Management of Fibrous Hamartoma of Infancy: A Contemporary Series.

BACKGROUND: Fibrous hamartoma of infancy (FHI) is a rare, benign, soft tissue mass that may be locally infiltrative. Primary excision is the mainstay of treatment; however, given the infiltrative nature, margin negativity can be difficult to achieve. The management of residual disease in the setting of positive margins after primary excision is not well described. METHODS: All patients undergoing FHI excision from 2012 to 2022 were included. Demographics, operative data, margin status, recurrence, and post-operative follow-up data were obtained via retrospective chart review. RESULTS: Nine patients were identified who underwent FHI excision. The median age at time of excision was 9 months (IQR 16). Seven (78%) were male, and the majority (78%) were white. Seven (78%) underwent preoperative imaging via ultrasound or MRI, and 4 (44%) had a preoperative biopsy to confirm diagnosis. Common locations included upper extremity (n = 4, 44%) and lower extremity/inguinal region (n = 4, 44%). Six patients (67%) had positive margins on pathology - 3 (33%) on the upper extremity, 2 (22%) on the lower extremity/inguinal region, and one (11%) on the flank. One patient (11%) had a local recurrence which did not undergo re-excision. CONCLUSIONS: FHI remains a rare diagnosis. There is a high margin positivity rate; however, local clinically significant mass recurrence remains uncommon. With low rates of clinically significant mass development coupled with the benign nature of disease, a "watch and wait" approach may be appropriate for patients with positive histologic margins after complete gross excision to avoid reoperation and need for complex reconstructions. LEVEL OF EVIDENCE: Level 4.

Transcystic Laparoscopic Common Bile Duct Exploration for Pediatric Patients with Choledocholithiasis: A Multi-Center Study.

BACKGROUND: Patients with choledocholithiasis are often treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Upfront LC, intraoperative cholangiogram (IOC), and possible transcystic laparoscopic common bile duct exploration (LCBDE) could potentially avoid the need for ERCP. We hypothesized that upfront LC + IOC ± LCBDE will decrease length of stay (LOS) and the total number of interventions for children with suspected choledocholithiasis. METHODS: A multicenter, retrospective cohort study was performed on pediatric patients (<18 years) between 2018 and 2022 with suspected choledocholithiasis. Demographic and clinical data were compared for upfront LC + IOC ± LCBDE and possible postoperative ERCP (OR1st) versus preoperative ERCP prior to LC (OR2nd). Complications were defined as postoperative pancreatitis, recurrent choledocholithiasis, bleeding, or abscess. RESULTS: Across four centers, 252 children with suspected choledocholithiasis were treated with OR1st (n = 156) or OR2nd (n = 96). There were no differences in age, gender, or body mass index. Of the LCBDE patients (72/156), 86% had definitive intraoperative management with the remaining 14% requiring postoperative ERCP. Complications were fewer and LOS was shorter with OR1st (3/156 vs. 15/96; 2.39 vs 3.84 days, p < 0.05). CONCLUSION: Upfront LC + IOC ± LCBDE for children with choledocholithiasis is associated with fewer ERCPs, lower LOS, and decreased complications. Postoperative ERCP remains an essential adjunct for patients who fail LCBDE. Further educational efforts are needed to increase the skill level for IOC and LCBDE in pediatric patients with suspected choledocholithiasis. LEVEL OF EVIDENCE: Level III.

Testicular torsion disparities in the pediatric population.

BACKGROUND: There are disparate findings in the literature on the impact of race and insurance status on gonadal loss in testicular torsion. We sought to determine if race or levels of social vulnerability influence the rate of torsion or gonadal loss. METHODS: Retrospective cross-sectional review between December 2017 and September 2019. Social vulnerability index was dichotomized using the 75th percentile. Primary outcome was the diagnosis of testicular torsion. RESULTS: 515 patients were included. There was no difference in median age, torsion diagnosis, and orchiectomy rate between the two institutions. Black/African American patients were >3 times more likely than Caucasian patients to be diagnosed with TT when controlled for dichotomized SVI, insurance, and age (OR 3.39, 95% CI 1.74 - 6.61, p < 0.01). CONCLUSION: Black/African American children have an increased risk of testicular torsion. Despite these patients having higher levels of social vulnerability, it was not associated.

The impact of social determinants of health on the overall wellbeing of children: A review for the pediatric surgeon.

Disparities in health care access, quality, and outcomes for pediatric patients, and their relationship to race and socioeconomic status (SES) have been extensively documented. The underlying causes behind such disparities have been less carefully studied, as clinicians and researchers often fail to look past immutable features such as race, into modifiable factors like social determinants of health (SDOH). A child's environment affects their patterns of social engagement, sense of security, and overall well-being. Resources such as affordable housing, access to education, public safety, and availability of healthy foods and safe play spaces impact and enhance quality of life, and have significant influence on both health and health care outcomes. These upstream indicators are often unrecognized or misidentified as health concerns. Few pediatric surgery publications discuss SDOH and their effects on children. This paper aims to introduce the five domains of SDOH (economic stability, education, social and community context, health and healthcare, and neighborhood and built environment) along with strategies to identify and address needs in these domains from a provider, hospital, and health system's perspective. It is anticipated that this information will serve as a foundation for pediatric surgeons to understand and develop processes that ameliorate disparities related to SDOH and improve surgical outcomes and the well-being of all children.

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.

Mitigating disparity in children with acute appendicitis: Impact of patient-driven protocols.

PURPOSE: Previous reports in the literature demonstrate racial and ethnic disparities for children diagnosed with acute appendicitis, with minorities experiencing worse outcomes. At our institution, we have developed an evidence based patient driven protocol for children following laparoscopic appendectomy. However, the influence of such protocol on mitigating racial and ethnic disparities in outcomes remains unknown. The purpose of our study is to assess the impact of our protocol by evaluating the influence of race and ethnicity on surgical outcomes among children treated for acute appendicitis. MATERIAL AND METHODS: A retrospective review of prospectively collected data was conducted. Children undergoing a laparoscopic appendectomy at our freestanding children's hospital between December 2015 and July 2017 were included. Demographic data, post-operative length of stay, same day discharge rates and hospital readmission rates were abstracted from patient medical records. Patients were classified by their race and ethnic background. Comparative analysis was performed in STATA with a p value <.05 determined as significant. RESULTS: A total of 786 children were included, with the majority being either White (70%, n = 547), Black (8%, n = 62) or Hispanic (17%, n = 133); 569 patients (72%) were found to have non-perforated appendicitis. There was no statistically significant difference in the rates of same day discharge among White, Black or Hispanic children respectively (88% vs. 77% vs. 86%, p = .126). Of the 217 children with perforated appendicitis, Hispanic children had increased rates of perforation (41%, n = 55) compared to White and Black children respectively (23%, n = 128 and 29%, n = 18, p = .001). However, average post-operative length of stay were similar among White, Black and Hispanic children (96 h vs. 95 h vs. 98 h, p = .015). On multivariate analysis, the only significant risk factor for an elevated post-operative length of stay was the presence of a perforation. CONCLUSION: Our evidence based patient driven protocol effectively mitigates racial and ethnic disparities found in children with acute appendicitis. Further prospective investigation into the role of such patient-driven protocols to mitigate healthcare disparities is warranted. LEVELS OF EVIDENCE: Therapeutic study; Level 3.

Epidural versus PCA Pain Management after Pectus Excavatum Repair: A Multi-Institutional Prospective Randomized Trial.

INTRODUCTION: Postoperative pain control remains the primary reason for inpatient stay after minimally invasive repair of pectus excavatum. In a previous study, our group reported that early pain control was better in patients managed with a thoracic epidural, while late pain control was better in patients managed with patient-controlled analgesia (PCA). After revising our epidural transition and modifying the PCA protocol, we conducted a multi-institutional prospective randomized trial to evaluate these two pain control strategies. MATERIALS AND METHODS: Patients were randomized to epidural or PCA following minimally invasive repair of pectus excavatum with standard protocols for each arm. Primary outcome was length of stay with secondary variables including mean patient pain scores, complications, and parental satisfaction. Scores were pooled for the two groups and reported as means with standard deviation. Results were compared using t-tests and one-way analysis of variance with p-value < 0.05 determining significance. RESULTS: Sixty-five patients were enrolled, 32 epidural and 33 PCA. Enrollment was stopped early when we developed an alternative strategy for controlling these patients' pain. There was no difference in length of stay in hours between the two arms; epidural 111.3 ± 18.5 versus PCA 111.4 ± 51.4, p = 0.98. Longer operative time was found in the epidural group. Nine patients in the epidural group (28%) required a PCA in addition to epidural for adequate pain control. Mean pain scores were lower on postoperative day 0 in the epidural group compared with the PCA groups, but were otherwise similar. CONCLUSION: In our prospective randomized trial, PCA is just as effective as thoracic epidural in decreasing early postoperative pain scores after minimally invasive repair of pectus excavatum.

Therapeutic Direction Versus Adverse Outcomes in Children Undergoing Lung Biopsy.

BACKGROUND: Lung biopsy is part of the diagnostic workup for multiple diseases. Although the morbidity of the procedure has decreased with the use of thoracoscopy, lung biopsy still holds substantial risk for patients. Therefore, we evaluated the likelihood of lung biopsies impacting treatment compared to complications. MATERIAL AND METHODS: This was a single-institution, retrospective chart review of patients less than aged 18 y undergoing lung biopsy from 2010 to 2016. Details of demographics, hospital course, adverse events, complications, pathology, and follow-up were recorded. All values are reported as medians with interquartile range. RESULTS: Thirty-seven patients met inclusion criteria. Median age was 7 y old (interquartile range 1.4, 15). Eighty-seven percent (33) of biopsies were performed thoracoscopically, with a 3% conversion rate. Adverse events occurred in 25% (9) of cases with the majority involving prolonged respiratory failure (n = 7). Complications occurred in 16% (6) of cases including pneumothorax (13%, n = 5) and cardiac arrest (3%, n = 1). A third of these complications (n = 2) required reoperation, and both were decompressions of tension pneumothoraces. Pathology established a diagnosis in 62% (n = 23) of cases, yet treatment was changed in only 43% of cases. No preoperative variables were associated with the pathology establishing a diagnosis or changing treatment. CONCLUSIONS: Lung biopsy for questionable pulmonary disease changed treatment in less than half of cases, with significant perioperative morbidity. Careful consideration should therefore be given to who would benefit most from lung biopsy.

Outcomes of Ostomy Location in Children: Placement of the Ostomy at the Umbilicus.

PURPOSE: Neonatal exploratory laparotomies are often performed with a transumbilical incision in our institution, so umbilical ostomy placement has become more common. The purpose of our study is to evaluate the outcomes of neonates with ostomy placement at the umbilicus in comparison to more traditional stoma locations. MATERIAL AND METHODS: Retrospective study of neonates that underwent an exploratory laparotomy with ostomy creation between January 2010 and September 2015. Demographics, presentation, feedings, ostomy position, postoperative complications, and outcomes were collected. Comparative analysis was performed in STATA with P-value <.05 determined as significant. Results reported as means ± standard deviation and medians with interquartile ranges. RESULTS: Fifty-four children were included, 37% (n = 20) had stomas at the umbilicus. Most common other stoma location was the right lower quadrant (63%, n = 34). Necrotizing enterocolitis (NEC) was the most common indication for surgery in both groups. Days to stoma output were similar between the two groups, [3 (1, 6) versus 2 (1, 5), P = .96]. Days to initiation of feeds were delayed in the umbilical ostomy group [15 (9.5, 23.5) versus 6 (4, 10), P = .02]. Comparing only NEC patients, initiation of feeds was similar [22 (14, 56) versus 15.5 (8, 43), P = .73]. Umbilical ostomies had an increase in prolapse/peristomal hernias (7 versus 3, P = .01), but no patients required operative revision. CONCLUSION: Umbilical ostomies had similar time to stoma function compared to other sites, but a delay in initiation of oral feeds likely secondary to a higher percentage of patients with NEC.

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.

Does muscle biopsy change the treatment of pediatric muscular disease?

BACKGROUND: Muscle biopsy is performed to confirm the diagnosis of neuromuscular disease and guide therapy. The purpose of our study was to determine if muscle biopsy changed patient diagnosis or treatment, which patients were most likely to benefit from muscle biopsy, and complications resulting from muscle biopsy. MATERIALS AND METHODS: An IRB-approved retrospective chart review of all patients less than 18 years old undergoing muscle biopsy between January 2010 and August 2016 was performed. Demographics, patient presentation, diagnosis, treatment, hospital course, and follow-up were evaluated. Descriptive and comparative (student's t test, Mann-Whitney U, and Fisher's exact test) statistical analysis was performed. Medians were reported with interquartile range (IQR). RESULTS: 90 patients underwent a muscle biopsy. The median age at biopsy was 5 years (2, 10). 37% (n = 34) had a definitive diagnosis. 39% (n = 35) had a change in their diagnosis. 37% (n = 34) had a change in their treatment course. In the 34 patients who had a change in their treatment, the most common diagnosis was inflammatory disease at 44% (n = 15). In the 56 patients who did not have a change in treatment, the most common diagnosis was hypotonia at 30% (n = 17). There was no difference in patients who had a change in treatment based on pathology versus those that did not. The median length of follow-up was 3 years (1, 5). CONCLUSIONS: Muscle biopsy should be considered to diagnose patients with symptoms consistent with inflammatory or dystrophic muscular disease. The likelihood of this altering the patient's treatment course is around 40%.

Abdominal Exploration in Neonates Using Transumbilical Exposure Compared with Transverse Laparotomies.

INTRODUCTION: The vertical transumbilical incision (TU) technique during neonatal abdominal exploration involves dissection and ligation of umbilical vessels, which allow access to all quadrants of the abdomen and complete bowel evisceration with minimal violation to the anterior abdominal wall. We compared patient characteristics and outcomes for neonates undergoing TU with standard transverse exploration. MATERIALS AND METHODS: A single-center retrospective review of neonates who underwent abdominal exploration between January 2010 and September 2015 was conducted after obtaining Institutional Review Board approval. Data included patient demographics, indication for operative intervention, operative details, complications, including incisional hernias, and long-term outcomes. RESULTS: There were 88 neonates under 4 months of age who underwent abdominal exploration, with a median age of 5.5 ± 17 days and a median gestational age of 32.8 ± 16 weeks. Exploration was emergent in 38 patients (43%) and 49 (56%) required ostomy formation. A transverse incision (TV) was used in 30 patients and a TU in 58 patients. Both groups had similar postoperative complication rates; 27 (47%) in the TU group and 11 (36%) in the TV group, P = .51. Median length of follow-up in the TU group was 5.1 ± 18 months and 6.2 ± 16 months in the TV group, P = .48. The TU group had 4 incisional/umbilical hernias (7%), none have required repair. CONCLUSION: TUs for abdominal explorations in neonates have similar outcomes as the standard TV while preserving the integrity of the anterior abdominal wall.

The role of 2-octyl cyanoacrylate in prevention of penile adhesions after circumcision: A prospective, randomized trial.

PURPOSE: Penile adhesions are the most common complication after circumcision, although strategies to decrease them are poorly studied. We conducted a prospective, randomized trial comparing the use of 2-octyl cyanoacrylate (glue) skin adhesive to hydrophobic ointment after circumcision. METHODS: Patients <7years old undergoing circumcision were randomized to glue around the sutures and corona of the penis or antibiotic ointment. The primary outcome variable was postoperative penile adhesions. Utilizing a power of 0.8 and an alpha of 0.05, 168 patients were calculated for each arm. Because of high attrition, we planned to include up to 500 patients. Presence/absence of adhesions was evaluated 2-4weeks postop. Parents subjectively scored happiness, comfort, distress, and concern on a Likert scale 1-5. RESULTS: From 11/2012 through 7/2016, 409 patients were enrolled. Adhesion data were available on 243 patients. There was no difference between glue (16.8%) and those with antibiotic ointment (15.2%) (p=0.88) or in parental satisfaction across all areas measured. 165 patients were lost to follow-up, evenly distributed between the two groups (38% vs. 42%, p=0.49). CONCLUSION: The placement of 2-octyl cyanoacrylate skin adhesive does not decrease the rate of postoperative penile adhesions after circumcision. Parent satisfaction outcomes are similar. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level II.

Impact of Epidural Failures on the Results of a Prospective, Randomized Trial.

INTRODUCTION: We conducted a prospective randomized trial to evaluate the merits of two established postoperative pain management strategies: thoracic epidural (EPI) versus patient-controlled analgesia (PCA) with intravenous narcotics after minimally invasive repair of pectus excavatum. Pain scores favored the EPI group for the first two postoperative days only. Critics of the trial suggest that if the epidural failure rate was not so high, results may have favored the EPI group. Therefore, we performed a subset analysis of the EPI group to evaluate the impact of these failures. METHODS: Patients for whom epidural catheter could not be placed or whose catheters were removed early owing to dysfunction were compared with those with well-functioning catheters. Those with well-functioning catheters were also compared with the PCA group. A two-tailed independent Student t-test and a two-tailed Fisher exact test were used where appropriate. RESULTS: Of 55 patients in the EPI group, 12 patients (21.8%) had failed placement or required early removal. Comparing those with failed placements with the rest of the group, there was no difference in daily visual analogue scale pain scores or measures of hospital course. Likewise, comparing those with well-functioning catheters only to those in the PCA group, the results of the trial are replicated in terms of pain scores, hospital course, and length of stay. CONCLUSION: In patients with failed epidural therapy, there is no significant difference in postoperative hospital course. Comparing those with well-functioning catheters to those in the PCA group, trial results are replicated-that is, no significant difference in length of stay, time to regular diet, or time to transition to oral medications. Therefore, failure rate in the EPI group did not influence the results of the trial.

Review of the Experience with Re-Operation After Laparoscopic Nissen Fundoplication.

INTRODUCTION: The risk of redo fundoplication has been demonstrated to be significantly higher in patients of younger age, those with ongoing retching, and those who underwent more extensive dissection of the esophageal hiatus at the initial operation. The purpose of this study was to review the management and outcomes of patients who required one or more re-operations for recurrence after laparoscopic fundoplication. MATERIALS AND METHODS: After obtaining Institutional Review Board approval, we performed a retrospective review of all patients who underwent laparoscopic Nissen fundoplication from 2000 to 2013 and subsequently required a redo operation for recurrence. Patient demographics, neurologic impairment, interval time between re-operations, operative approach, use of mesh, and length of follow-up were analyzed. Two-tailed independent Student's t test was used to compare continuous variables, and two-tailed chi-squared test with Yates's correction (Fisher's exact test where appropriate) was used for discrete variables. RESULTS: Eighty-two patients (10.3% of the sample) required re-operation during the study period. The mean age at initial surgery was 1.8 ± 3.6 years. Fifteen patients (18.3%) required more than one re-operation. Of the 102 re-operations performed, 68 were successfully managed laparoscopically, 3 required conversion to an open procedure, and 31 were performed open from the outset. Of those patients requiring more than one re-operation, there was no difference in age, weight, use of mesh, or time to subsequent re-operations compared with patients that only required one redo fundoplication. CONCLUSIONS: The incidence of patients requiring another operation after a redo operation after an initial laparoscopic fundoplication is 18%. Patient demographics and time to re-operation have not been found to be predictive of which patient will require multiple re-operations for recurrence. However, younger patients and those with a shorter time to re-operation may increase the likelihood of failure.

Safety of a new protocol decreasing antibiotic utilization after laparoscopic appendectomy for perforated appendicitis in children: A prospective observational study.

INTRODUCTION: In a previous randomized trial, we found children with perforated appendicitis could be safely discharged prior to completion of a 5 day intravenous antibiotics course. To progress the protocol further, patients who met discharge criteria early were discharged without oral antibiotics if leukocyte counts were normal. METHODS: Children undergoing laparoscopic appendectomy for perforated appendicitis were prospectively observed after institution of a new antibiotic regimen consisting of daily intravenous dosing ceftriaxone/metronidazole while an inpatient. Patients discharged prior to 5 days were discharged home without oral amoxicillin-clavulanate if no leukocytosis at discharge. Outcomes were compared to the previous protocol of daily intravenous ceftriaxone/metronidazole with completion of a 7-day antibiotic course with amoxicillin-clavulanate of all patients discharged prior to 5 days. RESULTS: 540 patients (270 new protocol, 270 old protocol) were identified. There was no significant difference in patient demographics, admission leukocyte count, time to regular diet, or length of stay. Postoperative abscess occurred in 21.8% in the new protocol compared to 19.3% of the previous (P=0.5). There was a significant decrease in the number of patients discharged home on oral antibiotic therapy (P<0.001). CONCLUSIONS: Patients meeting discharge criteria with normal leukocyte count prior to completion of 5 days IV antibiotic therapy can be safely discharged home without oral antibiotics after laparoscopic appendectomy for perforated appendicitis.

Granular cell tumors and congenital granular cell epulis in children: Similar entities.

BACKGROUND/PURPOSE: Granular cell tumor (GCT) is an unusual lesion thought to originate from Schwann cells. Congenital granular cell epulis (CGCE) is a rare fibroma-like lesion arising from the alveolar ridge in newborns. These entities have been described as distinct entities. METHODS: A retrospective review was performed of children with a histopathologic diagnosis of GCT or CGCE from 1991-2014. Data were recorded and analyzed. All values reported as the mean±standard deviation. RESULTS: GCT or CGCE was identified in 41 patients with a mean age of 7.8±6.1years. Thirty-one patients had GCT, and 10 had CGCE. All patients underwent excisional biopsy, except 1 who underwent incisional biopsy only. Fifteen patients had positive margins after excision (12 GCT and 3 CGCE). Only 1 had a local recurrence, and this same patient had multifocal GCT. Only 1 patient had an invasive lesion without recurrence after wide local excision. All patients survived, with a median follow-up of 42.5months (0.2-204.2months). CONCLUSION: In children, both GCT and CGCE exhibit benign behavior, and complete excision does not appear to be mandatory, as recurrence or invasive disease is rare. When invasive features are present, wide local excision should be undertaken.

Minimal vs. maximal esophageal dissection and mobilization during laparoscopic fundoplication: long-term follow-up from a prospective, randomized trial.

PURPOSE: We have previously conducted a prospective randomized trial (PRT) comparing circumferential phrenoesophageal dissection and esophageal mobilization (MAX) to minimal dissection/mobilization (MIN). The MIN group had a decreased incidence of postoperative wrap herniation and need for reoperation. This study provides long-term follow-up of the patients from our center who participated in the PRT. METHODS: Parents of patients in the PRT were queried regarding symptoms, medication use, postoperative complications, and additional procedures. Medical records were reviewed. Student's t-test was used for continuous variables. Fisher's exact and chi-square with Yates correction were used where appropriate. RESULTS: Of patients from our center, 75.4% MAX and 72.5% MIN patients were contacted. Median time to follow-up was 6.5 years. A rise in the incidence of herniation was noted in both groups (22.7% to 36.5% MAX vs 2.8% to 12.2% MIN). Time to diagnosis of hernia was significantly longer in the MIN group (14.7±9.5 months MAX vs 30.2±23.6 months MIN, P=0.04). There was no significant difference between MIN and MAX group in reflux symptoms or medication use. CONCLUSION: Long-term follow-up demonstrates an increase in incidence of herniation in both groups. Previously demonstrated higher risk of wrap herniation with maximal esophageal dissection during laparoscopic fundoplication remains supporting original findings.