Abstract 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.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
2.
Neonatal bowel obstruction Juang, David; Snyder, Charles L
The Surgical clinics of North America,
06/2012, Volume:
92, Issue:
3
Journal Article
Peer reviewed
Newborn intestinal obstructions are a common reason for admission to neonatal ICUs. The incidence is estimated to be approximately 1 in 2000 live births. There are 4 cardinal signs of intestinal ...obstruction in newborns: (1) maternal polyhydramnios, (2) bilious emesis, (3) failure to pass meconium in the first day of life, and (4) abdominal distention. The presentation may vary from subtle and easily overlooked findings on physical examination to massive abdominal distention with respiratory distress and cardiovascular collapse. A careful history and physical examination often identify the diagnosis. Concomitant resuscitation (volume, gastric decompression, and ventilatory support) may be necessary.
Optimal surgical treatment of infants with esophageal atresia (EA) and tracheoesophageal fistula (TEF) remains controversial. In order to better understand variability in management, we surveyed the ...International Pediatric Endosurgery Group (IPEG) membership.
An online-based survey, conducted in 2012, was sent to all IPEG members.
The survey was completed by 170 surgeons from 31 countries. A majority of respondents practiced in academic/university settings (86%) and performed one to three EA/TEF repairs annually (67%). Those practicing for over 15 years made up 39% of the study group, followed by those practicing 6-10 years (24%), 0-5 years (22%), and 11-15 years (15%). Utilization of a thoracoscopic approach was reported by half of the respondents with a frequency of 1-3 cases (76%), 4-6 cases (17%), and greater than 7 cases (7%) per year. Low birth weight, congenital heart disease, long gap length, and compromised physiologic status were identified as the most common exclusion criteria for thoracoscopic repair. The thoracoscopic repair was almost uniformly performed via an intrapleural approach (96%), in contrast with the open repair that was done extrapleurally in 89%. Preoperative bronchoscopy was routinely performed by 60%. Size 4-0 to 5-0 absorbable suture predominated for EA repair. Postoperative chest tube/drain and transanastomotic tube placement were used by 83%. A normal esophagram was required by 85% to initiate oral feeding. Sixty-six percent initiated transanastomotic feeds prior to obtaining an esophagram. Postoperative antibiotic use was common (76%) and varied from less than 1 to greater than 14 days. Acid suppression medication was used by 76% with duration ranging from 7 days to lifelong. For long gap EA, spiral myotomies were rarely performed (10%), and gastric transposition was the favored method for esophageal replacement (66%).
Considerable variability existed among the IPEG membership in treatment of patients with EA/TEF. The identification of variance is the first step in creating future studies to identify best practices.
Abstract Extracorporeal membrane oxygenation (ECMO) is a vital pre-operative adjunct for the stabilization of patients with severe congenital diaphragmatic hernia (CDH) that develop cardiorespiratory ...failure. The optimal timing of diaphragmatic repair in patients with CDH that require ECMO remains controversial. This article offers a review of the data available addressing the risks and outcomes of patients who require ECMO support with regard to timing of repair.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Purpose
Determining the integrity of the pancreatic duct is important in high-grade pancreatic trauma to guide decision making for operative vs non-operative management. Computed tomography (CT) is ...generally an inadequate study for this purpose, and magnetic resonance cholangiopancreatography (MRCP) is sometimes obtained to gain additional information regarding the duct. The purpose of this multi-institutional study was to directly compare the results from CT and MRCP for evaluating pancreatic duct disruption in children with these rare injuries.
Methods
Retrospective study of data obtained from eleven pediatric trauma centers from 2010 to 2015. Children up to age 18 with suspected blunt pancreatic duct injury who had both CT and MRCP within 1 week of injury were included. Imaging findings of both studies were directly compared and analyzed using descriptive statistics, Chi square, Wilcoxon rank-sum, and McNemar’s tests.
Results
Data were collected for 21 patients (mean age 7.8 years). The duct was visualized more often on MRCP than CT (48 vs 5%,
p
< 0.05). Duct disruption was confirmed more often on MRCP than CT (24 vs 0%), suspected based on secondary findings equally (38 vs 38%), and more often indeterminate on CT (62 vs 38%). Overall, MRCP was not superior to CT for determining duct integrity (62 vs 38%,
p
= 0.28).
Conclusions
In children with blunt pancreatic injury, MRCP is more useful than CT for identifying the pancreatic duct but may not be superior for confirmation of duct integrity. Endoscopic retrograde cholangiogram (ERCP) may be necessary to confirm duct disruption when considering pancreatic resection.
Level of evidence
III.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Abstract Complications from shunts placed in the peritoneum, either ventriculoperitoneal or subdural, are varied. Perforation of hollow organs and subsequent natural orifice protrusion is a rare but ...well known complication. We report a case of a transanal protrusion of a subdural peritoneal shunt in the setting of previous abdominal pain possibly consistent with acute appendicitis. While a report of transanal protrusion of a ventriculoperitoneal shunt via the appendix has been reported this is the first report where abdominal inflammation was also present. While patients with hollow organ perforation have been described as being managed conservatively after externalization of the proximal shunt and removal of the distal shunt, we managed our patient with an operation given our concern for appendicitis.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Pelvic angiography with embolization can successfully control hemorrhage in adults with pelvic fractures. However, evidence to support similar application in children is sparse. We describe our ...experience using angiography for pediatric pelvic fractures to further highlight the safety and efficacy of this treatment approach.
A retrospective review at a pediatric tertiary care center was performed from 2004 to 2014. Inpatients treated for a pelvic fracture were considered.
A total of 216 patients were analyzed. Four patients (1.9%) underwent pelvic angiography. Three of these patients had active contrast extravasation on angiography and underwent successful embolization. All patients who underwent angiography showed computed tomography (CT) or clinical evidence of ongoing hemorrhage. No surgical intervention was needed after angiography. No complications of angiography occurred. Three patients who were found to have active extravasation on CT did not require angiography and were stabilized in the intensive care unit; two patients went on to have delayed operative repair. Mortality was 2.3%. All deaths were secondary to concomitant traumatic brain injury. No mortality occurred in patients undergoing pelvic angiography or those with pelvic contrast extravasation on CT.
Pelvic angiography is a useful treatment option in pediatric patients with pelvic fractures and clinical evidence of ongoing blood loss without other explanation. Contrast extravasation on CT scan alone may not require further intervention.
Experience with Pilonidal Disease in Children Fike, Frankie B., M.D; Mortellaro, Vincent E., M.D; Juang, David, M.D ...
The Journal of surgical research,
09/2011, Volume:
170, Issue:
1
Journal Article
Peer reviewed
Background Controversy exists regarding the optimum treatment for pediatric pilonidal disease. It is a complex disease process with a high rate of recurrence. A spectrum of surgical strategies ...exists, including drainage, cyst marsupialization, complete cyst and sinus tract excision with primary versus secondary closure, and excision utilizing flap closure. There is little published in the pediatric literature; therefore, we reviewed our experience in an attempt to document how various interventions affect the natural history. Methods A retrospective review was conducted in which all patients who underwent surgical intervention for pilonidal disease at our institution from January 2000 to June 2010 were identified. Data collection included demographics, surgical procedure performed, presence of wound breakdown, presence of infection, recurrence, total procedures performed, number of follow-up visits, and total hospital days. Results In the study period, 120 patients were identified, and 58% were female. Mean age was 14.9 y old (1–19 y). These patients were then subdivided into closed versus open groups based on the status of their operative wound. In the closed group, 74 patients underwent excision with midline closure and 18 underwent excision with flap closure. There were 28 patients left open after excision. In the closed group, wound breakdown occurred in a total of 41 patients (45%). There was no difference in breakdown between midline and flap closure. Postoperative wound infection occurred in 15% of all patients. The midline closure group had a higher infection rate (20%) compared with those with flap closures (11%), which was not significant ( P = 0.30). There was no difference in recurrence rate between patients who were primarily closed and patients who were left open (20.6% versus 25%, P = 0.51). There was also no difference in their hospital length of stay (0.44 ± 2.53 d versus 1.18 ± 2.9 d, P = 0.18). Conversely, the patients who were left open had more follow-up visits (6.48 ± 7.6 versus 4.18 ± 3.3, P = 0.02) and subsequently required more operative procedures (1.71 ± 1.12 versus 1.25 ± 0.49, P = 0.002). Conclusion Management of pilonidal disease remains a complex problem, and operative intervention is fraught with complications, including wound breakdown, infection, and cyst recurrence. Primary closure appears to have better outcomes compared with healing by secondary intention. There does not appear to be a clear advantage of primary closure utilizing flaps over primary closure based on our early experience with flap closures.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Abscess after appendectomy for perforated appendicitis is the most common complication. We have completed three prospective trials and are conducting a fourth in which the included ...patients had either a hole in the appendix or a fecalith in the abdomen identified at the time of operation. The abscess rate in each of these trials was 20%. Multiple publications have focused on prevention and management of this postoperative complication but the total impact of an abscess on the hospital course has not been well documented. Therefore, we reviewed our experience with patients who developed a postoperative abscess to evaluate the total care received compared with those who recovered uneventfully. Methods Data from patients with abscess who have been enrolled in our prospective trials from April 2005 to December 2009 were utilized. Patients who recovered without complications in the most recent trial served as a comparison group, as this protocol offers the minimal length of stay without a predetermined length of stay. Data comparison included patient demographics, admission lab values, hospital length of stay, and hospital charges. Results There were 63 patients with a postoperative abscess and 61 patients without an abscess identified. Patients with an abscess were older (11.0 versus 9.7 y, P = 0.04) and had a higher mean body mass index (22.4 versus 19.5, P = 0.03). Total hospital length of stay was significantly longer in the abscess group (11.6 d versus 5.1 d, P ≤ 0.001). Total hospital charges doubled for patients who developed an abscess ($82,000 versus $40,000 P < 0.001). Conclusion A postoperative abscess after appendectomy for perforated appendicitis translates into an average of an extra week in hospital care with double the total hospital cost.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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