Routine Assessment of Surgical Resident Wellness-Related Concerns During Biannual Review.

BACKGROUND: Surgery residency confers stress burdens on trainees. To monitor and mitigate areas of concerns, our education team implemented a 6-item biannual survey querying potential stressors. We reviewed the initial 5-year experience to assess for trends and improve efforts in maintaining resident well-being. STUDY DESIGN: Surgery residents from all postgraduate years were asked to complete a survey of common concerns, prioritizing them in order of importance. The items to be ranked were: needs of family/friends; nonwork time for study; financial concerns; personal well-being needs; concerns for clinical performance; and administrative demands. Changes in ranking were trended across 10 review periods. Results were analyzed using a Kruskal-Wallis test. RESULTS: A completion rate of 96.5% was rendered from the completion of 333 surveys. Rankings changed significantly for nonwork time for study (p = 0.04), personal well-being needs (p = 0.03) and concerns for clinical performance (p = 0.004). Nonwork time for study and concerns on clinical performance were consistently ranked as top two stressors over study period, except for spring 2020. Personal well-being needs ranked highest in spring 2020; 41% of residents placed this as top 2 rankings. A decrease in concerns for clinical performance was observed in spring 2020, corresponding to the coronavirus disease 2019 (COVID-19) pandemic emergency declaration. CONCLUSIONS: Surgery residents generally prioritized time for study and concerns for assessment of clinical performance as highest areas of concern. With the occurrence of a pandemic, increased prioritization of personal well-being was observed. Used routinely with biannual reviews, the survey was able to identify plausible changes in resident concerns. Determination of levels of actual stress and actual association with the pandemic requires additional study.

Subcutaneous Endoscopic-Assisted Ligation of the Internal Ring for Inguinal Hernia Repair in Neonates Under Spinal Anesthesia.

Introduction: While laparoscopy is now widely accepted for inguinal hernia repair in infants, it traditionally has required general anesthesia. We sought to evaluate the safety of laparoscopic inguinal hernia repair in infants under spinal anesthesia. Materials and Methods: We performed a retrospective cohort study of all inguinal hernia repairs at a single institution between December 2011 and June 2019 in patients younger than 6 months of age. Four groups were compared: laparoscopic under general anesthesia, laparoscopic with spinal anesthesia, open with spinal anesthesia, and open under general anesthesia. Main outcome measures include operative time, cost, and postoperative outcomes. These were assessed using Kruskal-Wallis median comparison. Results: Of the 226 patients meeting inclusion criteria, 54% (122/226) of patients underwent general anesthesia, while 46% (104/226) had spinal. When compared to general anesthesia, spinal anesthesia was associated with significantly shorter procedure times (P < .01) and lower cost (P < .01) for both open and laparoscopic approaches. Complications were few and underpowered to calculate significance across each group. Conclusions: Laparoscopic inguinal hernia repair can be safely performed in infants under spinal anesthesia without significant compromise of early perioperative outcomes. Advantages may include shorter procedure time and lower cost.

Return of the Banana Knife: An Alternative Instrument for Laparoscopic Pyloromyotomy.

Background: When the disposable arthroscopic banana knife (Linvatec, Largo, FL) became unavailable, many pediatric surgeons adapted the use of spatula tip cautery for laparoscopic pyloromyotomy; however, reusable arthroscopic knives remain readily available and are well suited to the procedure. Methods: We compared laparoscopic pyloromyotomy with a reusable arthroscopic banana knife (Sklar, West Chester, PA; catalog no. 45-6050) to those using spatula tip cautery at a single institution between September 1, 2012, and December 31, 2019. Mann-Whitney U test was used to compare operative time, room time, and time to discharge between groups. Results: Overall, 109 patients underwent pyloromyotomy for hypertrophic pyloric stenosis during the study time period. Of these, 12 were open and one was undertaken with the Storz pyloromyotomy knife, so these were excluded. A total of 74 (77.1%) laparoscopic cases with spatula tip cautery and 22 (22.9%) with the banana knife were included. Mean age at the time of surgery was ∼37 days. The majority of patients in each group were white, male, and full term. The most common comorbid conditions were reactive airway disease and neonatal abstinence syndrome. There were no significant differences in operative time (P = .61), room time (P = .41), or time from surgery to discharge (P = .26) between procedures using the banana knife and those using the cautery spatula tip. There were no perforations or recurrences. Conclusion: Our findings suggest that the reusable banana knife is a safe and effective alternative to spatula tip cautery for laparoscopic pyloromyotomy, with no difference in operative time, time from surgery to discharge, or complications.

Boot Camp in a Box: Initial Experience with Pretraining Skills Preparation for New Interns.

PURPOSE: In order to increase selected skills at onset of training, we provided newly matched PGY-1 trainees with materials and instructions to practice these skills, as well as the opportunity to share video-recorded performance and receive feedback based on these videos. METHODS: Knot tying and suturing kits, instruments and supplies, and video instructions for task performance were sent to newly matched trainees to our program (n = 10), with instructions to practice 4 tasks (1- and 2-handed knot tying, interrupted and running suturing) until self-assessed comfort with each task was achieved or the 8-week time point before start of training was reached. Each trainee returned a video of each task, which was graded by blinded reviewers for time and errors using an itemized evaluation instrument (12 items for suturing and five items for knot-tying). Feedback (annotations of submitted videos) was provided after grading was completed. Task performance was repeated and reassessed at the time of new intern "Boot Camp" and again 8 weeks after start of training. Performance scores were compared for the 3 time points and with scores of PGY 2-4 residents using ANOVA with posthoc tests. RESULTS: Compliance with instruction for practice and return of video recorded tasks in the months before start of PGY-1 training was high, with only 1 of 10 failing to return knot-tying videos. A significant pattern of performance change (p < 0.05) was observed for all tasks with an initial decrease between the pre-employment practice period and the Boot Camp test followed by an increase to the highest level of performance 2 months after start of training. At that point, scores were not significantly different than those of more senior residents. CONCLUSIONS: A high level of compliance was achieved with requested skills practice and video documentation of performance. We attribute the consistently lower scores on the tasks during Boot Camp tests to higher stress test environment which was apt to be less favorable than having the trainee choose to submit their best possible preresidency video recording of performance in a low-stress situation. Subsequent achievement of significantly higher performance even compared to more senior residents may have been helped by incentivized pretraining practice.

Laparoscopic Pediatric Inguinal Hernia Repair: A Pilot Study in a Novel Guinea Pig Animal Model.

BACKGROUND: The purpose of this study was to compare different techniques for pediatric laparoscopic inguinal hernia repair. We hypothesize that the amount of dissection performed at the internal ring, with or without division of the peritoneum, will impact healing and thus long-term success of the repair. METHODS: Following the Institution's Animal Care and Use Committee approval (708024-4), 20 Hartley guinea pigs underwent laparoscopic repair of their natural open internal rings. The guinea pigs were divided equally into four surgical groups: intracorporeal suture repair (IS), hernia dissection and division with intracorporeal suture (DDIS) repair, subcutaneous endoscopically assisted ligation (SEAL), and Yueng (HOOK) repair. After a 6-week survival period, a necropsy was performed. Repairs were evaluated and tested under pressures up to 30 mmHg. The suture was then removed to assess primary healing. Experimental data were analyzed using chi-square test. RESULTS: There were no perioperative or postoperative complications. On initial evaluation, before suture removal, repair integrity was as follows: 5/10 IS, 10/10 DDIS, 7/10 SEAL, and 7/10 HOOK (P = .09). After suture removal, repair integrity was as follows: 3/10 IS, 10/10 DDIS, 5/10 SEAL, and 6/10 HOOK (P = .01). CONCLUSION: Overall, dissecting and dividing the sac with intracorporeal suture (DDIS) closure had the best outcome. This method appears to best replicate standard open high ligation.

Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma: Evaluation of the National Trauma Data Bank.

BACKGROUND: Traumatic pancreatic injury is associated with significant morbidity and mortality. We evaluated the differences in outcomes among children with blunt pancreatic injuries managed operatively and nonoperatively. STUDY DESIGN: The National Trauma Data Bank was evaluated from 2002 to 2011. Patients less than18 years of age with blunt pancreatic injuries and Abbreviated Injury Scale (AIS) scores ≥ 3 were identified. Patients were divided into nonoperative (NO), operative (O), and delayed operative (DO; operation performed 48 hours or more after admission) groups. Outcomes evaluated were total length of stay (LOS), ICU use/LOS, complications, and death. Univariate comparisons were performed using Fisher's exact and Kruskal-Wallis rank tests. Multivariable analyses were performed using robust regression and logistic regression. RESULTS: There were 424 cases analyzed. Mean (± SD) age was 10.6 ± 5.3 years, and mean Injury Severity Score (ISS) was 23.4 ± 13.4. Operative groups differed by age (p = 0.002), AIS severity (p = 0.04), and concomitant head injury (p = 0.01), but were similar with regard to sex, race, and ISS. Length of stay was significantly higher in the DO group compared with the NO or O groups; the NO group had the lowest LOS (covariate-adjusted: 18.7 days vs 11.8 days, p < 0.001 and 12.6 days, p < 0.001, respectively) and infection rates (10.2% vs 1.6% and 6.2%, respectively, p = 0.04). The ICU LOS was greatest in the DO group (vs NO, p = 0.03; O, p = 0.29), as was the likelihood of ICU use (vs NO, p = 0.02; O, p = 0.75). Groups did not differ with respect to outcomes including death (p = 0.94) and overall complication rate (p = 0.63). CONCLUSIONS: Overall, children managed nonoperatively have equivalent or better outcomes when compared with operative and delayed operative management in regard to death, overall complications, LOS, ICU LOS, and ICU use.

Evaluation of the treatment of pectus carinatum with compressive orthotic bracing using three dimensional body scans.

PURPOSE: The purpose of this study is to measure the effectiveness of compressive orthotic brace therapy for the treatment of pectus carinatum using an adjusted Haller Index (HI) measurement calculated from 3D body scan (BS) images. METHODS: Pediatric patients with pectus carinatum were treated with either compressive orthotic bracing or observation. An adjusted BS Haller index (HI) was calculated from serial 3D BS images obtained on all patients. Medical records were evaluated to determine treatment with bracing and brace compliance more than 12hours daily. Compliant patient measurements were compared to non-compliant and non-brace groups. RESULTS: Forty patients underwent compressive orthotic bracing, while ten were observed. Twenty-three patients were compliant with bracing, and seventeen patients were non-compliant. Compliant patients exhibited an 8.2% increase, non-compliant patients had a 1.5% increase, and non-brace patients exhibited a 2.5% increase in BS HI. The change in BS HI of compliant patients was significantly different compared to non-brace patients (p=0.004) and non-compliant patients (p<0.001). CONCLUSIONS: Three dimensional BS is an effective, radiation free, and objective means to evaluate patients treated with compressive orthotic bracing.

Guns and states: pediatric firearm injury.

BACKGROUND: A recent report indicates that firearm-related injuries are responsible for 30% of pediatric trauma fatality. The literature is however limited in examining pediatric firearm injuries and variations in state gun control laws. Therefore, we sought to examine the association between pediatric firearm injuries and the Stand-Your-Ground (SYG) and Child Access Protection (CAP) laws. METHODS: All pediatric (age, 0-20 years) hospitalizations with firearm injuries were identified from the Kids' Inpatient Database from 2006 and 2009. States were compared for SYG and CAP laws. RESULTS: A total of 19,233 firearm injury hospitalizations were identified, with 64.7% assault, 27.2% accidental, and 3.1% suicide injury. Demographics for assault injury were as follows: mean age of 17.6 years, 88.4% male, 44.4% black, 18.2% Hispanic, 70.5% from metropolitan areas, and 50.1% from the poorest median income neighborhoods. Suicide injury cases were more likely to be white (57.8% vs. 16.6%, p < 0.001) and female (15.1% vs. 9.8%, p < 0.001). States with the SYG law were associated with increased accidental injury (odds ratio [OR], 1.282; p < 0.001). There was no statistical association between CAP law and the incidence of accidental injury or suicide. Multivariate logistic regression analysis found other predictive demographic factors for firearm injury: black (OR, 6.164), urban areas (OR, 1.557), poorest median income neighborhoods (OR, 2.785), male (OR, 28.602), and 16 years or older (OR, 37.308). Total economic burden was estimated at more than $1 billion dollars, with a median length of stay of 3 days, 8.4% discharge to rehabilitation, and 6.2% in-hospital mortality. CONCLUSION: Pediatric firearm injuries continue to be a significant source of morbidity, mortality, and economic burden. A significant increase in accidental firearm injuries in states with the SYG law may highlight inadvertent effects of the law. Race, sex, and median income are additional contributing factors. Advocacy and focused educational efforts for specific socioeconomic and racial groups may potentially reduce firearm injuries. LEVEL OF EVIDENCE: Prognostic study, level II.

Less is more: management of pediatric splenic injury.

OBJECTIVE: To analyze national trends in the nonoperative management of pediatric splenic injury. DESIGN: Retrospective cohort analysis. PATIENTS: All children and adolescents 18 years or younger from 2 national databases who were hospitalized with pediatric splenic injury. SETTING: Data from 9 years of the National Inpatient Sample database (2000-2008) and 3 years of Kids' Inpatient Database (2000, 2003, and 2006). MAIN OUTCOME MEASURES: We calculated and chronicled rates of splenectomy, angiography, and transfusion from 2000 to 2008. RESULTS: During the study period, the rate of splenectomy decreased from 18.25% to 10.86%. Changes in nonoperative management included more than a 2-fold increase in angiography, from 2.43% to 6.94%, and a significant increase in transfusion, from 7.71% to 11.49%. Operative management was associated with increased length of stay (9.15 vs 6.52 days) and higher mean total hospital charges ($74 981.26 vs $36 156.30). Cases occurring in rural locations were more likely to undergo operative management (odds ratio, 1.24 [95% CI, 1.18-1.31]; P < .001), but less likely to undergo angiography (0.82 [0.76-0.89]; P < .001). CONCLUSIONS: Children with pediatric splenic injury are undergoing fewer splenectomies but more angiography. Rural location may be an independent risk factor for operative management. Further studies are needed to assess for disparity in access to and availability of aggressive nonoperative management.

Surgical management of pediatric adhesive bowel obstruction.

INTRODUCTION: The objective of this study was to analyze a population-based database for recent trends in surgical management of pediatric adhesive bowel obstruction and compare open versus laparoscopic lysis of adhesions (LOA). SUBJECTS AND METHODS: Pediatric adhesive bowel obstruction cases were identified in the Kids' Inpatients Database from 1997, 2000, 2003, 2006, and 2009. Data analysis included patients' demographics, hospital variables, length of stay (LOS), and total hospital charges (THC). Complications analysis included postoperative shock, hemorrhage, hematoma, seroma, wound complications, infection, fistula, and pulmonary complications. RESULTS: In total, 20,679 pediatric adhesive bowel obstruction cases were identified during the study period. These were characterized by a median age of 11 years old, with 59.0% of the population female. Overall treatment included 88.6% open and 11.4% laparoscopic LOA. A more than twofold increase in utilization of laparoscopy was observed from 7.2% in 1997 to 17.2% in 2009 (P<.001). Complication rates were lower for laparoscopic LOA versus open (5.6% versus 10.4%; odds ratio 0.512; 95% confidence interval 0.394-0.667; P<.001), especially accidental puncture or laceration rate (2.2% versus 3.9%; odds ratio 0.566; 95% confidence interval 0.375-0.854; P=.006). Conversion to open LOA occurred in 1.9%. Laparoscopy was associated with a shorter median LOS (6 versus 8 days; P<.001) and a lower mean THC ($38,241.11 versus $48,552.51; P<.001) compared with open LOA. Multivariate regression analysis did not find hospital bed size, location, teaching status, and regions to be statistically significant predictors for utilization of laparoscopy. CONCLUSIONS: Laparoscopic LOA is a safe option for pediatric adhesive bowel obstruction with lower complication rates and a reduced economic burden. Despite the increase in utilization of laparoscopy in recent years, only a minority of patients underwent laparoscopic LOA. Further studies are needed to identify and characterize the subgroup of patients who benefit from laparoscopic LOA.

Missed opportunities in the treatment of pediatric appendicitis.

INTRODUCTION: This study sought to evaluate the outcomes of in-hospital delay and determine associated co-morbidities in the treatment of pediatric acute appendicitis. METHODS: This was a retrospective analysis of the national inpatient sample from 2000 to 2008. Immediate treatment was defined as treatment in hospital day 0 or 1. Delay in treatment was defined as treatment in hospital day 2 and beyond. RESULTS: During the study period, 683,016 pediatric appendicitis were identified. 17,737 (2.6%) experienced a delay in treatment. Multivariate analysis identified associated co-morbidities for delay in treatment: ALL (OR 12.84, CI 11.04-14.94), AML (OR 9.41, CI 7.58-11.68), neutropenia (OR 5.53, CI 4.60-6.65), and ovarian cyst without torsion (OR 3.17, CI 2.94-3.42). Surgical management included more than 13-fold increase in drainage procedures (5.5 vs. 0.4%), sixfold increase in cecectomy (1.2 vs. 0.2%), 14-fold increase in hemicolectomy (1.4 vs. 0.1%), 11-fold increase in small bowel laceration suture repair (1.1 vs. 0.1%), and 15-fold increase in small bowel resection (1.5 vs. 0.1%). CONCLUSIONS: In-hospital delay beyond 2 days is associated with significant negative outcomes with regard to complications, economic burden, and subsequent surgical management. Using the co-morbidity index, high-risk co-morbidities with associated delay in treatment were identified.

Is partial colectomy the operation of choice in pediatric Clostridium difficile colitis?

PURPOSE: This study examined the national trends in incidence and surgical management of pediatric Clostridium difficle colitis (CDC) hospitalizations. METHODS: This was a cross-sectional Nationwide Inpatient Sample (NIS) analysis of pediatric CDC from 2000 to 2008. Data analysis included patient demographics, procedures, length of stay (LOS), total hospital charges (THC), and in-hospital mortality. RESULTS: During the 9-year study period, the total number of CDC hospitalizations per year increased almost twofold, from 2,513 in 2000 to 4,817 in 2008. The rate per 100,000 discharges followed a similar trend, increasing from 38.08 in 2000 to 72.57 in 2008. Abdominal colectomy was performed in 0.35 %, with partial colectomy performed more often than total colectomy. Mortality, mean LOS, and mean THC were not statistically different between partial versus total colectomy. Children with ulcerative colitis were more likely to undergo total colectomy, (OR 35.700, CI 11.025-115.98, P < 0.001). Infants under the age of 1 year were less likely to undergo total colectomy (OR 0.568, 0.477-0.677, P < 0.001). CONCLUSION: Pediatric hospitalizations for CDC are on the rise. Partial colectomy is performed more often than total colectomy without statistical compromise of mortality, length of stay, and total hospital charges. Further studies are needed to determine the standard surgical management of pediatric CDC.

Primary repair of facial dog bite injuries in children.

OBJECTIVES: The management of dog bite wounds is controversial, and current data on risk of infection are variable and inconsistent. Furthermore, the use of prophylactic or empiric antibiotics for the treatment of these wounds is debatable. We investigate the rate of wound infections and other complications after primary repair of pediatric facial dog bite injuries. METHODS: We reviewed 87 consecutive patients aged 18 years or younger who had facial dog bite injuries from January 2003 to December 2008. Variables examined were age, sex, setting of repair, number of sutures used for repair, whether surgical drains were used, and antibiotic administration. End points measured were incidence of wound infection, need for scar revision, and any wound complications. RESULTS: The mean age of patients was 6.8 years, and the majority were women (53%). All facial injuries were primarily repaired at the time of presentation either in the emergency department (ED; 46%), operating room (OR; 51%), or an outpatient setting (3%). All patients received an antibiotic course, none of the patients developed wound infection, and no subsequent scar revisions were performed. Three patients repaired in the OR underwent placement of a total of 4 closed-suction drains. The mean (SD) age of patients repaired in the OR was significantly younger than those repaired in the ED (5.7 [3.9] vs 8.0 [4.5] years, respectively; P < 0.01). The number of sutures used were greater for patients repaired in the OR than in the ED (66.4 [39.6] vs 21.7 [12.5], respectively; P < 0.01). CONCLUSIONS: Intuitively, younger patients and patients with greater severity injuries are more likely to undergo repair in the OR, and this was supported by our data. Overall, we found that primary repair of pediatric facial dog bite injuries, including complex soft-tissue injuries, is safe when performed in conjunction with antibiotic administration; however, further cross-specialty studies are needed to fully characterize these end points in a larger population.

Geographic distribution of community-acquired methicillin-resistant Staphylococcus aureus soft tissue infections.

PURPOSE: The goal of this study is to look at the geographic growth patterns of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections in our local region and to determine if specific geographic areas are at increased risk. METHODS: After Institution Review Board approval (132603-3), a retrospective chart review was conducted of 614 patients who underwent incision and drainage of an abscess by a single pediatric surgical practice from January 2004 to December 2008. In addition, previously published data from 195 patients who underwent incision and drainage of an abscess from January 2000 to December 2003 were reviewed. RESULTS: The most commonly cultured organism found in the pediatric population undergoing incision and drainage was S aureus (n = 388), of which 258 (66%) were methicillin resistant. This is a 21% increase from the rate of MRSA cultures identified from 2000 to 2003. Geographic information system space-time analysis showed that a cluster of 14 MRSA cases was located within a 1.44-km radius between 2000 and 2003, and 5 separate clusters of more than 20 MRSA infection cases each were identified in 3 separate cities over the 8-year time span using geographic information system spatial analysis (P value = .001). CONCLUSION: Methicillin-resistant S aureus has now become the most prevalent organism isolated from cultures of community-acquired abscesses requiring incision and drainage in the pediatric population in our local region. Significant clustering of MRSA infections has appeared in several different cities within our geographic region.

Endoscopic treatment with Deflux for refluxing duplex systems.

PURPOSE: The aim of this study was to review the experience of a single institution with the endoscopic Deflux (Q-Med Scandinavia, Uppsala, Sweden) procedure and assess its effectiveness in the treatment of refluxing duplex systems. MATERIALS AND METHODS: A retrospective review of all patients that underwent endoscopic Deflux treatment for vesicoureteral reflux (VUR) in duplex systems between June 2003 and July 2007 was performed. Data collection included: age, gender, side of refluxing ureter, preoperative radiologic grade of VUR on a voiding cystourethrogram (VCUG), presence of VUR on a radionuclide VCUG 3 months postprocedure, volume of Deflux injected, number of Deflux injections performed per patient, and number of patients that underwent reimplantation surgery. RESULTS: Sixteen patients with duplex systems, two being bilateral, for a total of 18 duplex ureteral systems, underwent the Deflux procedure. Grades of reflux were as follows: grade II: 4 ureters; grade III: 8 ureters; grade IV: 4 ureters; and grade V: 2 ureters. Deflux injection volume ranged from 0.28 to 1.5 cc (mean, 0.84). Fourteen ureteral systems required one injection, three required two injections, and one required three injections. The overall success rate of the procedure after a maximum of three injections was 94%. One patient with preoperative unilateral grade V reflux had persistent high-grade reflux after two injections and opted to proceed with surgical reimplantation. The mean follow-up was 24 months (mean, 6-48). CONCLUSIONS: We conclude that the Deflux procedure is a safe, effective minimally invasive treatment alternative for patients with refluxing duplex systems.

Improving tactile sensation in minimally invasive pediatric surgery.

PURPOSE: The aim of this study was to investigate factors that impact tactile sensation during minimally invasive pediatric surgery. METHODS: Three different 3-mm Maryland laparoscopic instruments were tested with and without the resistance of a trocar (Ethicon 3-mm): Jarit (24-cm shaft, 113 g), Storz (30-cm shaft, 62 g), and an ultra-light prototype (24-cm shaft, 5 g). Experiments were conducted in a custom-designed laparoscopic simulator that directs instruments at fixed angles toward a central target. Surgeons were instructed to insert the instruments into the simulator and make contact with the target with as little force as possible. Instantaneous pressure measurements on the target were measured and recorded every 0.0001 seconds. The differences between impact pressures were compared with a paired, two-tailed, Student's t test. RESULTS: Twenty-seven (27) surgeons participated in the study. The ultra-light prototype had significantly lower impact pressures than the Storz instrument at all angles both with a trocar (P < 0.05) and without a trocar (P < 0.001). The ultra-light prototype had significantly lower impact pressures than the Jarit instrument at all angles in the absence of a trocar (P < 0.001), but with a trocar in place the only significant difference was at 5 degrees (P < 0.001). The presence of the trocar on the ultra-light prototype had a negative impact on tactile sensation that was statistically significant (P < 0.01). CONCLUSIONS: The presence of a trocar negatively impacted the surgeon's tactile sensation. Decreasing instrument mass by 10- to 20 fold did make a statistically significant improvement in tactile sensation.

Outcomes after a Ladd procedure for intestinal malrotation with heterotaxia.

PURPOSE: Intestinal rotation abnormalities and complex congenital heart disease associated with heterotaxia coexist. Despite the risk for midgut volvulus, performing a Ladd procedure for asymptomatic malrotation with heterotaxia remains to be controversial because the presumed risk for postoperative complications is thought to exceed the benefits of the operation. The purpose of this study was to review the incidence of complications after a Ladd procedure in asymptomatic patients with heterotaxia to guide recommendations for this patient population. METHODS: The medical records of all patients with heterotaxia who underwent a Ladd procedure for asymptomatic malrotation between 1984 and 2004 were reviewed. Type of cardiac disease, postoperative complications, and survival were recorded. RESULTS: Twenty-two patients (9 boys and 13 girls) with heterotaxia underwent an elective Ladd procedure after their medical stabilization or surgical correction or palliation of their cardiac anomaly. Of these patients, 19 were younger than 1 month at the time of the operation. The remaining 3 patients underwent the operation when they were between 2 and 5 months old. Three of the 22 patients (14%) developed postoperative intestinal obstruction: lysis of adhesions was performed in 1 patient; another patient required a staged bowel resection for a closed loop obstruction; and yet another patient had recurrent midgut volvulus 4 years after an incomplete initial Ladd procedure. All patients survived the initial and secondary procedures. Four deaths, all more than 1 month after the surgery, occurred as sequelae of the underlying cardiac anomaly. Length of follow-up ranged from 1 to 17 years. CONCLUSIONS: We report on a 14% risk of postoperative bowel obstruction after an elective Ladd procedure, as compared with a small but significant incidence of midgut volvulus in patients with malrotation in the setting of complex congenital heart disease. Our results support the conclusion that an elective Ladd procedure at a time of relative cardiac stability for selected patients with heterotaxia has an acceptably low morbidity and should be considered to prevent midgut volvulus.

The appendix sign: a radiographic marker for irreducible intussusception.

PURPOSE: Radiographic reduction (hydrostatic or pneumatic) of intussusception has become the standard of care in the pediatric population with success rates of more than 80%. Identification of those patients who are likely to fail nonoperative management could lead to earlier operation, a reduction in radiation exposure, and a decreased risk for complications after repeated attempts at enema reduction. During successful radiographic reduction, the small bowel is almost always visualized before the appendix. Visualization of the appendix before visualization of the small bowel during a successful reduction of an intussusception is a rare event. We report a new radiographic sign that we have termed the appendix sign (radiographic visualization of the appendix without reflux of air or contrast into the small intestine), which we hypothesize may have association with failure of nonoperative management. METHOD: We performed a retrospective review of the last 12 years of irreducible intussusception. The associated studies were then reviewed to examine the incidence, sensitivity, and specificity of this radiographic finding. RESULTS: Ninety-one cases of intussusception were identified and had films available for review. Seventy-seven (76%) of the studies included the appropriate image. The appendix sign was visualized in 14 studies for an incidence of 18%. Of 14 patients, 10 failed enema reduction (positive predictive value, 71%). The sensitivity of the appendix sign is 43%. The specificity of the sign is 93%. CONCLUSIONS: Our experience suggests that the presence of an appendix sign is associated with failing enema reduction of an intussusception and may be useful as a marker for determining the end point for further attempts at radiographic reduction.

Postoperative paraplegia secondary to the use of oxidized cellulose (Surgicel).

Iatrogenic paraplegia after thoracic surgery is a devastating complication. In this report, the authors present a case of paraplegia in a toddler after the resection of a mediastinal neuroblastoma. In this case, the paraplegia was caused by spinal cord compression after migration of oxidized cellulose into the spinal canal.