Role of Mechanical Bowel Preparation and Perioperative Antibiotics in Pediatric Pull-Through Procedures.

BACKGROUND: There are no clear guidelines for the use of mechanical bowel preparation and postoperative antibiotics in children undergoing elective colorectal pull-through surgery. The objective of this study was to determine whether preoperative bowel preparation administration or duration of postoperative antibiotics impacted the rate of complications after elective pediatric pull-through surgery. MATERIALS AND METHODS: Patients aged <18 y who underwent a pull-through procedure between 2011 and 2017 were retrospectively identified. Patient data included diagnosis, procedure, administration of mechanical bowel preparation, and duration of perioperative intravenous (IV) antibiotics. Outcomes of interest included surgical site infections and anastomotic complications. RESULTS: A total of 180 patients met inclusion criteria, of which 47.2% received mechanical bowel preparation. The combined rate of infectious and anastomotic complications was 12.2%. There was no significant difference in combined complication rate among those receiving bowel preparation compared with those who did not (14.1% versus 10.5%, P = 0.46). Administration of bowel preparation in the perineal anoplasty subgroup was associated with higher rates of wound infection (33.3% versus 3.3%, P = 0.05). One hundred five patients (58.3%) received perioperative IV antibiotics for ≤24 h. This group had similar rates of complications (13.3%) compared with those receiving IV antibiotics for longer than 24 h (11.6%, P = 0.74). CONCLUSIONS: Although mechanical bowel preparation did not affect the overall complication rate for pull-through procedures, it was associated with more wound infections in those undergoing perineal anoplasty. Duration of postoperative IV antibiotics was not significantly associated with the rate of wound and anastomotic complications.

Partial versus total splenectomy in children with hereditary spherocytosis.

BACKGROUND: Partial splenectomy is utilized selectively in children with hereditary spherocytosis (HS) to decrease hemolysis while maintaining immunity. Our aim was to compare outcomes between laparoscopic total splenectomy (LTS) and laparoscopic partial splenectomy (LPS). METHODS: After obtaining institutional review board approval, we reviewed the records for all children ≤18 years with HS undergoing LTS and LPS between 2002 and 2012. Wilcoxon rank-sum tests were used. RESULTS: Eighty-seven HS children underwent LTS (n = 71) and LPS (n = 16). Mean age was 7.1 ± 3.6 years (LTS) and 5.5 ± 2.8 years (LPS; P = .14). Concomitant cholecystectomy was performed in 32% of LTS and 38% of LPS cases. Operative time was 87 ± 33 minutes (LTS) and 140 ± 36 minutes (LPS; P = .0005). Duration of stay was 1.2 ± 0.5 days (LTS) and 2.4 ± 1.4 days (LPS; P = .003). Reticulocyte and hemoglobin levels improved after both operations. LPS children had lower preoperative (8.8 ± 1.9 vs 10.2 ± 1.7 g/dL; P = .0148) and postoperative (10.5 ± 1.7 vs 13.8 ± 1.1 g/dL; P < .0001) hemoglobin levels than did LTS patients. Three LPS children required transfusion (at 2, 4 and 5 postoperative years) for parvovirus-associated aplastic crises. No LTS child developed splenic function or anemia. CONCLUSION: These data demonstrate that LPS decreases hemolysis, although LTS is more effective. LPS children had lower preoperative hemoglobin levels, indicating more severe hemolysis. LPS also has greater operative time and duration of stay, disadvantages balanced by retained immunity.

Impact of primary omentectomy on longevity of peritoneal dialysis catheters in children.

BACKGROUND: The purpose of this study was to determine the impact of omentectomy on peritoneal dialysis catheter failure rates in pediatric patients with renal failure. METHODS: A retrospective review of children undergoing peritoneal catheter placement was performed over a 22-year period. Children were segregated into those undergoing catheter placements with omentectomy or without. RESULTS: One hundred sixty-three patients were reviewed, with a 1:1.03 ratio of male to female patients. The mean age was 6.25 ± 5.58 years. Fifty-three percent underwent omentectomy. Catheter failure was observed in 63 children (39%). Catheter obstruction was identified in 36%. Peritonitis led to failure in 9.8%. Catheter failure rate was significantly reduced with the performance of omentectomy (23% without omentectomy vs 15% with omentectomy, P = .0054). Differences in time to catheter failure did not reach statistical significance in the omentectomy group (759 vs 280 days, P = .13). CONCLUSIONS: Omentectomy conferred improved utility of peritoneal catheters in children. Omentectomy appears useful in children undergoing peritoneal dialysis catheter placement.

Use of the Hunt-Lawrence pouch in congenital microgastria--a report of 2 cases.

Congenital microgastria is an uncommon condition and often associated with other abnormalities. We present 2 patients with congenital microgastria who underwent repair with a Hunt-Lawrence pouch.

Wound infection after colostomy closure for imperforate anus in children: utility of preoperative oral antibiotics.

BACKGROUND/PURPOSE: There is little published data on the efficacy of surgical infection prophylaxis in children. The purpose of this study was to assess wound infection rate in children undergoing colostomy closure for imperforate anus and evaluate the impact of bowel preparation and antibiotics. METHODS: Children younger than 18 years with imperforate anus who had a colostomy closure between January 1996 and December 2007 were identified. Data collected included demographics, bowel preparation, antibiotics, operative details, and postoperative infections. Comparison of mechanical bowel preparation and intravenous antibiotics with and without oral antibiotics was compared using chi(2) tests. Significance was defined as P < .05. RESULTS: A total of 118 patients were identified. Primary skin closure was done in 97%. Mechanical bowel preparation was used in 93%, intravenous antibiotics in 97%, and oral preoperative antibiotics in 52%. Wound infections occurred in 14% (n = 17). The addition of oral antibiotics to the standard regimen of mechanical bowel preparation with intravenous antibiotics did not alter infection rate (13% versus 17%, P = .64). CONCLUSION: Wound infection in children undergoing elective colostomy closure for imperforate anus was 14%. Infection rate was not affected by use of oral antibiotics. Future studies may allow specific guideline development for infection prophylaxis in pediatric patients.

Influence of extracorporeal membrane oxygenation on subsequent surgeries after congenital diaphragmatic hernia repair.

PURPOSE: Congenital diaphragmatic hernia (CDH) is a complex anomaly requiring intensive pulmonary and hemodynamic management. Survival has increased in this population placing them at risk for subsequent morbidities including surgery. The purpose of this study is to review the need for subsequent surgeries in the CDH population. METHODS: After receiving institutional review board approval, a retrospective chart review of all CDH patients between 1980 and 2007 was conducted noting subsequent surgeries and the impact of extracorporeal membrane oxygenation (ECMO) on the types of surgical procedures. Comparison of groups was done by Fisher's Exact test or nonparametric Wilcoxon rank-sum test where appropriate. A P value of less than .05 was considered significant. RESULTS: Data were analyzed for 227 of 294 patients during this period. Extracorporeal membrane oxygenation support was used in 45% of patients. Subsequent surgery was required in 117 patients. Seventy patients in the ECMO group (69%) required a subsequent operation. The most common operative procedures included inguinal hernia/orchiopexy, antireflux, and recurrent diaphragmatic hernias. CONCLUSION: In this series, ECMO survivors are at a high risk for requiring subsequent surgeries compared to the total CDH group. This information can be used as an education tool for referring physicians and parents as they care for this group of children.

Percutaneous endoscopic gastrostomy buttons in children: superior to tubes.

BACKGROUND: There is a paucity of literature comparing outcomes of percutaneous endoscopic gastrostomy (PEG) tubes vs PEG buttons. Primary PEG buttons offer an advantage of being a single-step low-profile enteral access device with potentially fewer complications. METHODS: A retrospective review of patients undergoing PEG tubes and buttons (January 2006-August 2007) was performed. Power analysis demonstrated that 105 patients in each group were needed. Patient characteristics were collected in each group and evaluated by chi(2) and t tests. P values of less than .05 were considered significant. RESULTS: A total of 223 children having undergone PEG (110 tubes, 113 buttons) were identified. No differences were found in operative time, intraoperative complications, clogging, breakage, infections, emergency department visits, or hospital readmissions. However, children undergoing PEG button placement were more likely to spend only one night in the hospital vs PEG tube (60% vs 25%, respectively; P < .001). In addition, PEG buttons had fewer dislodgements (4 vs 15; P < .05). CONCLUSION: The PEG buttons are less likely to become dislodged than PEG tubes. Infection rates were not found to be different between groups. Children with PEG buttons were more likely to be discharged earlier than children with PEG tubes. Primary PEG buttons are clinically comparable to PEG tubes with less concern for dislodgements.

Complete colonic duplication--a case report.

Duplications of the entire colon are very rare. An 18-month-old boy presented with symptoms of chronic constipation and was noted with a complete colonic duplication. The presentation and management are discussed.

An evaluation of medication errors-the pediatric surgical service experience.

BACKGROUND: Medication errors in pediatric patients are well recognized. The need for weight-adjusted dosing and changes in pharmacokinetic parameters make this patient population susceptible. Surgical literature discussing this topic is limited. The purpose of this study was to review the medication errors (variances) on surgical services at a major children's teaching hospital. METHODS: Medication variances occurring from January 2004 to June 2006 were reviewed. Data included service, physician, medication, type of variance, severity, explanation of variance, and time of occurrence. RESULTS: There were 757 patients affected hospital-wide by a medication variance (n = 1340) for which 180 patients were on a surgical service (n = 308 variances). Residents accounted for 82% of all variances. Medication variances occurred most frequently on the general (36%) and neurosurgery services (20.5%). Seventy-one percent of the variances were classified as potential to cause harm but were corrected before reaching the patient. Five percent of variances reached the patient and caused temporary harm. Incorrect dose accounted for 72% of variances, followed by incorrect dosage form or omission in 5%, and missed allergies in 4%. Antibiotics were implicated in 31% of variances. Most errors occurred during daytime work hours. CONCLUSION: Our data show that most of prescribing medication variances never reached the patient and were recognized by pharmacy or nursing. There is a continued need to enhance local education (resident) using a service-specific clinical pharmacist to focus on appropriate dosing especially in regard to antibiotics. Computerized physician order entry when implemented will help to minimize some of these errors. However, in the interim, a service-specific medication dosing card is being implemented. Quarterly service-specific data will be incorporated into the resident/fellow clinical conferences to minimize future variance occurrences.

Survey of pediatric surgeons on current practices of bowel preparation for elective colorectal surgery in children.

BACKGROUND: Guidelines regarding bowel preparation exist for the adult but not the pediatric population. Our aim was to evaluate the bowel preparation practices, including antibiotic usage for elective colorectal operations in children. METHODS: A survey was designed and administered to a nationwide group of pediatric surgeons to ascertain current practices of bowel preparation. RESULTS: Four hundred ninety-three surveys were administered, and 136 physicians responded (28%). Mechanical bowel preparation was used by 96% of the respondents. Preoperative intravenous antibiotics were used by 99% of respondents. The number of years in practice did not significantly affect the use of oral antibiotics (P = .62) or the duration of intravenous antibiotics (P = .78). CONCLUSIONS: There is a wide variation in bowel preparation practices in children. A prospective, randomized trial would be helpful to identify the role of oral antibiotics and optimal duration of intravenous antibiotics in this population.