Same-day discharge for pediatric laparoscopic gastrostomy.

BACKGROUND: Laparoscopic gastrostomy is a common procedure in children. We developed a same-day discharge (SDD) protocol for laparoscopic button gastrostomy. METHODS: We performed a prospective observational study of children undergoing laparoscopic button gastrostomy and were eligible for SDD from August 2017-September 2019. Patients were eligible if: 1) the family was comfortable with eliminating overnight admission and were suitable candidates for outpatient surgery (absence of major co-morbidities), 2) they were not undergoing additional procedures requiring admission, and 3) they received pre-operative education. RESULTS: Sixty-two patients who underwent laparoscopic button gastrostomy were eligible for SDD. The median age was 2.1 years [IQR 0.9-4.1], and the median weight was 10.5 kg [IQR 7.6-15.5]. Forty-one (66%) were previously nasogastric fed. The median operative time was 22 min [IQR 16-29]. The median time to initiation of feeds was 4.4 h [IQR 3.4-5.5]. Fifty-one (82%) were discharged the same day with a median length of stay of 9 h [IQR 7-10]. Eleven were admitted, most commonly for further teaching. Eleven SDD patients were seen in the emergency room <30 days at a median 5 days [IQR 3-12] post-operatively, primarily for mechanical complications. CONCLUSION: Same-day discharge following laparoscopic gastrostomy is safe and feasible for select pediatric patients who undergo pre-operative education. The SDD pathway results in a low admission rate and relatively low ER visits. TYPE OF STUDY: Prospective Observational Study. LEVEL OF EVIDENCE: Level II.

Complications of Cryptosporidium infection after pediatric liver transplantation: Diarrhea, rejection, and biliary disease.

BACKGROUND: Cryptosporidium enteritis can be devastating in the immunocompromised host. In pediatric liver transplant recipients, infection may be complicated by prolonged carriage of the parasite, rejection, and biliary tree damage and fibrosis. Herein, we report on six patients and their long-term outcomes following cryptosporidiosis. METHODS: We reviewed all cases of cryptosporidiosis in a pediatric liver transplant population over a 17-year period at a single center. Six patients with infection were identified, and their outcomes were analyzed. RESULTS: Infection was associated with significant diarrhea and dehydration in all cases, and led to hospitalization in one-half of patients. Four of the six patients developed biopsy-proven rejection following infection, with three of those patients developing rejection that was recalcitrant to intravenous steroid treatment. Additionally, three patients developed biliary tree abnormalities with similarity to sclerosing cholangitis. In one patient, those biliary changes led to repeated need for biliary drain placement and advancing fibrotic liver allograft changes. CONCLUSIONS: Cryptosporidiosis in pediatric liver transplant recipients may lead to significant complications, including recalcitrant episodes of rejection and detrimental biliary tree changes. We advocate for increased awareness of this cause of diarrheal disease and the allograft injuries that may accompany infection.

Conservative Management of Pneumatosis Intestinalis and Portal Venous Gas After Pediatric Liver Transplantation.

BACKGROUND: Pneumatosis intestinalis (PI) is a rare pathologic finding in pediatric liver transplant (PLT) recipients. The presentation and course of PI can range from asymptomatic and clinically benign to life threatening, with no consensus regarding management of PI in children. We aim to review the clinical presentation and radiologic features of PLT recipients with PI and to report the results of conservative management. METHODS: A retrospective medical chart review was conducted on PLT recipients between November 1995 and May 2016. Parameters evaluated at PI diagnosis included pneumatosis location, presence of free air or portal venous gas (PVG), symptoms, laboratory findings, and medication regimen. RESULTS: PI developed in 10 of 130 PLT patients (7.7%) between 8 days and 7 years (median: 113 days) posttransplant. Five of the patients were male, and the median age was 2 years (range, 1-17 years). PI was located in 1 to 2 abdominal quadrants in 6 patients, and 3 patients had PVG. At diagnosis, all patients were on steroids and immunosuppressant medication and 6 patients had a concurrent infection. Laboratory findings were unremarkable. Symptoms were present in 7 patients. Nine patients were managed conservatively, and 1 patient received observation only. All patients had resolution of PI at a median of 7 days (range, 2-14 days). CONCLUSIONS: PI can occur at any time after PLT and appears to be associated with steroid use and infectious agents. If PI/PVG is identified and the patient is clinically stable, initiation of a standard management algorithm may help treat these patients conservatively, thus avoiding surgical intervention.

Health-Related Quality of Life and Cognitive Functioning in Pediatric Liver Transplant Recipients.

The goal of this work was to examine the change in health-related quality of life (HRQOL) and cognitive functioning from early childhood to adolescence in pediatric liver transplantation (LT) recipients. Patients were recruited from 8 North American centers through the Studies of Pediatric Liver Transplantation consortium. A total of 79 participants, ages 11-18 years, previously tested at age 5-6 years in the Functional Outcomes Group study were identified as surviving most recent LT by 2 years and in stable medical follow-up. The Pediatric Quality of Life 4.0 Generic Core Scale, Pediatric Quality of Life Cognitive Function Scale, and PROMIS Pediatric Cognitive Function tool were distributed to families electronically. Data were analyzed using repeated measures and paired t tests. Predictive variables were analyzed using univariate regression analysis. Of the 69 families contacted, 65 (94.2%) parents and 61 (88.4%) children completed surveys. Median age of participants was 16.1 years (range, 12.9-18.0 years), 55.4% were female, 33.8% were nonwhite, and 84.0% of primary caregivers had received at least some college education. Median age at LT was 1.1 years (range, 0.1-4.8 years). The majority of participants (86.2%) were not hospitalized in the last year. According to parents, adolescents had worse HRQOL and cognitive functioning compared with healthy children in all domains. Adolescents reported HRQOL similar to healthy children in all domains except psychosocial, school, and cognitive functioning (P = 0.02; P < 0.001; P = 0.04). Participants showed no improvement in HRQOL or cognitive functioning over time. For cognitive and school functioning, 60.0% and 50.8% of parents reported "poor" functioning, respectively (>1 standard deviation below the healthy mean). Deficits in HRQOL seem to persist in adolescence. Over half of adolescent LT recipients appear to be at risk for poor school and cognitive functioning, likely reflecting attention and executive function deficits.

Safety of Laparoscopic Gastrostomy in Children Receiving Peritoneal Dialysis.

BACKGROUND: The preferred method of dialysis for children is chronic peritoneal dialysis (CPD), and these children may require delayed gastrostomy tube (GT) placement. Investigators have reported a high risk of fungal peritonitis, early bacterial peritonitis, and catheter loss when percutaneous endoscopic gastrostomy is performed in children already undergoing CPD. Current International Society for Peritoneal Dialysis guidelines recommend only open GT for these patients. We sought to report the safety of laparoscopic gastrostomy (LG) among children already receiving PD. MATERIALS AND METHODS: We conducted a retrospective chart review of children who had initiated CPD before GT placement between 2010 and 2017 at our pediatric hospital. Demographic data, clinical details, and peritonitis rates were recorded. Peritonitis was defined as peritoneal WBC count >100/mm3 and >50% neutrophils, with or without a positive peritoneal culture. RESULTS: Twenty-three subjects had both undergone CPD and had a GT placed in the study period. Of these, 13 had a GT placed after CPD had been initiated. One of these was excluded for open technique and another excluded because of no overlap of GT and PD catheter, leaving 11 for analysis. Median age at the time of LG was 1.32 y and median weight-for-age z-score was -1.86 (IQR -2.9, -1.3). Median days to PD catheter and GT use after LG were 2 (range 0-4) and 1 (range 0-2). Median weight z-score change at 90 d was +0.5 (IQR -0.1, +0.9). All patients received antifungal and antibiotic coverage at time of GT placement. No subjects developed fungal peritonitis or early bacterial peritonitis, although one developed bacterial peritonitis within 30 d. The overall rate of peritonitis after laparoscopic gastrostomy tube was 0.35 episodes/patient-year. This was similar to a rate of 0.45 episodes/patient-year during PD but before laparoscopic gastrostomy tube in the same patients (P = 0.679). Four subjects required periods of hemodialysis, two of which were because of PD catheter removal due to infection. One of the latter was due to a relapse of pre-LG peritonitis and the patient later resumed PD. The other was due to remote post-LG peritonitis and the patient continued hemodialysis until renal transplant, both after 6 mo. CONCLUSIONS: We found that, in children already receiving PD, LG is similar in safety profile, efficacy, and technical principle to open gastrostomy. LG is therefore an appropriate and safe alternative to open gastrostomy in this setting.

20- to 25-year patient and graft survival following a single pediatric liver transplant-Analysis of the United Network of Organ Sharing database: Where to go from here.

To understand factors contributing to liver graft loss and patient death, we queried a national database designed to follow pediatric patients transplanted between 1987 and 1995 till adulthood. A comparison was made to a cohort transplanted between 2000 and 2014. The 5-, 10-, 15-, 20-, and 25-year patient survival and graft survival were 95.5%, 93.7%, 89.1%, 80.8%, and 73.1%, and 92.5%, 86.7%, 77.6%, 68.7%, and 62.2%, respectively. The twenty-year patient/graft survival was significantly worse in those transplanted between 5 and 17 years of age compared to those transplanted at <5 years of age (P < 0.001). For the modern era cohort, the 3-year patient survival was significantly lower in children transplanted at 16-17 years of age compared to those transplanted at <5 and 11-15 years of age (P ≤ 0.02). The 3-year graft survival was similarly lower in children transplanted at 16-17 years of age compared to those transplanted at <5, 5-10, and 11-15 years of age (P ≤ 0.001). Infection as a cause of death occurred either early or >15 years post-transplant. Chronic rejection remained the leading cause of graft loss in both cohorts and the commonest indication for retransplantation 20-25 years following primary transplant. Further research is required to identify modifiable factors contributing to development of chronic rejection.

Indications and efficacy of conversion from tacrolimus- to sirolimus-based immunosuppression in pediatric patients who underwent liver transplantation for unresectable hepatoblastoma.

SRL-based immunosuppressive strategies in pediatric liver transplantation are not clearly defined, especially within the first year after liver transplant. TAC is the more common, traditional immunosuppressant used. However, SRL may modulate TAC-associated kidney injury and may also have antiproliferative properties that are valuable in the management of patients following liver transplantation for HB. We sought to determine whether early conversion from TAC to SRL was safe, effective, and beneficial in a subset of liver transplant recipients with unresectable HB exposed to CDDP-based chemotherapy. Between 2008 and 2013, six patients were transplanted for unresectable HB. All patients received at least one cycle of CDDP-based chemotherapy prior to transplant. All patients were switched from TAC- to SRL-based immunosuppression within 1 year of transplant. Five patients had improvement in their mGFR, while one patient had a slight decline. The improvement in mGFR was statistically significant. No adverse events were identified. Three patients had BPAR that responded to pulsed steroids. Historical controls showed similar rates of BPAR within the first year after transplant. There were no identified HB recurrences in the follow-up time period. Conversion from TAC to SRL appears to be safe and effective in this selected group of pediatric liver transplant recipients without adverse reaction or HB recurrences.

The impact of thromboelastography on resuscitation in pediatric liver transplantation.

Although TEG directs effective resuscitation in adult surgical patients, pediatric data are lacking. We performed a retrospective comparative review of the effect of TEG on blood product utilization and outcomes following pediatric liver transplantation in 38 patients between 2008 and 2014. Diagnoses, laboratory values, fluid and blood product use, and outcomes were examined. Nineteen patients underwent liver transplantation prior to the implementation of TEG, and 19 had perioperative TEG. The most common indications for transplant were BA (n = 14), HB (n = 7), and metabolic disorders (n = 7). Intraoperative blood loss, urine output, fluid and blood product use were similar between groups. However, the use of fresh frozen plasma decreased significantly in TEG patients within the first 24 hours (29 vs 0 mL/kg, P < .01), and between 24 and 48 hours (12 vs 0 mL/kg, P = .01) post-operatively. The total use of fresh frozen plasma during hospitalization was markedly reduced (111 vs 17 mL/kg, P < .01). Four patients in the TEG group had thromboembolic graft complications, including portal vein or hepatic artery thrombosis, and underwent retransplantation. The decreased use of fresh frozen plasma since implementation of TEG is an important finding for resource utilization and patient safety. However, the increased incidence of thromboembolic complications requires further investigation.

Right trisegmentectomy after portal vein embolization in a high-risk toddler with hepatoblastoma.

Portal vein embolization (PVE) is a pre-operative treatment modality in adults undergoing hepatectomy with concerns of post-operative liver failure from insufficient future liver remnant (FLR). PVE induces growth in the FLR. The success of this technique is well described in adults, but not in young children with hepatoblastoma.

Organ allocation and utilization in pediatric transplantation.

Pediatric transplant candidates include heart, lung, liver, pancreas, small intestine, and kidney. The purpose of this article is to review the history and current methods for determining priority of the above-mentioned transplantable organs. The methods used by the authors involved the review of historical and current manuscripts and UNOS policy documents. We summarized the findings in order to create a concise review of the current policies and wait times for transplantation in pediatric transplant patients.

Transition of Techniques to Treat Choledochal Cysts in Children.

INTRODUCTION: Traditionally open resection with hepaticojejunostomy (HJ) reconstruction has been the surgical treatment for cases of choledochal cyst. Our center has recently transitioned from open to laparoscopic and HJ to hepaticoduodenostomy (HD) as our preferred method of excision and biliary reconstruction. Our initial experience is presented here. MATERIALS AND METHODS: A single-center retrospective chart review was performed from 2005 to 2014. All patients undergoing surgical treatment for choledochal disease were considered. RESULTS: During the study period 18 patients had surgical treatment for choledochal cyst disease. The average age of all patients was 4.7 years (range, 2 months-15.5 years). Eleven of these patients had laparoscopic excision and reconstruction. Of these 11 patients, 7 had an HD anastomosis. Comparing the laparoscopic with the open group and the HD with the HJ group, there was no significant difference in operative time, estimated blood loss, time to regular diet, length of stay, or complication rate. Mean follow-up of 3.1 years revealed no documented cases of bile reflux or cholangitis. A recent adaptation in technique may improve ease of HD anastomosis. In this method, two strands of temporary monofilament suture cut to 8-10 cm each are tied extracorporeally. This knot is then placed on the outside of the medial corner. The anastomosis is then completed in a running fashion with the two strands and then secured intracorporeally at the lateral corner. CONCLUSIONS: Laparoscopic choledochal cyst resection with both HJ and HD reconstruction appears safe and has equivalent outcomes to open procedures in our series.

Single incision versus standard 4-port laparoscopic cholecystectomy: a prospective randomized trial.

BACKGROUND: Laparoscopy through a single umbilical incision is an emerging technique supported by case series, but prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing single site umbilical laparoscopic cholecystectomy to 4-port laparoscopic cholecystectomy. METHODS: After IRB approval, patients were randomized to laparoscopic cholecystectomy via a single umbilical incision or standard 4-port access. The primary outcome variable was operative time. Utilizing a power of 0.8 and an alpha of 0.05, 30 patients were calculated for each arm. Patients with complicated disease or weight over 100 kg were excluded. Post-operative management was controlled. Surgeons subjectively scored degree of technical difficulty from 1=easy to 5=difficult. RESULTS: From 8/2009 through 7/2011, 60 patients were enrolled. There were no differences in patient characteristics. Operative time and degree of difficulty were greater with the single site approach. There were more doses of analgesics used and greater hospital charges in the single site group that trended toward significance. CONCLUSION: Single site laparoscopic cholecystectomy produces longer operative times with a greater degree of difficulty as assessed by the surgeon. There was a trend toward more doses of post-operative analgesics and greater hospital charges with the single site approach.

Irrigation versus suction alone during laparoscopic appendectomy for perforated appendicitis: a prospective randomized trial.

BACKGROUND: The efficacy of irrigating the peritoneal cavity during appendectomy for perforated appendicitis has been debated extensively. To date, prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing peritoneal irrigation to suction alone during laparoscopic appendectomy in children. METHODS: Children younger than 18 years with perforated appendicitis were randomized to peritoneal irrigation with a minimum of 500 mL normal saline, or suction only during laparoscopic appendectomy. Perforation was defined as a hole in the appendix or fecalith in the abdomen. The primary outcome variable was postoperative abscess. Using a power of 0.8 and alpha of 0.05, a sample size of 220 patients was calculated. A battery-powered laparoscopic suction/irrigator was used in all cases. Pre- and postoperative management was controlled. Data were analyzed on an intention-to-treat basis. RESULTS: A total of 220 patients were enrolled between December 2008 and July 2011. There were no differences in patient characteristics at presentation. There was no difference in abscess rate, which was 19.1% with suction only and 18.3% with irrigation (P = 1.0). Duration of hospitalization was 5.5 ± 3.0 with suction only and 5.4 ± 2.7 days with group (P = 0.93). Mean hospital charges was $48.1K in both groups (P = 0.97). Mean operative time was 38.7 ± 14.9 minutes with suction only and 42.8 ± 16.7 minutes with irrigation (P = 0.056). Irrigation was felt to be necessary in one case (0.9%) randomized to suction only. In the patients who developed an abscess, there was no difference in duration of hospitalization, days of intravenous antibiotics, duration of home health care, or abscess-related charges. CONCLUSIONS: There is no advantage to irrigation of the peritoneal cavity over suction alone during laparoscopic appendectomy for perforated appendicitis. The study was registered with clinicaltrials.gov at the inception of enrollment (NCT00981136).

Single incision versus standard 3-port laparoscopic appendectomy: a prospective randomized trial.

BACKGROUND: Laparoscopic appendectomy through a single umbilical incision is an emerging approach supported by several case series. However, to date, prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing single site umbilical laparoscopic appendectomy to 3-port laparoscopic appendectomy. METHODS: After Internal Review Board approval, patients were randomized to laparoscopic appendectomy via a single umbilical incision or standard 3-port access. The primary outcome variable was postoperative wound infection. Using a power of 0.9 and an alpha of 0.05, 180 patients were calculated for each arm. Patients with perforated appendicitis were excluded. The technique of ligation/division of the appendix and mesoappendix was left to the surgeon's discretion. There were 7 participating surgeons dictated by the call schedule. All patients received the same preoperative antibiotics and postoperative management was controlled. RESULTS: There were 360 patients were enrolled between August 2009 and November 2010. There were no differences in patient characteristics at presentation. There was no difference in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity. Operative time, doses of narcotics, surgical difficultly and hospital charges were greater with the single site approach. Also, the mean operative time was 5 minutes longer for the single site group. CONCLUSION: The single site umbilical laparoscopic approach to appendectomy produces longer operative times resulting in greater charges. However, these small differences are likely of marginal clinical relevance. The study was registered with clinicaltrials.gov at the inception of enrollment (NCT00981136).

Single-incision laparoscopic surgery in children: initial single-center experience.

BACKGROUND: In continued efforts to further improve the advantages of minimally invasive surgery to patients, surgeons have developed single-incision laparoscopic techniques. We report our initial experience in children with a variety of single-site procedures. METHOD: A retrospective chart review was performed on patients who underwent a single-site procedure from April 2009 to April 2010. RESULTS: There were 142 consecutive procedures: 24 cholecystectomies, 103 appendectomies for nonperforated appendicitis, 2 splenectomies, 1 combined splenectomy/cholecystectomy, 8 ileocecectomies, 2 Meckel diverticulectomies, 1 small bowel duplication resection, and 1 jejunal stricture resection. There were 12 conversions to conventional laparoscopy: 10 during appendectomy and 2 during cholecystectomy. Mean operative time was 34 minutes for appendectomy, 73 minutes for cholecystectomy, 90 minutes for splenectomy, 116 minutes for combined splenectomy/cholecystectomy, 86 minutes for ileocecectomy, and 43 minutes for the small bowel procedures. The only complications were umbilical surgical site infections after appendectomy in 6 patients. CONCLUSION: This institution's preliminary experience suggests that single-incision laparoscopic surgery in children has at least comparable outcomes to conventional laparoscopic surgery. However, prospective data are needed to prove that single-incision laparoscopic surgery is superior to conventional laparoscopy.

Analysis of the pediatric surgery match: factors predicting outcome.

INTRODUCTION: Applicants in the NRMP for pediatric surgery have little objective data available regarding factors predicting successful matching. We analyzed data from applicants at our institution to attempt to identify parameters correlated with three outcomes: successfully matching, or attaining either a top ten or top three ranking in our final submitted match list. METHODS: After IRB approval, we reviewed ERAS documents for all applicants (n = 146) over 3 years (candidates for the 2007, 2008, and 2009 fellowship years). An interview was offered to 75% of the applicants (Table 1). We analyzed over 20 factors; including demographics, number of publications and first author publications, number of book chapters, national presentations, prior match attempts, advanced degrees, quality of recommendation letters, and ABSITE scores. Significant variables were evaluated with multiple logistic regression analysis to identify independent predictors. RESULTS: Variables correlated with successful outcome for each of the three endpoints are shown in Table 2. The number of peer-reviewed publications and first author publications, and AOA membership were highly correlated with a favorable outcome for all three endpoints. High ABSITE scores were significantly correlated with top ten rank. Research experience and outstanding letters of recommendation were significantly associated with a top ten ranking and overall match success. Variables associated only with overall match success included number of book chapters, graduation from a US medical school, quality of recommendation letters, and being granted an interview at our institution. Logistic regression analysis demonstrated no independent factors for overall match success; number of publications was significant for both top ten and top three ranking (P = 0.006 for each); number of first author publications (P = 0.002) and AOA membership (P = 0.03) were independent predictors for top three ranking. CONCLUSIONS: Applicant variables associated with success in the match included quality of letters, number and type of publications, research experience, graduation from a US medical school, and AOA membership. Factors not correlated with outcome included advanced degrees (PhD, Masters), other fellowship training, and community-based versus university-based residency training. Logistic regression analysis demonstrated no independent factors for overall match success.

Neutropenic colitis in children.

BACKGROUND: Neutropenic colitis (NC) or typhlitis has an incidence of approximately 5% in patients receiving chemotherapy for malignancy. The precise cause is unknown, but almost all patients are neutropenic; most profoundly so. We reviewed our experience with neutropenic colitis over the past 10 y to assess the incidence, management, and outcome. MATERIALS AND METHODS: Hospital records were reviewed after obtaining IRB approval (# 10-10-184E). There were 1224 children treated for cancer at our institution over the study interval. Neutropenic colitis was strictly defined as the presence of both clinical and radiographic findings consistent with the diagnosis, since there are no definitive diagnostic criteria. Patients with confirmed appendicitis were excluded. Medical management consisted of bowel rest and/or decompression, broad-spectrum IV antibiotics and anti-fungal coverage, and serial clinical exams and radiographic studies. Clinical deterioration and free air were the primary indications for surgery. Demographic factors, signs, symptoms, clinical presentation, underlying disease process, white blood cell count (WBC), and absolute neutrophil count (ANC) prior to the onset of the disease, treatment, and outcome were analyzed. RESULTS: Neutropenic colitis was confirmed in 17 children (1.4% incidence). Three patients had more than one episode. Leukemia was the most common underlying diagnosis (53%). There was no gender predominance, and the mean age at diagnosis was 8.4 y. Mean WBC and ANC at onset were 670 and 164, respectively. A sharp decline in the ANC usually immediately preceded the onset of NC; 2/17 (12%) underwent operation, but both patients had only pneumatosis at exploration. Overall survival was 9/17 (53%), but no deaths were directly attributable to the colitis. CONCLUSION: Neutropenic colitis is an uncommon occurrence in children with neoplasia (1.4% in the current study). Leukemia is the most common cause. A precipitous decline in ANC usually occurs prior to the onset of NC. Most patients do not require operation and the overall mortality directly attributable to NC is low.

Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children.

PURPOSE: The aim of this study was to validate the safety, and quantify the impact of, an abbreviated protocol for blunt spleen/liver injury (BSLI), we instituted a prospective study with early ambulation. METHODS: Following institutional review board approval, data were collected prospectively in all patients with BSLI up to 8 weeks after discharge. There were no exclusion criteria, and patient accrual was consecutive. Bedrest was restricted to 1 night for grade I and II injuries and 2 nights for grade III or higher. RESULTS: A total of 131 patients with BSLI were enrolled. Injuries included isolated spleen in 72 (55%), liver only in 55 (42%), and both in 4 (3%). One splenectomy was required for a grade 5 injury. Transfusions were used in 24 patients, with 18 patients undergoing transfusion because of injured solid organ. Bedrest was applicable to 110 patients (84%), for which the mean grade of injury was 2.6 and mean bedrest was 1.6 days. The need for bedrest was the limiting factor for length of stay in 86 patients (66%). There were 2 deaths, and no patients were readmitted. CONCLUSIONS: An abbreviated protocol of 1 night of bedrest for grade I and II injuries and 2 nights for grade III or higher can be safely used, resulting in dramatic decreases in hospitalization compared with the current American Pediatric Surgical Association recommendations.

A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial.

INTRODUCTION: In a previous prospective randomized trial, we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient, cost-effective treatment for children with perforated appendicitis. In this study, we evaluated the safety of discharging patients to complete an oral course of antibiotics. METHODS: Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study. Perforation was defined as a hole in the appendix or fecalith in the abdomen. Patients were randomized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days (intravenous [IV] arm) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet (IV/PO arm) to complete 7 days. RESULTS: One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in age, weight, sex distribution, days of symptoms, maximum temperature, or leukocyte count between the 2 groups. There was no difference in the postoperative abscess rate between the two treatment groups. Discharge was possible before day 5 in 42% of the patients in the IV/PO arm. CONCLUSIONS: When patients are able to tolerate a regular diet, completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation.

Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial.

INTRODUCTION: Perforated appendicitis is a common condition in children, which, in a small number of patients, may be complicated by a well-formed abscess. Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy. Although this strategy has become well accepted, there are no published data comparing initial nonoperative management (drainage/interval appendectomy) to appendectomy upon presentation with an abscess. Therefore, we conducted a randomized trial comparing these 2 management strategies. METHODS: After internal review board approval (#06 11-164), children who presented with a well-defined abdominal abscess by computed tomographic imaging were randomized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess (when possible), followed by interval laparoscopic appendectomy approximately 10 weeks later. This was a pilot study with a sample size of 40, which was based on our recent volume of patients presenting with appendicitis and abscess. RESULTS: On presentation, there were no differences between the 2 groups regarding age, weight, body mass index, sex distribution, temperature, leukocyte count, number of abscesses, or greatest 2-dimensional area of abscess in the axial view. Regarding outcomes, there were no differences in length of total hospitalization, recurrent abscess rates, or overall charges. There was a trend toward a longer operating time in patients undergoing initial appendectomy (61 minutes versus 42 minutes mean, P = .06). CONCLUSIONS: Although initial laparoscopic appendectomy trends toward a requiring longer operative time, there seems to be no advantages between these strategies in terms of total hospitalization, recurrent abscess rate, or total charges.