Comparative Effectiveness of Ceftriaxone plus Metronidazole versus Anti-Pseudomonal Antibiotics for Perforated Appendicitis in Children.

Background: Appendicitis is the most common pediatric surgical emergency and one of the most common indications for antibiotic use in hospitalized children. The antibiotic choice differs widely across children's hospitals, and the optimal regimen for perforated appendicitis remains unclear. Methods: We conducted a retrospective cohort study comparing initial antibiotic regimens for perforated appendicitis at a large tertiary-care children's hospital. Children hospitalized between January 2011 and March 2015 who underwent surgery for perforated appendicitis were identified by ICD-9 codes with confirmation by chart review. Patients were excluded if they had been admitted ≥48 hours prior to diagnosis, had a history of appendicitis, received inotropic agents, were immunocompromised, or were given an antibiotic regimen other than ceftriaxone plus metronidazole (CTX/MTZ) or an anti-pseudomonal drug (cefepime, piperacillin/tazobactam, ciprofloxacin, imipenem, or meropenem) within the first two days after diagnosis. The primary outcome of interest was post-operative complications, defined as development of an incisional infection or abscess within six weeks of hospital discharge. Results: Of the 353 children who met the inclusion criteria, 252 (71%) received CTX/MTZ and the others received an anti-pseudomonal regimen. A post-operative complication occurred in 37 (14.7%) of the CTX/MTZ group versus 18 (17.8%) of the anti-pseudomonal group. Antibiotic-related complications occurred in 4.4% of children on CTX/MTZ and 6.9% of children on anti-pseudomonal antibiotics (p = 0.32). In a multivariable logistic regression model adjusting for sex, age, ethnicity, and duration of symptoms prior to presentation, the adjusted odds ratio for post-operative complications in children receiving anti-pseudomonal antibiotics was 1.25 (95% confidence interval 0.66-2.40). Conclusion: Post-operative complication rates did not differ for children treated with CTX/MTZ versus a broader-spectrum regimen.

Laparoscopy in Pediatric Abdominal Trauma: A 13-Year Experience.

Introduction Abdominal injuries are common, costly, deadly, and a source of considerable uncertainty in pediatric trauma. In some circumstances, laparoscopy offers a diagnostic and therapeutic alternative with less morbidity than standard exploration, and more certainty than most imaging. In this study, we review our experience with laparoscopic exploration for trauma. We hypothesized that laparoscopy could be employed effectively in stable blunt or penetrating trauma patients in whom diagnostic uncertainty was unresolved by imaging. Patients and Methods A retrospective review of the trauma database identified all children admitted to our Level I pediatric trauma center between January 1, 2000, and December 31, 2012, requiring surgical abdominal exploration. The utilization of laparoscopy and laparotomy was charted over the 13-year period. Negative laparoscopies and laparotomies and nontherapeutic laparoscopies and laparotomies were examined to investigate clinical scenarios in which laparotomy might have been avoided. Statistical analyses were performed using descriptive statistics, simple linear regression analysis, and Mann-Whitney U test (p < 0.05). Results Over the 13-year study period, there were 16,321 trauma admissions. Of these, 119 patients (0.7%) required surgical abdominal exploration: 81 patients underwent laparotomy and 38 patients underwent laparoscopy. In 13 patients (34.2%), laparoscopic exploration ruled out injuries. In nine patients (23.7%), laparoscopy identified an injury for which no surgical intervention was necessary. In nine patients (23.7%), an injury was repaired laparoscopically. In seven cases (18.4%), the identified injury required conversion to laparotomy. There were no missed injuries. In the laparotomy group, a less invasive approach could have yielded the same information in 8.7% of patients. Laparoscopy was more likely to be used after a qualitative change in institutional minimally invasive surgical capability. Conclusion Laparoscopy reliably resolves diagnostic uncertainty in selected cases of pediatric abdominal blunt and penetrating trauma. In a hemodynamically stable patient with a concerning exam and inconclusive imaging, laparoscopy provides sensitive diagnostic capability and opportunity for definitive repair with diminished surgical morbidity.

The contribution of hiatal hernia to severe gastroesophageal reflux disease in patients with gastroschisis.

BACKGROUND: A relationship between gastroschisis-associated gastroesophageal reflux (GER) and hiatal hernia (HH) has not been previously reported. In reviewing our experience with gastroschisis-related GER, we noted a surprising incidence of associated HH in patients requiring antireflux procedures. METHODS: A single center retrospective chart review focused on GER in all gastroschisis patients repaired between January 1, 2000 and December 31, 2012 was performed. RESULTS: Of the 141 patients surviving initial gastroschisis repair and hospitalization, 16 (11.3%) were noted to have an associated HH (12 Type I, 3 Type II, 1 Type III) on upper gastrointestinal series for severe reflux. Ten of the 13 (76.9%) patients who required an antireflux procedure had an associated HH. The time to initiation of feeds was similar in all patients, 19 and 23 days. However, time to full feedings and discharge was delayed until a median of 80 and 96 days, respectively, in HH patients. CONCLUSIONS: This study describes a high incidence of associated HH in gastroschisis patients. The presence of large associated HH correlated with severe GER, delayed feeding, requirement for antireflux surgery, and a prolonged hospital stay. Patients with gastroschisis and clinically severe GER should undergo early assessment for associated HH.

Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass.

OBJECTIVES: A precipitating factor for marginal ulcer formation after Roux-en-Y gastric bypass may be the prolonged irritation by foreign material, such as nonabsorbable suture at the gastrojejunostomy. This study examines the incidence of marginal ulcers before and after a change was made from using nonabsorbable suture to using absorbable suture for the inner layer of the anastomosis. METHODS: A total of 3285 laparoscopic Roux-en-Y gastric bypass operations were performed during a 5-year period. The gastrojejunostomy technique was modified in August 2002. Those patients who developed a marginal ulcer postoperatively were identified, and their charts were retrospectively analyzed for the operative technique, patient age, history of previous gastric surgery, presence of preoperative diabetes, coronary artery disease, or peptic ulcer disease, and use of nonsteroidal anti-inflammatory medications or tobacco. RESULTS: The incidence of marginal ulceration after Roux-en-Y gastric bypass decreased significantly from 2.6% (28/1095) with the use of nonabsorbable suture to 1.3% (29/2190) after the change to absorbable suture for the inner layer of the gastrojejunal anastomosis (P < .001). The incidence of visible suture adjacent to the ulcer on endoscopy was also significantly reduced (64.3% vs 3.4%; P < .001). When the results were corrected for length of follow-up, the difference in the incidence of ulcers occurring within 1 year of surgery remained significant between the two groups (P = .002). There were no other significant differences in the factors analyzed. CONCLUSIONS: The use of nonabsorbable sutures for the inner layer of the gastrojejunal anastomosis is associated with an increased incidence of marginal ulcers, and the adoption of absorbable suture material has reduced this incidence.

Characterization of the expression of inducible nitric oxide synthase in rat and human liver during hemorrhagic shock.

It has been previously shown that the inducible nitric oxide (NO) synthase (iNOS; NOS-2) is elevated after hemorrhage, and that iNOS-derived NO participates in the upregulation of inflammation as well as lung and liver injury postresuscitation from shock. The purpose of this study was to elucidate the time course of iNOS mRNA expression, as well as the cellular and subcellular localization of iNOS protein in the liver posthemorrhage in rats subjected to varying durations of hemorrhagic shock (HS; mean arterial blood pressure [MAP] = 40 mmHg) with or without resuscitation. Expression of iNOS mRNA in rat liver by real-time reverse transcriptase (RT)-PCR demonstrated iNOS upregulation in shocked animals as compared with their sham counterparts as early as 60 min after the initiation of hemorrhage. By 1 h of HS, iNOS protein was detectable in rat liver by immunofluorescence, and this expression increased with time. Immunofluorescence localized iNOS primarily to the hepatocytes, and in particular to hepatocytes in the centrilobular regions. This analysis, confirmed by immunoelectron microscopy, revealed that iNOS colocalizes with catalase, a peroxisomal marker. Furthermore, we determined that iNOS mRNA is detectable by RT-PCR in liver biopsies from human subjects with HS (MAP < 90 mmHg) associated with trauma (n = 18). In contrast, none of the seven nontrauma surgical patients studied had detectable iNOS mRNA in their livers. Collectively, these results suggest that hepatic iNOS expression, associated with peroxisomal localization, is an early molecular response to HS in experimental animals and possibly in human patients with trauma with HS.