Maturation of effect size during enrollment of prospective randomized trials.

BACKGROUND: Randomized clinical trials are powered by calculating the minimum sample size required to achieve statistical significance, given an estimated effect size (ES). The ES is the raw difference between two treatment arms. ES quantifies the actual magnitude of clinical differences between cohorts and is usually reflective of the true meaning of the trial, regardless of statistical significance. Under a fixed protocol, we hypothesize that the ES may be attained at a smaller sample than predesigned. To investigate patterns of ES during enrollment, we analyzed completed trials that were completed at our institution. METHODS: Outcomes of 11 prospective randomized clinical trials from our institution were reviewed. ES was calculated at intervals throughout each trial to determine at which point a steady clinical difference was achieved between treatment cohorts. RESULTS: ES stabilized at a median of 64% enrollment. All patients were needed to meet the precise ES in our smallest study, indicating the need for full enrollment in smaller studies. Otherwise, 50% of our trials required between 48% and 76% of patient enrollment to meet ES. In comparing clinical outcomes, 9 of 12 found a final difference that was nearly identical to the difference that could have been determined much earlier. Categorical outcomes met stabilized ES at 51% enrollment and continuous outcomes at 68%. CONCLUSIONS: ES and final clinical outcomes were achieved before the completion of enrollment for most of our studies. This suggests that clinical differences detected by randomization may not necessarily require the robust sample size often needed to establish statistical significance. This is particularly relevant in fixed-protocol interventional trials of homogenous populations.

Endoloop versus endostapler: what is the best option for appendiceal stump closure in children with complicated appendicitis? Results of a multicentric international survey.

BACKGROUND: There is a limited and conflicting evidence about the most appropriate method for appendiceal stump closure during laparoscopic appendectomy (LA). We aimed to compare endoloop (EL) versus endostapler (ES) for stump closure during LA for complicated perforated appendicitis in children. METHODS: We retrospectively reviewed the records of 708 patients (463 boys and 245 girls with an average age of 9.8 years) who underwent LA for complicated appendicitis in 5 international centers of Pediatric Surgery over a 5-years period (January 2011-December 2016). The appendix was perforated with localized peritonitis in 470 cases and diffuse peritonitis in 238 patients. EL was used in 374 cases (G1), whereas ES was adopted in 334 cases (G2). RESULTS: No intra-operative complication occurred in both groups but 5 conversions to open surgery were reported in G1 (1.3%) and 4 in G2 (1.1%) (OR 1.1; 95% CI 0.30-4.19). Use of EL was significantly associated with higher incidence of intra-abdominal abscess (OR 1.36; 95% CI 0.84-2.18), postoperative ileus (OR 3.61; 95% CI 0.76-17.11), and re-operations/readmissions (OR 6.46; 95% CI 1.46-28.62) compared to ES. The average cost of supplies for LA was significantly higher in G2 (€ 915.60) compared to G1 (€ 578.36) (p = 0.0001). The average cost of re-operations/readmissions was significantly higher in G1 (€ 4.091,39) compared to G2 (€ 2.127,88) (p = 0.0001) (OR 1.72; 95% CI 1.47-2.01). CONCLUSIONS: Our study is the first in the pediatric population to demonstrate that the method used for appendiceal stump closure may influence the outcome of LA in complicated appendicitis. Although ES is more expensive compared to EL, our results demonstrated that appendix stump closure should be performed using ES rather than EL in complicated perforated appendicitis since its use was associated with a lower incidence of postoperative intra-abdominal abscess and postoperative ileus and lower re-operations and readmissions rates and costs.

Technical standardization of laparoscopic repair of Morgagni diaphragmatic hernia in children: results of a multicentric survey on 43 patients.

BACKGROUND: This study aimed to standardize the surgical correction technique of congenital Morgagni diaphragmatic hernia (CMDH), analyzing the results of an international multicentric survey. METHODS: The medical records of 43 patients (29 boys, 14 girls) who underwent laparoscopic repair of CMDH in 8 pediatric surgery units in a 5-year period were retrospectively reviewed. Their average age was 3.3 years. Ten patients (23.2%) presented associated malformations: 9 Down syndrome (20.9%) and 1 palate cleft (2.3%). Thirty-five patients (81.4%) were asymptomatic, whereas 8 patients (18.6%) presented symptoms such as respiratory distress, cough or abdominal pain. As for preoperative work-up, all patients received a chest X-ray (100%), 15/43 (34.8%) a CT scan, 8/43 (18.6%) a barium enema and 4/43 (9.3%) a US. RESULTS: No conversion to open surgery was reported. Average operative time was 61.2 min (range 45-110 min). In 38/43 (88.3%) patients, a trans-parietal stitch was positioned in order to reduce the tension during the repair. In 14/43 cases (32.5%), the sac was resected; in only 1/43 case (2.3%) a dual mesh of goretex was adopted to reinforce the closure. Average hospital stay was 2.8 days. The average follow-up was 4.2 years, and it consisted in annual clinical controls and chest X-ray. We recorded 2 complications (4.6%): one small pleural opening that required no drain and one recurrence (2.3%), re-operated in laparoscopy, with no further recurrence. CONCLUSIONS: To the best of our knowledge, this is the largest series published in the literature on this topic. Laparoscopic CMDH repair is well standardized: The full-thickness anterior abdominal wall repair using non-resorbable suture with interrupted stitches is the technique of choice. Postoperative outcome was excellent. Recurrence rate was very low, about 2% in our series. We believe that children with CMDH should be always treated in laparoscopy following the technical details reported in this paper.

Thoracoscopic surgery for esophageal atresia.

This review centers on the thoracoscopic management of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF). The first thoracoscopic repair of EA was performed by Rothenberg and Lobe in Berlin in 1999 just prior to an IPEG meeting. Since that time, the largest report describing the use of thoracoscopy for EA/TEF repair came in 2005 with a multi-national, multi-institutional retrospective review from six institutions around the world. The outcomes reported were quite good and very comparable to large series of open operations that had been previously reported. This review will describe a single surgeon's technique for thoracoscopic repair of EA/TEF. In addition, further controversies regarding the usefulness of preoperative bronchoscopy, ligation of the distal TEF, and type of suture used for the esophageal anastomosis will also be discussed. Finally, there is a discussion on the advantages and disadvantages of the thoracoscopic approach.

Computed Tomography Utilization for the Diagnosis of Acute Appendicitis in Children Decreases With a Diagnostic Algorithm.

OBJECTIVE: The primary objective of this project was to decrease computed tomography (CT) utilization for the diagnosis of appendicitis in an academic children's hospital emergency department (ED) through a multidisciplinary quality improvement initiative. BACKGROUND: Appendicitis is the most common abdominal diagnosis leading to the hospitalization of children in the United States. However, the diagnosis of appendicitis in children can be difficult and many centers rely heavily upon CT scans. Recent recommendations emphasize decreasing CT use among pediatric patients because of an increased lifetime risk of radiation-induced malignancies. METHODS: A retrospective review was conducted of patients diagnosed with appendicitis in the ED at Children's Mercy Hospital from January 1, 2011 to February 28, 2014 to establish a baseline cohort. From August 1, 2014 to July 31, 2015, a newly designed diagnostic algorithm was used in the ED and patients were prospectively followed. Any patient discharged from the ED received a follow-up phone call. Patients treated for appendicitis before and after pathway implementation were compared. In addition, any patient evaluated for appendicitis after implementation of the algorithm was analyzed for adherence to the clinical pathway. Differences between the 2 groups were analyzed using ANOVA, Wilcoxon Rank Sum, χ, and Fisher Exact tests. RESULTS: Of 840 patients seen after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. After implementation of the algorithm, CT utilization decreased from 75.4% to 24.2% (P < 0.0001) in patients with appendicitis. CT utilization was 27.3% after implementation, regardless of the ultimate diagnosis or algorithm adherence. The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%. CONCLUSIONS: Implementation of a diagnostic algorithm for appendicitis in children significantly decreases CT utilization, whereas maintaining a high sensitivity and specificity.

The impact of developing a pectus center for chest wall deformities.

PURPOSE: In 2011, we established a dedicated center for patients with chest wall deformities. Here, we evaluate the center's effect on patient volume and management. METHODS: A retrospective review of 699 patients with chest wall anomalies was performed. Patients were compared, based on the date of initial consultation, before the pectus center opened (July 2009-June 2011, Group 1) versus after (July 2011-June 2013, Group 2). Analysis was performed utilizing Chi-square and Mann-Whitney U tests. RESULTS: 320 patients were in Group 1 and 379 in Group 2, an 18.4 % increase in patient volume. Excavatum patients increased from 172 (Group 1) to 189 (Group 2). Carinatum patients increased from 125 (Group 1) to 165 (Group 2). Patients undergoing operative repair of carinatum/mixed defects dropped significantly from 15 % (Group 1) to 1 % (Group 2) (p < 0.01), whereas those undergoing nonoperative bracing for carinatum/mixed defects rose significantly from 19 % (Group 1) to 63 % (Group 2) (p < 0.01). Patients traveled 3-1249 miles for a single visit. CONCLUSION: Initiating a dedicated pectus center increased patient volume and provided an effective transition to nonoperative bracing for carinatum patients. The concentrated focus of medical staff dedicated to chest wall deformities has allowed us to treat patients on a local and regional level.

Fever after redo Nissen fundoplication with hiatal hernia repair.

BACKGROUND: Fevers often arise after redo fundoplication with hiatal hernia repair. We reviewed our experience to evaluate the yield of a fever work-up in this population. METHODS: We performed a retrospective review of children undergoing redo Nissen fundoplication with hiatal hernia repair between December 2001 and September 2012. Temperatures and fever evaluations of those children receiving a mesh repair were compared with those without mesh. A fever defined as temperature ≥38.4°C. RESULTS: Fifty one children received 46 laparoscopic, 4 open, and 1 laparoscopic converted to open procedures. Biosynthetic mesh was used in 25 children whereas 26 underwent repair without mesh. A fever occurred in 56% of those repaired with mesh compared with 23.1% without mesh (P = 0.02). A fever evaluation was conducted in 32% of those with mesh compared with 11.5% without mesh (P = 0.52). A urinary tract infection was identified in one child after mesh use and an infection was identified in two children without mesh, one pneumonia and one wound infection (P = 1). In those repaired with mesh, there was no significant difference in maximum temperature. CONCLUSIONS: Fever is common after redo Nissen fundoplication with hiatal hernia repair and occurs more frequently, and with higher temperatures in those with mesh. Fever work-up in these patients is unlikely to yield an infectious source and is attributed to the extensive dissection during the redo procedure.

Radiation exposure from head computed tomography scans in pediatric trauma.

BACKGROUND: We have previously reported that children receive significantly less radiation exposure after abdominal and/or pelvis computed tomography (CT) scanning for acute appendicitis when performed at our children's hospital (CH) rather than at outside hospitals (OH). In this study, we compare the amount of radiation children receive from head CTs for trauma done at OH versus those at our CH. METHODS: A retrospective chart review was performed on all children transferred to our hospital after receiving a head CT for trauma at an OH between July 2012 and December 2012. These children were then blindly case matched based on date, age, and gender to children at our CH. RESULTS: There were 50 children who underwent head CT scans for trauma at 28 OH. There were 21 females and 29 males in each group. Average age was 7.01 ± 0.5 y at the OH and 7.14 ± 6.07 at our CH (P = 0.92). Average weight was 30.81 ± 4.69 kg at the OH and 32.69 ± 27.21 kg at our CH (P = 0.81). Radiation measures included dose length product (671.21 ± 22.6 mGycm at OH versus 786.28 ± 246.3 mGycm at CH, P = 0.11) and CT dose index (53.4 ± 2.26 mGy at OH versus 49.2 ± 12.94 mGy at CH, P = 0.56). CONCLUSIONS: There is no significant difference between radiation exposure secondary to head CTs for traumatic injuries performed at OH and those at a dedicated CH.

The role of minimally invasive surgery in pediatric trauma: a collective review.

Although minimally invasive surgery (MIS) has been utilized in selective trauma patients, there a relative paucity of literature on its role in both blunt and penetrating trauma in the pediatric population. Our purpose is to review the current literature on the role of MIS in abdominal and thoracic pediatric trauma. A review of the literature, indications, risks, and benefits of MIS in trauma will be presented. Relevant literature was obtained from use of the PubMed database.

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).

Increasing severity of pectus excavatum is associated with reduced pulmonary function.

OBJECTIVE: To determine whether pulmonary function decreases as a function of severity of pectus excavatum, and whether reduced function is restrictive or obstructive in nature in a large multicenter study. STUDY DESIGN: We evaluated preoperative spirometry data in 310 patients and lung volumes in 218 patients aged 6 to 21 years at 11 North American centers. We modeled the impact of the severity of deformity (based on the Haller index) on pulmonary function. RESULTS: The percentages of patients with abnormal forced vital capacity (FVC), forced expiratory volume in 1 second (FEV(1)), forced expiratory flow from 25% exhalation to 75% exhalation, and total lung capacity findings increased with increasing Haller index score. Less than 2% of patients demonstrated an obstructive pattern (FEV(1)/FVC <67%), and 14.5% demonstrated a restrictive pattern (FVC and FEV(1) <80% predicted; FEV(1)/FVC >80%). Patients with a Haller index of 7 are >4 times more likely to have an FVC of ≤80% than those with a Haller index of 4, and are also 4 times more likely to exhibit a restrictive pulmonary pattern. CONCLUSIONS: Among patients presenting for surgical repair of pectus excavatum, those with more severe deformities have a much higher likelihood of decreased pulmonary function with a restrictive pulmonary pattern.

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.

Laparoscopic Cholecystectomy in Children.

The incidence of gallbladder disease in children is rising due to an increase in the development of nonhemolytic cholelithiasis in this age group. Laparoscopic cholecystectomy is the gold standard for treatment for gallbladder disease in adults and, with the technique's widespread adoption, it has now become the mainstay of treatment for gallbladder disease in children as well. Complications are infrequent and is now often performed as an outpatient surgery. Although the standard approach is through a 4-port technique, it can also be performed using a single-site technique. We describe our thoughts on laparoscopic cholecystectomy in children with a focus on the standard approach.

Esophageal perforation in children: a review of one institution's experience.

BACKGROUND: The current approach to esophageal perforation treatment in children has shifted towards conservative management. However, the consensus of what constitutes conservative management is unclear, with various therapies and protocols described, including the need for various decompression and drainage procedures. Our institution utilizes conservative management with minimal intervention guided by the patient's clinical course. The purpose of this study is to report our management and add to the growing evidence for conservative management of esophageal perforation in children. METHODS: We performed a retrospective chart review of all patients with an ICD-9 diagnosis of esophageal perforation from January 1995 to July 2009. Patients with postoperative anastomotic leaks with drains in place were excluded, although patients with anastomotic leaks that were not controlled by drains were included. Data collected included patient demographics, etiology, diagnosis, treatment, complications, and outcome. RESULTS: Eight patients were identified who met inclusion criteria. Mean age was 28 mo (1 d-10 y), and the average time from causative event to diagnosis was 1.4 d (0-2 d). The etiology for esophageal perforation included esophagoscopy with dilation (n = 4), button battery ingestion (n = 1), coin ingestion (n = 1), nasogastric tube placement (n = 1), and leak after stricture resection (n = 1). All the patients were treated conservatively without primary surgery or thoracic drainage, and the mean time to perforation healing was 10.2 d (1-24 d). The average length of antibiotic therapy was 10 d (0-26 d). Enteral nutrition was utilized in five patients, and total parenteral nutrition (TPN) was utilized in five patients. No patient developed a new-onset esophageal stricture. CONCLUSION: Conservative management, guided by the patient's clinical course, with antibiotics and nutritional support is a safe and effective treatment for esophageal perforations in children.

Laparoscopic Fundoplication for the Surgical Management of Gastroesophageal Reflux Disease in Children.

Gastroesophageal reflux (GER) is common in infants generally resolving in early childhood. However, gastroesophageal reflux disease (GERD) is diagnosed when persistent troublesome symptoms and/or complications of GER develop. These symptoms and complications can significantly affect the quality of life, thus requiring medical or surgical treatment. Medical management is typically trialed, but operative treatment is indicated with severe symptoms such as aspiration pneumonia, apneic episodes, bradycardia, apparent life-threatening events, severe vomiting, failure to thrive, esophagitis, stricture, and failed medical therapy. We review the recent literature on the indications and outcomes for laparoscopic fundoplication in the management of pediatric GERD.

Postoperative pain control modalities for pectus excavatum repair: A prospective observational study of cryoablation compared to results of a randomized trial of epidural vs patient-controlled analgesia.

BACKGROUND: Pain following bar placement for pectus excavatum is the dominant factor post-operatively and determines length of stay (LOS). We recently adopted intercostal cryoablation as our preferred method of pain control following minimally invasive pectus excavatum repair. We compared the outcomes of cryoablation to results of a recently concluded trial of epidural (EPI) and patient-controlled analgesia (PCA) protocols. METHODS: We conducted a prospective observational study of patients undergoing bar placement for pectus excavatum using intercostal cryoablation. Results are reported and compared with those of a randomized trial comparing EPI with PCA. Comparisons of medians were performed using Kruskal-Wallis H tests with alpha 0.05. RESULTS: Thirty-five patients were treated with cryoablation compared to 32 epidural and 33 PCA patients from the trial. Cryoablation was associated with longer operating time (101 min, versus 58 and 57 min for epidural and PCA groups, p < 0.01), resulted in less time to pain control with oral medication (21 h, versus 72 and 67 h, p < 0.01), and decreased LOS (1 day, versus 4.3 and 4.2 days, p < 0.01). CONCLUSION: Intercostal cryoablation during minimally invasive pectus excavatum repair reduces LOS and perioperative opioid consumption compared with both EPI and PCA. LEVEL OF EVIDENCE: II.

Laparoscopic management of intussusception in pediatric patients.

INTRODUCTION: Minimally invasive approaches are beginning to be employed in the management of pediatric patients with intussusception who fail radiographic reduction. Successful laparoscopic reduction has been demonstrated, but the utility of laparoscopy, for more complex cases, is less well documented. Therefore, we reviewed our experience with laparoscopy in patients with radiographically irreducible intussusception to document the safety and effectiveness of this approach. METHODS: We conducted a retrospective review of all of the patients who had a radiographically irreducible intussusception treated via the laparoscopic approach at a single institution from 1998 to 2008. Means are expressed +/- standard deviation. RESULTS: A total of 22 patients were identified, with an average age of 2.9 +/- 3.0 years. Average length of stay was 2.67 +/- 1.5 days (median, 2). Sixteen (73%) of the 22 patients were male. There were 19 ileocecal and 3 small bowel intussusceptions. Twenty patients (91%) were able to be managed entirely laparoscopically or via extension of the umbilical incision, while 2 necessitated conversion, using a right-lower quadrant incision. Nine patients had an extension of the umbilical incision; 7 of these underwent a bowel resection. Ten patients (46%) had a bowel resection, of which 5 were an ileocecectomy and 5 were segmental small bowel resection. There were a total of 9 patients with a pathologic lead point, 5 patients with lymphoid hyperplasia, and 4 with Meckel's diverticula. CONCLUSION: We conclude that laparoscopy is a reasonable approach to pediatric intussusception, even in the event when bowel resection is necessary.

Laparoscopic fundoplication after previous open abdominal operations in infants and children.

BACKGROUND: There have been multiple reports in the adult literature stating that previous open operations should no longer be considered a contraindication to the laparoscopic approach. However, there are little data on this topic in the pediatric population, particularly in patients with neonatal abdominal pathology unique to the newborn population. Therefore, we reviewed our experience with laparoscopic fundoplication after a variety of previous abdominal conditions and operations in the pediatric population. METHODS: An institutional review board-approved retrospective chart review was performed on all patients undergoing laparoscopic fundoplication after a previous open operation between October 2000 and December 2007. The data collected demographics, comorbid conditions, previous abdominal operations, gastrostomy tube placement, time interval between the initial operation and laparoscopic fundoplication, conversions, and complications. RESULTS: Forty-five patients underwent a laparoscopic Nissen fundoplication after an open operation during the study interval. Mean age was 41.3 months (range, 1-233) with a mean weight of 14.3 kg (range, 2.9-63.6), and 31 were (78.9%) male. A total of 61 previous abdominal operations were performed (range, 1-4). Mean time between last open operation and laparoscopic fundoplication was 27.3 months (range, 0.5-147). Mean operative time was 161 minutes (range, 73-420). There were no conversions and 3 perioperative complications occurred (splenic hematoma, clogged gastrostomy tube, and liver bleed). Early reoperations were performed in 2 patients (4.4%): 1 for bleeding on day 2 and the other for leaking gastrostomy day 12. CONCLUSION: Our data demonstrate that laparoscopic fundoplication after a previous open operation is feasible and safe.

Short-term natural history of the standard approaches for gastrostomy tube placement in the pediatric patient.

INTRODUCTION: Gastrostomy placement is a common procedure in the pediatric population. Standard approaches of tube placement include open, laparoscopic, and percutaneous endoscopic methods. Placement of the gastrostomy in relation to the fundus and the anterior abdominal wall is crucial to ensure adequate comfort and functionality. Misplacement may require repositioning of the gastrostomy, the rate of which has not been well documented. We, therefore, have reviewed a multi-institutional experience with gastrostomy tube placement to determine the short-term natural history of placement, based on approach, and to establish a cohort to determine the long-term natural history. METHODS: We conducted a retrospective review of all pediatric patients who underwent percutaneous endoscopic, laparoscopic, or open gastrostomy placement at two institutions from 2000 to 2008. RESULTS: There were a total of 1534 patients who underwent gastrostomy tube placement during this time period. The most common procedure was fundoplication with gastrostomy (N = 832), followed by gastrostomy alone (N = 420), and then percutaneous endoscopic gastrostomy (PEG) (N = 285). There were 4 (0.3%) gastrostomy tubes that required repositioning to a new site due to encroachment upon the rib margin. Two were open and 2 were PEG (P > 0.99). Twenty of 39 patients who had an open fundoplication following gastrostomy had the gastrostomy taken down during the procedure, compared to 5 of 31 patients (P = 0.03), who underwent laparoscopic fundoplication following gastrostomy. CONCLUSIONS: These data demonstrate that the need for gastrostomy tube repositioning is rare in the short term, regardless of approach, although a takedown of the gastrostomy is more likely when an open fundoplication is performed.