients from rural counties were more likely to be unintentionally injured (72.0%) than those from micropolitan (54.4%) or metropolitan counties (44.0%, P = .04). While need for inpatient admission and length of stay were similar, those transported from rural counties had significantly longer transport times (P < .01) and less frequent need for operative intervention (P = .03), as well as trends toward lower injury severity (P = .08) and mortality (P = .06). CONCLUSION: Management of pediatric firearm injury is a unique challenge with significant regional variability. Opportunities exist for outreach, telehealth, and decision support to ensure equitable distribution of resources in rural trauma systems. LEVEL OF EVIDENCE: Epidemiological, Level III.

Experience with the optical access trocar for safe and rapid entry in the performance of laparoscopic gastric bypass.

BACKGROUND: In laparoscopic surgery, serious complications caused by the blind insertion of trocars are well known. The open technique is compromised by the leakage of carbon dioxide and can also be time consuming, especially in morbidly obese patients. Our aim was to determine whether the optical access trocar can be used to establish a safe and rapid entry during laparoscopic gastric bypass. METHODS: The data on a single surgeon's experience with 370 laparoscopic gastric bypass procedures during a 4-year period were reviewed. The Optiview trocar was used for all except the initial 21 patients. The entry time for the optical trocar was measured in 10 patients. RESULTS: Of the 370 patients undergoing laparoscopic gastric bypass from November 2000 to September 2004, the initial 21 were treated using the standard Veress needle to create the pneumoperitoneum. The next 22 were treated using the Veress needle to create the pneumoperitoneum, followed by insertion of the optical access trocar in the left upper quadrant as the initial trocar. From this point to the present, the optical access trocar has been inserted without the use of a Veress needle. There have been no trocar-related bowel or vascular injuries in the entire series. The mean optical trocar insertion time was 28 +/- 1.2 s. CONCLUSIONS: This is the first laparoscopic gastric bypass series to report the results of its experience with the optical access trocar. This device provides a safe and rapid technique for placement of the initial trocar for laparoscopic gastric bypass. Insertion of the optical trocar with a 10-mm laparoscope into the left upper quadrant is our procedure of choice for obtaining the pneumoperitoneum in this patient population.

Myotomy: follow-up study of 50 patients.

Laparoscopic myotomy has become the standard treatment for definitive management of achalasia. This study was undertaken to assess the long-term results of the procedure. Perioperative data, including a symptom score questionnaire, were collected prospectively on all patients undergoing laparoscopic myotomy. The same questionnaire was readministered by phone to patients with follow-up greater than 3.75 years. The long-term success of myotomy was defined as a 50% or greater decrease in the dysphagia score and absence of further therapy (responders). Fifty of 95 patients (age = 57 years, 23 females) were successfully contacted. Average follow-up was 6.2 years. The overall long-term success rate was 64% (responders). Forty-two patients (84%) were able to gain or maintain their weight after the procedure. Five patients (10%) required one or more endoscopic dilations after the myotomy. The mean change in dysphagia score was higher in the responder group (7.8 +/- 1.9 vs. 1.9 +/- 2.1; P = 0.001). The two groups were similar in terms of age, gender distribution, and follow-up interval (P > .05). Dor fundoplication was performed in six patients (12%), and the outcome comparisons of these patients showed no significant differences from those patients undergoing Heller alone. Overall satisfaction was achieved in 94% of contacted patients. These results confirm that laparoscopic myotomy is an effective procedure with excellent long-term symptom resolution and overall satisfaction in patients with achalasia.