A review of postoperative feeding regimens in infantile hypertrophic pyloric stenosis

Infantile hypertrophic pyloric stenosis is a condition well known to pediatric surgeons. Postoperative length of hospital stay is a financial concern and remains a potential target for reduction in hospital costs. Ultimately, these costs are directly affected by the ability to effectively advance postoperative enteral nutrition. This review will serve to: 1) identify clinically relevant postoperative feeding patterns following pyloromyotomy, 2) review the relevant literature to determine an optimal feeding pattern, and 3) identify possible preoperative predictors that may determine the success of postoperative feeding regiments.

Distribution of feeding styles after pyloromyotomy among pediatric surgical training programs in North America

INTRODUCTION

The feeding regimen employed after pyloromyotomy for pyloric stenosis continues to be a topic of debate and has yet to be evaluated in a prospective, randomized trial. To understand the spectrum of current feeding schedules being utilized in the various training programs, we queried the program directors or representatives about their feeding schedules.

METHODS

Through the use of multiple electronic communication resources, we surveyed 47 pediatric training programs in the United States and Canada about their postpyloromyotomy feeding schedules. Questions included time to first feed, how the schedule is advanced, and criteria for stopping feeds and discharge.

RESULTS

Responses were received from 34 of the 47 institutions. Six programs had variable times of delay before instituting feeding whether ad libitum (ad lib) or protocol. The average time of delay was 4.3 hours. Six programs reported both ad lib feed and protocol feeding regiments. Twelve institutions used ad lib feeding regiments. Eight started feeding without delay. Twenty-six programs including our institution currently employ a protocol-based feeding regiment. Of these programs, seven begin the protocol without delay.

CONCLUSIONS

Despite retrospective evidence in support of ad lib feeds after pyloromyotomy, the majority of teaching institutions employs protocols for the postpyloromyotomy feeding schedule. There is clearly a role for a prospective, randomized trial to compare ad lib to schedule feeding.

Utility of pH/multichannel intraluminal impedance probe in identifying operative patients in infants with gastroesophageal reflux disease

INTRODUCTION

Gastroesophageal reflux is a common clinical problem in infants, but identifying which infants may benefit from a fundoplication remains a conundrum. Esophageal pH and multichannel intraluminal impedance (MII) measurements are useful diagnostic tools in adults and older children, but their diagnostic efficacy in infants is unclear. Therefore, we reviewed our experience with the combined pH/MII probe in this population.

SUBJECTS AND METHODS

A retrospective review of patients ≤ 6 months of age who were studied with the pH/MII probe from 2006 to 2010 was performed. Test results, interventions, and outcomes were reviewed. Patients were divided into operative and nonoperative groups, and pH probe and MII results were compared.

RESULTS

Fifty-seven patients (53% male) were identified. Mean age at the time of pH/MII probe was 3.1 months. Regarding the operative group (n = 33), 21% had an abnormal pH probe, and 100% had an abnormal MII; 97% had symptom improvement at a mean follow-up of 16 months (range, 0.4-38 months). In the nonoperative group (n = 24), 29% had an abnormal pH probe, and 100% had an abnormal MII. There was no significant difference in reflux index, Boix-Ochoa score, or percentage of acid and non-acid reflux between the two groups.

CONCLUSIONS

The pH and MII studies are poor indicators of pathologic reflux in infants and do not adequately discern which patients will benefit from fundoplication.

Overnight observation in former premature infants undergoing inguinal hernia repair

BACKGROUND

Overnight observation for apneic events is standard practice in former preterm infants. However, the literature supporting current protocols is dated. Therefore, we retrospectively evaluated the post-anesthetic risks in these patients.

METHODS

A retrospective review was conducted on former preterm infants admitted after an inguinal herniorrhaphy between 1/00 and 10/09. The protocol for overnight admission was for patients born before 37 weeks gestation who are less than 60 weeks post-conceptional age (PCA).

RESULTS

There were 363 patients, of which 23 were <40 weeks PCA (group 1), 244 were 40 to 49.9 weeks PCA (group 2), and 96 were 50 to 60 weeks PCA (group 3). Events registered by alarms occurred in 4 patients (1.1%), 2 from group 1 and 2 from group 2. In Group 1, one occurred during nasogastric tube placement and resolved spontaneously. In group 2, one was apnea-induced bradycardia that resolved spontaneously, and one was in a patient on home monitors with an event similar to home reports. There were no events in group 3.

CONCLUSION

Conservative guidelines for overnight observation after inguinal hernia repair could be set for patients born before 37 weeks gestation who are under 50 weeks PCA.

Management of anterior mediastinal masses in children

BACKGROUND

Children with anterior mediastinal masses are at risk for life-threatening airway compromise during anesthesia, and can present a diagnostic and management challenge for pediatric surgeons.

METHODS

We performed a retrospective chart review of all children presenting with an anterior mediastinal mass from 1994-2009. Parameters studied included demographics, historical and physical findings at diagnosis, radiographic evidence of airway compression, diagnostic studies, diagnosis, and complications.

RESULTS

There were 26 patients with anterior mediastinal masses over a 15-year period. The mean age was 11.3 years, and there were no gender differences. The diagnoses were lymphoma (62%, 16/26), leukemia (15%, 4/26), and other (23%, 6/26). Diagnosis was made by CBC/peripheral smear in 2/4 patients with leukemia, by bone marrow biopsy in 2/4 patients with leukemia, by thoracentesis in 3/16 patients with lymphoma, by lymph node biopsies in 6/16 patients with lymphoma, and by biopsy of a mediastinal mass in 7/16 patients with lymphoma and in 6/6 patients with other diagnoses. Radiographic evidence of airway compression was seen in 62% (16/26) of children. Only 12% (3/26) had a tracheal cross-sectional area (TCA) <50%. Correlation of symptoms with anatomical airway obstruction or complications was poor. Pulmonary function studies were obtained in 38%, 10/26 children. Only 2 children had a PEFR (peak expiratory flow rate) <50% predicted. This data also correlated poorly with anatomical airway obstruction or complications. 3 patients had anesthesia-related complications: one desaturation during induction prior to median sternotomy, one with significant desaturation and bradycardia during biopsy under local anesthesia with minimal sedation, and one with prolonged (5 days) mechanical ventilation after general anesthesia. 2 of these patients had a TCA <50%, and 2 had SVC obstructions. There were no anesthesia-related deaths, and the overall survival was 85% (22/26).

CONCLUSION

Anterior mediastinal masses in children should be approached in a step-wise fashion with multi-disciplinary involvement, starting with the least invasive techniques and progressing cautiously. The surgeon should have a well-defined and preoperatively established contingency plan if these children require general anesthesia for diagnosis.

The utility of computed tomography in the management of patients with spontaneous pneumothorax

BACKGROUND

Spontaneous pneumothorax may result from rupture of subpleural blebs. Computed tomography (CT) has been used to identify blebs to serve as an indication for thoracoscopy. We reviewed our experience with spontaneous pneumothorax to assess the utility of CT in these patients.

METHODS

A retrospective review was conducted of all patients who underwent an operation for spontaneous pneumothorax from January 1999 to October 2009. All procedures were performed thoracoscopically.

RESULTS

We identified 39 pneumothoraces in 34 patients who underwent evaluation and a procedure for spontaneous pneumothorax. Mean age was 16.1 years (range, 10-23 years), with an average of 1.7 spontaneous pneumothoraces before operation (range, 1-4). Preoperative chest CT scans were obtained in 26 cases. Blebs were demonstrated on 8 CT scans. The presence of blebs was confirmed at operation in all 8 patients. Of the 18 negative scans, 14 (77.8%) were found to have blebs intraoperatively, 7 of these patients were initially managed nonoperatively and developed recurrence. The sensitivity of CT for identifying blebs was 36%.

CONCLUSIONS

Chest CT does not appear to be precise in the identification of pleural blebs and a negative examination does not predict freedom from recurrence. Operative decisions should be based on clinical judgment without the use of preoperative CT.

Quality of life assessment between laparoscopic appendectomy at presentation and interval appendectomy for perforated appendicitis with abscess: analysis of a prospective randomized trial

PURPOSE

The current study examined the impact of immediate laparoscopic surgery vs nonoperative initial management followed by interval appendectomy for appendicitis with abscess on child and family psychosocial well-being.

METHODS

After obtaining Internal Review Board approval, 40 patients presenting with a perforated appendicitis and a well-formed abscess were randomized to surgical condition. Parents were asked to complete child quality of life and parenting stress ratings at presentation, at 2 weeks postadmission, and at approximately 12 weeks postadmission (2 weeks postoperation for the interval appendectomy group).

RESULTS

Children in the interval arm experienced trends toward poorer quality of life at 2 and 12 weeks postadmission. However, no group differences in parenting stress were observed at 2 weeks postoperation. At 12 weeks postadmission, participants in the interval condition demonstrated significant impairment in both frequency and difficulty of problems contributing to parenting distress.

CONCLUSION

Families experience significant parenting distress related to the child's functioning and disruption in the child's quality of life that may be because of the delay in fully resolving the child's medical condition. In addition, parents experience negative consequences to their own stress as a result of the delay before the child's appendectomy.

Outcomes in children with hypoplastic left heart syndrome undergoing open fundoplication

BACKGROUND/PURPOSE

Some institutions recommend early fundoplication in patients with hypoplastic left heart syndrome (HLHS) with signs of gastroesophageal reflux disease because of the risk of reflux-related cardiac events. However, their cardiac physiology may impose high perioperative morbidity and mortality. Therefore, we reviewed our experience with fundoplication in this population to allow for assessment of the risk-benefit ratio.

METHODS

A retrospective review of patients with a diagnosis of HLHS who underwent a fundoplication from January 1990 to July 7, 2009, was performed. All patients underwent open fundoplication between first and second stages of cardiac repair.

RESULTS

Thirty-nine patients were identified. There were 3 intraoperative complications: hemodynamic instability (n = 2) and a pulmonary hypertensive crisis requiring extracorporeal membrane oxygenation and termination of the procedure (n = 1). There were 27 postoperative complications in 16 patients. There were 2 deaths (4%) within 30 days, and there were 9 deaths (23%) in patients between their first and second stage of cardiac repair during the study period.

CONCLUSIONS

Noncardiac surgical procedures in patients palliated for HLHS have a high morbidity and mortality. We recommend that routine fundoplication in this population should only be performed under prospective protocols until the relative risk of operation vs risk of reflux is delineated.

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.

Laparoscopic ileocecectomy in pediatric patients with Crohn's disease

INTRODUCTION

Definitive management for medically refractory ileocecal Crohn's disease is resection with primary anastomosis. Laparoscopic resection has been demonstrated to be effective in adults. There is a relative paucity of data in the pediatric population. We therefore audited our experience with laparoscopic ileocecectomy in patients with medically refractory ileocecal Crohn's disease to determine its efficacy.

METHODS

We conducted a retrospective review of all pediatric patients who underwent laparoscopic ileocecal resection for medically refractory Crohn's disease at a single institution from 2000 to 2009.

RESULTS

Thirty patients aged 10-18 years (mean: 15.3 years) with a mean weight of 50 kg (standard deviation: ± 15.5 kg) underwent laparoscopic ileocecectomy for Crohn's disease. Five of these were performed using a single-incision laparoscopic approach. The indications for surgery were obstruction/stricture (21), pain (10), abscess (3), fistula (3), perforation (2), and bleeding (1). Some patient's had multiple indications. There were a total of five abscesses encountered at operation. Eight patients were on total parenteral nutrition at the time of resection. Twenty-five patients (83.3%) were being treated with steroids at operation. The anastomosis was stapled in 26 patients and hand-sewn in 4. Two patients developed a postoperative abscess, and both of them were taking 20 mg of prednisone daily. One patient developed a small bowel obstruction due to a second Crohn's stricture that manifested itself after the more severe downstream obstruction was relieved with ileocecectomy. Of the 5 patients who underwent a single-incision laparoscopic operation, 3 underwent for obstruction/stricture and 2 for perforation. There were no intraoperative or postoperative complications. The patients were followed up for a maximum of 80.7 months (average: 14.7 months; median: 9.7 months). There were no anastomotic leaks or wound infections.

DISCUSSION

This series demonstrates that laparoscopic ileocecectomy, both single-incision laparoscopic approach and standard laparoscopy, is safe and effective in the setting of medically refractory Crohn's disease in pediatric patients.

Outcomes of laparoscopic and open total colectomy in the pediatric population

INTRODUCTION

Total colectomy, performed either with proctecomy and ileal pouch anal anastomosis or with ileorectostomy, is standard for pediatric patients with ulcerative colitis or familial adenomatous polyposis syndrome, respectively. The complication rates from adult series have been reported to be as high as 40%-50%. We audited our experience to define the complication rates in children and determine whether the use of laparoscopy has the potential to lessen the number or change the type of complications.

METHODS

We conducted a retrospective review of all pediatric patients who underwent total colectomy with either proctectomy with ileal pouch anal anastomosis or with ileorectostomy at a single institution from 1998 to 2008. Data are expressed as mean +/- standard deviation. Continuous variables were analyzed using a Student's t-test; and discrete variables were analyzed using a Fisher's exact test, where appropriate. Significance was set as P < or = 0.05.

RESULTS

Forty-four patients aged 58 days to 18 years (mean 11.7 +/- 5.3 years) underwent total colectomy from 1998 to 2008. The indications for surgery were ulcerative colitis (27), familial adenomatous polyposis syndrome (11), total colonic Hirschprungs (2), and others (3). Follow-up was significantly greater in the open group (2.8 years) than in the laparoscopic group (1.1 years, P = 0.02). Nineteen patients (43%) suffered major complications (other than pouchitis). There was 1 anastomotic leak. There were no statistically significant differences found between the laparoscopic and open approaches with regard to postoperative small bowel obstruction, postoperative abdominal or pelvic abscess, anal stricture requiring dilation, wound infection, other complications, or time to complication. Patients who underwent laparoscopic ileal pouch anal anastomosis had one occurrence of pouchitis (1/10) compared with 19/34 in the open group (P = 0.03).

CONCLUSIONS

This series demonstrates that laparopscopic colectomy yields similar outcomes as the traditional open method, both in type and severity of complications. Patients who had an ileal pouch created through the laparoscopic approach had fewer occurrences of pouchitis.

Outcome of congenital diaphragmatic hernia repair depending on patch type

INTRODUCTION

Patch repair of a congenital diaphragmatic hernia is associated with a much higher rate of recurrence than when primary repair is feasible. The biosynthetic options for the repair materials continue to expand. We therefore reviewed our experience to benchmark complication rates as we progress with the use of new materials.

METHODS

A retrospective review was conducted of all patients who underwent repair of congenital diaphragmatic hernia from January 1994 to May 2009.

RESULTS

Of the 155 patients included in the study, 101 patients had primary closure and 54 received a diaphragmatic patch. The rates of recurrence, Small Bowel Obstruction (SBO), and subsequent abdominal operation were all significantly higher in the group of patients requiring patch repair. There were 3 types of patch repairs: 37 patients received a SIS patch, 12 had a nonabsorbable patch, and 5 received an AlloDerm patch. The incidence of SBO in patients with a nonabsorbable mesh was 17% and was associated with a 50% recurrence rate and 67% re-recurrence rate. SIS was associated with 19% incidence of SBO, a recurrence rate of 22% and a 50% re-recurrence rate, whereas AlloDerm had a 40% incidence of SBO, 40% recurrence rate, and 100% re-recurrence rate.

DISCUSSION

As we move towards the next generation of materials, these data do not justify the continued comparison with nonabsorbable patches. We do not have enough comparative data to define a superior biosynthetic material, but we plan to use our data on SIS to benchmark our experience with future generation materials.

Single-incision laparoscopic surgery and the necessity for prospective evidence

Laparoscopic surgery has become the standard approach for most thoracic, abdominal, and pelvic procedures in adults and children. We now know that laparoscopy has proven benefits; however, at its introduction, laparoscopy was adopted without appropriate clinical evidence to justify the approach as an alternative to open surgery. In continued efforts to increase the benefits of minimally invasive surgery to their patients, surgeons have innovated new techniques to further decrease the impact of the operation on patients. These innovations range from decreasing the size of ports and instruments to the current group of techniques termed "scarless" surgery. In the current era of evidence-based medicine, it is the surgeon's responsibility to prove that the benefits outweigh the risk before new techniques are widely applied to patients. This article seeks to review the history of laparoscopic surgery, apply lessons learned to the evolution of single-incision laparoscopic surgery, and make a statement urging for sound prospective evaluation.

15-Year experience in the treatment of rectal prolapse in children

BACKGROUND

Rectal prolapse is a common and usually self-limited condition in children. Several surgical techniques have been advocated for refractory prolapse. We reviewed our experience with treatment and the outcome of refractory rectal prolapse.

METHODS

Retrospective review was conducted on patients undergoing surgery for rectal prolapse from January 1993 to March 2009. Patients with imperforate anus/cloacal abnormalities, Hirschsprung disease, spina bifida, or prior pull-through were excluded.

RESULTS

Twenty patients underwent 23 procedures for rectal prolapse. There were 10 posterior sagittal rectopexies, 6 transabdominal rectopexies, 5 laparoscopic rectopexies, 1 hypertonic saline injection, and 1 anal cerclage. The mean duration of symptoms was 1.6 years (range, 1-10 years). The mean age at operation was 6.8 years (range, 4 months-19 years), with a 5:1 male predominance. There was no operative or perioperative mortality. Median length of follow-up was 7.2 months; 2 patients were lost to follow-up. The overall recurrence rate was 35%. All recurrences followed posterior sagittal rectopexies, which had a 70% recurrence rate. Four patients required reoperation, all done transabdominally (2 open and 2 laparoscopically). None of the 3 remaining patients with mild recurrences required reoperation.

CONCLUSIONS

A variety of options for management of refractory rectal prolapse in children exist. Laparoscopic rectopexy seems to be safe and a comparatively successful option in these children.

Review of the technical variants in the repair of pectus excavatum

INTRODUCTION

Many technical variations have been introduced for the surgical correction of pectus excavatum (PE). The authors reviewed the literature to provide a detailed overview of the general principles of pectus excavatum repair, bar insertion and removal techniques.

MATERIALS AND METHODS

A comprehensive review of the literature was undertaken.

RESULTS

A summary of the different approaches and techniques of pectus excavatum repair, bar insertion and removal is presented. Various procedures, their advantages and disadvantages, the techniques employed and associated complications are discussed in depth.

CONCLUSION

Pectus excavatum repair has undergone many changes since its first description. Despite previous descriptions of evolving procedures, comparative overviews of surgical variations, outcomes after pectus bar insertion and removal techniques are rare in the literature. The authors reviewed the literature to summarize the previous and current understanding of techniques and highlight the variations.

Does an upper gastrointestinal study change operative management for gastroesophageal reflux?

BACKGROUND

In patients with gastroesophageal reflux disease, an upper gastrointestinal (UGI) contrast study is often the initial study performed for those patients being considered for fundoplication. The accuracy of UGI for diagnosing reflux is known to be poor, but there are no data on how often this study influences management. Therefore, we reviewed our experience in patients undergoing fundoplication to quantify the impact of the UGI.

METHODS

A retrospective analysis of our most recent 7-year experience with patients undergoing fundoplication was performed. Results of the diagnostic tests and operative course were recorded.

RESULTS

From January 2000 to June 2007, 843 patients underwent fundoplication. An UGI study was obtained in 656 patients. A pH study was also performed in 379 of these patients who had an UGI. The sensitivity of the UGI for reflux compared with pH study was 30.8%. An abnormality besides gastroesophageal reflux disease or hiatal hernia that impacted the operative plan was found on the UGI in 30 patients (4.5%). The most common anomaly was malrotation, which was found in 26 patients (4.0%). Malrotation was confirmed in 16 patients and ruled out in 6 patients during fundoplication, and 4 patients had undergone a previous Ladd procedure. Esophageal dilation was performed in 5 patients with the fundoplication for a stricture found on the UGI. Pyloroplasty was performed with the fundoplication in 2 patients, and 1 patient underwent exploration of the duodenum for possible obstruction.

CONCLUSIONS

The UGI study is a poor study for accurately delineating which patients have pathologic reflux. However, it reveals a finding that may influence management in approximately 4% of cases.

A review of venovenous and venoarterial extracorporeal membrane oxygenation in neonates and children

The use of extracorporeal membrane oxygenation (ECMO) has increased since its inception. As this modality gained wider acceptance, its application in a variety of disease states has increased. The initial use of ECMO required cannulation of both the carotid artery and internal jugular vein (VA ECMO). Ligation of the carotid artery and concern regarding potential long-term sequelae prompted the development of the single cannula venous only (VV ECMO) technique. Various reports in the literature have compared VV ECMO and VA ECMO. We present a review of the literature with regard to both physiology and clinical application.