Testicular Workup for Ischemia and Suspected Torsion in Pediatric Patients and Resource Utilization.

BACKGROUND: Testicular torsion (TT) is a pediatric emergency requiring prompt diagnosis and management. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) scores patients on clinical symptoms and can predict TT. This study aimed to determine if the application of TWIST to children with acute scrotal pain could decrease the use of Doppler ultrasonography (DUS) and emergency department (ED) length of stay and ischemic time. MATERIALS AND METHODS: A retrospective cohort study applying TWIST to patients who presented to a pediatric ED with acute testicular pain from December 2017 to June 2019 was performed. Demographics, TWIST score, diagnosis, DUS, consults, and time to the operation were recorded. Patients were stratified into low (LR), intermediate (IR), and high (HR) risk groups for TT based on TWIST score. Descriptive and comparative analyses were performed. RESULTS: Seventy-seven patients were included in the study and had a mean age of 9.24 y ±5.24. All 9 HR patients (TWIST = 5-7) had TT, and none of the 57 LR patients (TWIST = 0-2) had TT. Use of TWIST could have reduced the number of DUS needed to diagnose TT from 69 to 11 (75.3% reduction in DUS). CONCLUSIONS: TWIST accurately predicts torsion in HR groups and excludes torsion in LR groups. Application of TWIST to HR patients may eliminate the need for DUS and decrease ischemic time and cost of care. Application of TWIST in LR patients may likewise eliminate the need for DUS and decrease ED length of stay and cost of care.

Therapeutic Direction Versus Adverse Outcomes in Children Undergoing Lung Biopsy.

BACKGROUND: Lung biopsy is part of the diagnostic workup for multiple diseases. Although the morbidity of the procedure has decreased with the use of thoracoscopy, lung biopsy still holds substantial risk for patients. Therefore, we evaluated the likelihood of lung biopsies impacting treatment compared to complications. MATERIAL AND METHODS: This was a single-institution, retrospective chart review of patients less than aged 18 y undergoing lung biopsy from 2010 to 2016. Details of demographics, hospital course, adverse events, complications, pathology, and follow-up were recorded. All values are reported as medians with interquartile range. RESULTS: Thirty-seven patients met inclusion criteria. Median age was 7 y old (interquartile range 1.4, 15). Eighty-seven percent (33) of biopsies were performed thoracoscopically, with a 3% conversion rate. Adverse events occurred in 25% (9) of cases with the majority involving prolonged respiratory failure (n = 7). Complications occurred in 16% (6) of cases including pneumothorax (13%, n = 5) and cardiac arrest (3%, n = 1). A third of these complications (n = 2) required reoperation, and both were decompressions of tension pneumothoraces. Pathology established a diagnosis in 62% (n = 23) of cases, yet treatment was changed in only 43% of cases. No preoperative variables were associated with the pathology establishing a diagnosis or changing treatment. CONCLUSIONS: Lung biopsy for questionable pulmonary disease changed treatment in less than half of cases, with significant perioperative morbidity. Careful consideration should therefore be given to who would benefit most from lung biopsy.

Enteric duplication in children.

INTRODUCTION: Enteric duplication is a congenital anomaly with varied clinical presentation that requires surgical resection for definitive treatment. This had been approached with laparotomy for resection, but has changed with minimally invasive technique. The purpose of our study was to determine the demographics, natural history, operative interventions, and outcomes of pediatric enteric duplication cysts in a contemporary cohort. METHODS: With IRB approval, we performed a retrospective chart review of all patients less than 18 years old treated for enteric duplication between January 2006 and August 2016. Demographics, patient presentation, operative technique, intraoperative findings, hospital course, and follow-up were evaluated. Descriptive statistical analysis was performed; all medians were reported with interquartile range (IQR). RESULTS: Thirty-five patients underwent surgery for enteric duplication, with a median age at surgery of 7 months (2.5-54). Median weight was 7.2 kg (6-20). Most common patient presentations included prenatal diagnosis 37% (n = 13). Thirty-four patients (97%) had their cyst approached via minimally invasive technique (thoracoscopy or laparoscopy) with only three (8%) requiring conversion to an open operation. Median operative time was 85 min (54-133) with 27 (77%) patients requiring bowel resection. Median length of bowel resected was 4.5 cm (3-7). Most common site of duplication was ileocecal (n = 15, 42%). Postoperative median hospital length of stay was 3 days (2-5) and median number of days to regular diet was 3 (1-4). No patients required re-operation during their hospital stay. Median follow-up was 25 days (20-38). CONCLUSION: In our series, most enteric duplication cysts were diagnosed prenatally. These can be managed via minimally invasive technique with minimal short-term complications, even in neonates and infants.

Does muscle biopsy change the treatment of pediatric muscular disease?

BACKGROUND: Muscle biopsy is performed to confirm the diagnosis of neuromuscular disease and guide therapy. The purpose of our study was to determine if muscle biopsy changed patient diagnosis or treatment, which patients were most likely to benefit from muscle biopsy, and complications resulting from muscle biopsy. MATERIALS AND METHODS: An IRB-approved retrospective chart review of all patients less than 18 years old undergoing muscle biopsy between January 2010 and August 2016 was performed. Demographics, patient presentation, diagnosis, treatment, hospital course, and follow-up were evaluated. Descriptive and comparative (student's t test, Mann-Whitney U, and Fisher's exact test) statistical analysis was performed. Medians were reported with interquartile range (IQR). RESULTS: 90 patients underwent a muscle biopsy. The median age at biopsy was 5 years (2, 10). 37% (n = 34) had a definitive diagnosis. 39% (n = 35) had a change in their diagnosis. 37% (n = 34) had a change in their treatment course. In the 34 patients who had a change in their treatment, the most common diagnosis was inflammatory disease at 44% (n = 15). In the 56 patients who did not have a change in treatment, the most common diagnosis was hypotonia at 30% (n = 17). There was no difference in patients who had a change in treatment based on pathology versus those that did not. The median length of follow-up was 3 years (1, 5). CONCLUSIONS: Muscle biopsy should be considered to diagnose patients with symptoms consistent with inflammatory or dystrophic muscular disease. The likelihood of this altering the patient's treatment course is around 40%.

Initial experience with same day discharge after laparoscopic appendectomy for nonperforated appendicitis.

BACKGROUND: Although many laparoscopic procedures are performed on an outpatient basis, patients who have undergone a laparoscopic appendectomy have typically stayed at least overnight. Recently, data in both the pediatric and adult literature suggest that same day discharge (SDD) for acute nonperforated appendicitis is safe and associated with high patient and parent satisfaction. We have recently begun attempting SDD for nonperforated appendicitis, and this study is an analysis of our initial experience. METHODS: A retrospective chart review of all patients who underwent laparoscopic appendectomy for nonperforated appendicitis at our institution from January 2012 to July 2013 was performed. Demographics, length of stay, hospital course, and outcomes were measured. Data are expressed as mean±standard deviation. Comparative analysis was performed using a t-test. RESULTS: A total of 588 laparoscopic appendectomies for nonperforated appendicitis were performed over an 18-mo period. Approximately 28% (n=128) were discharged on the day of surgery. Of the remaining patients, 12.9% (n=59) stayed overnight for medical reasons, 0.4% (n=2) stayed for social reasons, 3.9% (n=18) stayed because the operation ended late in the evening, and 82.8% (n=381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, P=0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P=1.0), and complication rate (0.7% versus 2.6%, P=0.3). Patients whose operation ended later in the day had a longer hospital stay. We observed a trend toward more SDDs, the further we got from the initiation of our protocol. CONCLUSIONS: SDD is safe for children undergoing laparoscopic appendectomy for nonperforated appendicitis. The two main barriers to SDD were time of day for the operation and provider habit, both of which improved as more practitioners felt comfortable with the concept. SDD requires extensive education within the hospital system, and we have initiated an aggressive prospective protocol to improve the results.

Management of electrical and chemical burns in children.

BACKGROUND: Pediatric electrical and chemical burns are rare injuries, and the care of these patients varies significantly. We reviewed our experience in management of electrical and chemical burns to analyze the clinical course, management, and outcomes. METHODS: A retrospective review was conducted on children with chemical and electrical burns presenting to two large regional pediatric burn centers over a 10-y period (2002-2012). Clinical data including patient demographics, nature of burns, management, and outcomes were collected and analyzed. RESULTS: There were 50 cases, 25 chemical and electrical burns each. Overall, the mean±standard deviation age was 6.2±5.6 y, and the mean total body surface area burn was 4.3±3.2%. Chemical burns were larger, had less depth, and shorter length of stay, whereas electrical burns were smaller, deeper, and had a longer length of stay. Two chemical burns and six electrical burns required grafting. Twelve percent of electrical burns required rehabilitation, and 20% required compression garments for hypertrophic scars. Six percent required late surgeries. CONCLUSIONS: Pediatric electric and chemical burns are rare and require specialized care. Graft rates are not high but are mostly noted in electrical burns.

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.

Demographic disparities of children presenting with symptomatic Meckel's diverticulum in children's hospitals.

PURPOSE: Most of the literature about Meckel's diverticulum (MD) consists of single institutional longitudinal case series. We queried the pediatric hospital information system (PHIS) database to obtain information about the epidemiology of MD from a large number of children at geographically diverse locations. METHODS: After IRB approval, the PHIS database was queried over a 9-year period for de-identified patients with both ICD-9 diagnoses of MD and a procedure code for Meckel's diverticulectomy. Data from five hospitals were excluded due to incomplete information. RESULTS: 4,338,396 were children admitted during the study interval; 945 had a symptomatic MD. The incidence decreased with age: 56.4% were under 5 years old, 26.8% were between the ages of 6-12 years, and 16.8% were older than 12 years. 74% were male, which was significantly higher than the PHIS population (53.8% male, P < 0.0001). Caucasians are over-represented in the symptomatic MD group (63.4%) compared to the rest of the PHIS population (48.1%, P < 0.0001). CONCLUSIONS: According to the PHIS data, there appears to be significant gender and race influence on symptomatic MD. Males present more commonly, as do non-Hispanic White patients, while it is less common among non-Hispanic Black patients.

Ceftriaxone-induced pseudolithiasis in children treated for perforated appendicitis.

PURPOSE: Ceftriaxone has been associated with development of pseudolithiasis. In our institution, it is used for treatment of perforated appendicitis in children. This study evaluated the occurrence of ceftriaxone-related pseudolithiasis in this population. METHODS: After obtaining IRB approval, we performed a retrospective chart review over 51 months. We included patients undergoing laparoscopic appendectomy for perforated appendicitis. All patients were treated with ceftriaxone post-operatively. Patients without initial or post-treatment gallbladder imaging available for review were excluded. RESULTS: There were 71 patients who met inclusion criteria with a mean (±SD) age of 10.8 ± 3.8 years. Of these, 14 % (n = 10) developed stones or sludge in the gallbladder. The mean duration of ceftriaxone therapy was 8.7 ± 3.8 days. The average time to post-antibiotic imaging was 11.5 ± 10.3 days from initiation of antibiotics. There was no significant difference in duration of ceftriaxone therapy in the children that developed pseudolithiasis or sludge (10.0 ± 4.9 days) compared to those that did not (8.5 ± 3.6, p = 0.26). One child (10 %) with pseudolithiasis went on to become symptomatic, requiring a laparoscopic cholecystectomy. CONCLUSIONS: In our experience, ceftriaxone use for perforated appendicitis is associated with a significant incidence of biliary pseudolithiasis, and is unrelated to duration of ceftriaxone therapy.

Multi-institutional experience with penetrating pancreatic injuries in children.

PURPOSE: Penetrating pancreatic injuries in children are uncommon and are not well described in the literature. We report a multi-institutional experience with penetrating pancreatic injuries in children. METHODS: A retrospective review of children sustaining penetrating pancreatic injuries was performed at eight pediatric trauma centers. RESULTS: Sixteen patients were identified. Eleven patients were male; (mean ± SE) age was 11.7 ± 1.2 years. The mechanism of injury was gun-shot wound in 14 patients and mean injury-severity score was 18 ± 3. All patients had associated injuries, most frequently small bowel injuries (n = 9). Patients had either grade I (n = 4), grade II (n = 7), or grade III (n = 4) injuries; there was a single grade V injury. All patients underwent exploratory celiotomy. Drainage of the injured pancreas was performed in 11 patients, and 2 patients underwent pancreatorrhaphy in addition to drainage; 3 underwent resection for grade III (n = 2) and grade V (n = 1) injuries. Thirteen patients required other intra-abdominal procedures. All patients required intensive care over a mean 11.0 ± 3.0 days. Mean duration of stay was 30.1 ± 5.6 days. Post-operative morbidity was 62.5% with no mortalities. CONCLUSIONS: Penetrating pancreatic injuries in children are uncommon and most often due to firearms. There is a high association with other injuries particularly hollow viscous perforation.

Multiple Intestinal Anomalies in a Newborn with 22q11.2 Microdeletion Syndrome: A Case Report and Literature Review.

Although 40 years have passed since the first case of DiGeorge's syndrome was described, and the knowledge about this disorder has steadily increased since that time, 22q11.2 deletion syndrome (DS) remains a challenging diagnosis because its clinical presentation varies widely. We describe an infant with 22q11.2 DS who presented with annular pancreas, anorectal malformation, Morgagni-type congenital diaphragmatic hernia, and ventricular septal defect. This constellation of anomalies has never been described in DiGeorge's syndrome. Here, we provide a case presentation and a thorough review of the literature.

Management of Fibrous Hamartoma of Infancy: A Contemporary Series.

BACKGROUND: Fibrous hamartoma of infancy (FHI) is a rare, benign, soft tissue mass that may be locally infiltrative. Primary excision is the mainstay of treatment; however, given the infiltrative nature, margin negativity can be difficult to achieve. The management of residual disease in the setting of positive margins after primary excision is not well described. METHODS: All patients undergoing FHI excision from 2012 to 2022 were included. Demographics, operative data, margin status, recurrence, and post-operative follow-up data were obtained via retrospective chart review. RESULTS: Nine patients were identified who underwent FHI excision. The median age at time of excision was 9 months (IQR 16). Seven (78%) were male, and the majority (78%) were white. Seven (78%) underwent preoperative imaging via ultrasound or MRI, and 4 (44%) had a preoperative biopsy to confirm diagnosis. Common locations included upper extremity (n = 4, 44%) and lower extremity/inguinal region (n = 4, 44%). Six patients (67%) had positive margins on pathology - 3 (33%) on the upper extremity, 2 (22%) on the lower extremity/inguinal region, and one (11%) on the flank. One patient (11%) had a local recurrence which did not undergo re-excision. CONCLUSIONS: FHI remains a rare diagnosis. There is a high margin positivity rate; however, local clinically significant mass recurrence remains uncommon. With low rates of clinically significant mass development coupled with the benign nature of disease, a "watch and wait" approach may be appropriate for patients with positive histologic margins after complete gross excision to avoid reoperation and need for complex reconstructions. LEVEL OF EVIDENCE: Level 4.

Transcystic Laparoscopic Common Bile Duct Exploration for Pediatric Patients with Choledocholithiasis: A Multi-Center Study.

BACKGROUND: Patients with choledocholithiasis are often treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Upfront LC, intraoperative cholangiogram (IOC), and possible transcystic laparoscopic common bile duct exploration (LCBDE) could potentially avoid the need for ERCP. We hypothesized that upfront LC + IOC ± LCBDE will decrease length of stay (LOS) and the total number of interventions for children with suspected choledocholithiasis. METHODS: A multicenter, retrospective cohort study was performed on pediatric patients (<18 years) between 2018 and 2022 with suspected choledocholithiasis. Demographic and clinical data were compared for upfront LC + IOC ± LCBDE and possible postoperative ERCP (OR1st) versus preoperative ERCP prior to LC (OR2nd). Complications were defined as postoperative pancreatitis, recurrent choledocholithiasis, bleeding, or abscess. RESULTS: Across four centers, 252 children with suspected choledocholithiasis were treated with OR1st (n = 156) or OR2nd (n = 96). There were no differences in age, gender, or body mass index. Of the LCBDE patients (72/156), 86% had definitive intraoperative management with the remaining 14% requiring postoperative ERCP. Complications were fewer and LOS was shorter with OR1st (3/156 vs. 15/96; 2.39 vs 3.84 days, p < 0.05). CONCLUSION: Upfront LC + IOC ± LCBDE for children with choledocholithiasis is associated with fewer ERCPs, lower LOS, and decreased complications. Postoperative ERCP remains an essential adjunct for patients who fail LCBDE. Further educational efforts are needed to increase the skill level for IOC and LCBDE in pediatric patients with suspected choledocholithiasis. LEVEL OF EVIDENCE: Level III.

The impact of social determinants of health on the overall wellbeing of children: A review for the pediatric surgeon.

Disparities in health care access, quality, and outcomes for pediatric patients, and their relationship to race and socioeconomic status (SES) have been extensively documented. The underlying causes behind such disparities have been less carefully studied, as clinicians and researchers often fail to look past immutable features such as race, into modifiable factors like social determinants of health (SDOH). A child's environment affects their patterns of social engagement, sense of security, and overall well-being. Resources such as affordable housing, access to education, public safety, and availability of healthy foods and safe play spaces impact and enhance quality of life, and have significant influence on both health and health care outcomes. These upstream indicators are often unrecognized or misidentified as health concerns. Few pediatric surgery publications discuss SDOH and their effects on children. This paper aims to introduce the five domains of SDOH (economic stability, education, social and community context, health and healthcare, and neighborhood and built environment) along with strategies to identify and address needs in these domains from a provider, hospital, and health system's perspective. It is anticipated that this information will serve as a foundation for pediatric surgeons to understand and develop processes that ameliorate disparities related to SDOH and improve surgical outcomes and the well-being of all children.

Testicular torsion disparities in the pediatric population.

BACKGROUND: There are disparate findings in the literature on the impact of race and insurance status on gonadal loss in testicular torsion. We sought to determine if race or levels of social vulnerability influence the rate of torsion or gonadal loss. METHODS: Retrospective cross-sectional review between December 2017 and September 2019. Social vulnerability index was dichotomized using the 75th percentile. Primary outcome was the diagnosis of testicular torsion. RESULTS: 515 patients were included. There was no difference in median age, torsion diagnosis, and orchiectomy rate between the two institutions. Black/African American patients were >3 times more likely than Caucasian patients to be diagnosed with TT when controlled for dichotomized SVI, insurance, and age (OR 3.39, 95% CI 1.74 - 6.61, p < 0.01). CONCLUSION: Black/African American children have an increased risk of testicular torsion. Despite these patients having higher levels of social vulnerability, it was not associated.

Mitigating disparity in children with acute appendicitis: Impact of patient-driven protocols.

PURPOSE: Previous reports in the literature demonstrate racial and ethnic disparities for children diagnosed with acute appendicitis, with minorities experiencing worse outcomes. At our institution, we have developed an evidence based patient driven protocol for children following laparoscopic appendectomy. However, the influence of such protocol on mitigating racial and ethnic disparities in outcomes remains unknown. The purpose of our study is to assess the impact of our protocol by evaluating the influence of race and ethnicity on surgical outcomes among children treated for acute appendicitis. MATERIAL AND METHODS: A retrospective review of prospectively collected data was conducted. Children undergoing a laparoscopic appendectomy at our freestanding children's hospital between December 2015 and July 2017 were included. Demographic data, post-operative length of stay, same day discharge rates and hospital readmission rates were abstracted from patient medical records. Patients were classified by their race and ethnic background. Comparative analysis was performed in STATA with a p value <.05 determined as significant. RESULTS: A total of 786 children were included, with the majority being either White (70%, n = 547), Black (8%, n = 62) or Hispanic (17%, n = 133); 569 patients (72%) were found to have non-perforated appendicitis. There was no statistically significant difference in the rates of same day discharge among White, Black or Hispanic children respectively (88% vs. 77% vs. 86%, p = .126). Of the 217 children with perforated appendicitis, Hispanic children had increased rates of perforation (41%, n = 55) compared to White and Black children respectively (23%, n = 128 and 29%, n = 18, p = .001). However, average post-operative length of stay were similar among White, Black and Hispanic children (96 h vs. 95 h vs. 98 h, p = .015). On multivariate analysis, the only significant risk factor for an elevated post-operative length of stay was the presence of a perforation. CONCLUSION: Our evidence based patient driven protocol effectively mitigates racial and ethnic disparities found in children with acute appendicitis. Further prospective investigation into the role of such patient-driven protocols to mitigate healthcare disparities is warranted. LEVELS OF EVIDENCE: Therapeutic study; Level 3.

Epidural versus PCA Pain Management after Pectus Excavatum Repair: A Multi-Institutional Prospective Randomized Trial.

INTRODUCTION: Postoperative pain control remains the primary reason for inpatient stay after minimally invasive repair of pectus excavatum. In a previous study, our group reported that early pain control was better in patients managed with a thoracic epidural, while late pain control was better in patients managed with patient-controlled analgesia (PCA). After revising our epidural transition and modifying the PCA protocol, we conducted a multi-institutional prospective randomized trial to evaluate these two pain control strategies. MATERIALS AND METHODS: Patients were randomized to epidural or PCA following minimally invasive repair of pectus excavatum with standard protocols for each arm. Primary outcome was length of stay with secondary variables including mean patient pain scores, complications, and parental satisfaction. Scores were pooled for the two groups and reported as means with standard deviation. Results were compared using t-tests and one-way analysis of variance with p-value < 0.05 determining significance. RESULTS: Sixty-five patients were enrolled, 32 epidural and 33 PCA. Enrollment was stopped early when we developed an alternative strategy for controlling these patients' pain. There was no difference in length of stay in hours between the two arms; epidural 111.3 ± 18.5 versus PCA 111.4 ± 51.4, p = 0.98. Longer operative time was found in the epidural group. Nine patients in the epidural group (28%) required a PCA in addition to epidural for adequate pain control. Mean pain scores were lower on postoperative day 0 in the epidural group compared with the PCA groups, but were otherwise similar. CONCLUSION: In our prospective randomized trial, PCA is just as effective as thoracic epidural in decreasing early postoperative pain scores after minimally invasive repair of pectus excavatum.

Outcomes of Ostomy Location in Children: Placement of the Ostomy at the Umbilicus.

PURPOSE: Neonatal exploratory laparotomies are often performed with a transumbilical incision in our institution, so umbilical ostomy placement has become more common. The purpose of our study is to evaluate the outcomes of neonates with ostomy placement at the umbilicus in comparison to more traditional stoma locations. MATERIAL AND METHODS: Retrospective study of neonates that underwent an exploratory laparotomy with ostomy creation between January 2010 and September 2015. Demographics, presentation, feedings, ostomy position, postoperative complications, and outcomes were collected. Comparative analysis was performed in STATA with P-value <.05 determined as significant. Results reported as means ± standard deviation and medians with interquartile ranges. RESULTS: Fifty-four children were included, 37% (n = 20) had stomas at the umbilicus. Most common other stoma location was the right lower quadrant (63%, n = 34). Necrotizing enterocolitis (NEC) was the most common indication for surgery in both groups. Days to stoma output were similar between the two groups, [3 (1, 6) versus 2 (1, 5), P = .96]. Days to initiation of feeds were delayed in the umbilical ostomy group [15 (9.5, 23.5) versus 6 (4, 10), P = .02]. Comparing only NEC patients, initiation of feeds was similar [22 (14, 56) versus 15.5 (8, 43), P = .73]. Umbilical ostomies had an increase in prolapse/peristomal hernias (7 versus 3, P = .01), but no patients required operative revision. CONCLUSION: Umbilical ostomies had similar time to stoma function compared to other sites, but a delay in initiation of oral feeds likely secondary to a higher percentage of patients with NEC.

Abdominal Exploration in Neonates Using Transumbilical Exposure Compared with Transverse Laparotomies.

INTRODUCTION: The vertical transumbilical incision (TU) technique during neonatal abdominal exploration involves dissection and ligation of umbilical vessels, which allow access to all quadrants of the abdomen and complete bowel evisceration with minimal violation to the anterior abdominal wall. We compared patient characteristics and outcomes for neonates undergoing TU with standard transverse exploration. MATERIALS AND METHODS: A single-center retrospective review of neonates who underwent abdominal exploration between January 2010 and September 2015 was conducted after obtaining Institutional Review Board approval. Data included patient demographics, indication for operative intervention, operative details, complications, including incisional hernias, and long-term outcomes. RESULTS: There were 88 neonates under 4 months of age who underwent abdominal exploration, with a median age of 5.5 ± 17 days and a median gestational age of 32.8 ± 16 weeks. Exploration was emergent in 38 patients (43%) and 49 (56%) required ostomy formation. A transverse incision (TV) was used in 30 patients and a TU in 58 patients. Both groups had similar postoperative complication rates; 27 (47%) in the TU group and 11 (36%) in the TV group, P = .51. Median length of follow-up in the TU group was 5.1 ± 18 months and 6.2 ± 16 months in the TV group, P = .48. The TU group had 4 incisional/umbilical hernias (7%), none have required repair. CONCLUSION: TUs for abdominal explorations in neonates have similar outcomes as the standard TV while preserving the integrity of the anterior abdominal wall.