Report of 52nd annual meeting of the pacific association of pediatric surgeons

This is the report of the 52nd Annual Association of Pediatric Surgeons held in Christchurch, New Zealand, March 10-March 14, 2019.

Longboard injuries treated at a level 1 pediatric trauma center

INTRODUCTION

Recreation on longboards is gaining in popularity. The purpose of this study is to detail the injury patterns, treatment and management of children with longboarding injuries seen at a level 1 pediatric trauma center.

METHODS

A retrospective review using our trauma registry from 2006 to 2016 of pediatric patients who sustained injuries while riding a longboard.

RESULTS

Of 12,920 injured children, 64 (0.5%) were treated for injuries that occurred while riding a longboard. Median age was 14.5 years (IQR 13.6, 15.4) and 84% were male. Fifty-one (80%) suffered a traumatic brain injury (TBI) including 32 intracranial hemorrhages (ICH), 17 concussions, and 31 skull fractures. Seven (11%) were wearing helmets. Three patients required neurosurgical intervention. Extremity fractures were the most common reason for surgery. Ninety-six percent of patients were admitted to the hospital with a median length of stay of 1 day (IQR 1, 3). All children survived to discharge. Compared with skateboard injuries during the same period, TBI, ICH, concussion, and skull fractures were all greater.

CONCLUSIONS

TBI ranging from concussion to ICH requiring craniotomy is common in children injured while riding a longboard, and greater than rates after skateboarding injuries. Extremity fracture was the most common reason for operative intervention.

LEVEL OF EVIDENCE

III.

Reduction of resource utilization in children with blunt solid organ injury

BACKGROUND/PURPOSE

Nonoperative management of blunt solid organ injuries continues to progress and improve cost-effective utilization of resources while maximizing patient safety. The purpose of this study is to compare resource utilization and patient outcomes after changing admission criteria from a grade-based protocol to one based on hemodynamic stability.

METHODS

A retrospective review of isolated liver and spleen injuries was done using prospectively collected trauma registry data from 2013 to 2017. The 2 years preceding the change were compared to the 2 years after protocol change. All analyses were performed using SAS 9.4.

RESULTS

There were 121 patients in the preprotocol cohort and 125 patients in the postprotocol cohort. Baseline demographics were similar along with injury mechanisms and severity. The ICU admission rate decreased from 40% to 22% (p = 0.002). There were no adverse events on the floor and no patient needed to be transferred to the ICU.

CONCLUSIONS

A protocol for ICU admission based on physiologic derangement versus solely on radiologic grade significantly reduced admission rates to the ICU in children with solid organ injury. The protocol was safe and effectively reduced resource utilization.

LEVEL OF EVIDENCE

Level II, prospective comparison study.

Report of PAPS meeting

This is a report of the Pacific Association of Pediatric Surgeons Fifty-First Scientific Meeting held in Sapporo, Japan, from May 13to May 17, 2018.

Longitudinal analysis of hospital charges following injury in a level 1 pediatric trauma system

BACKGROUND

The treatment of injured children contributes substantially to the financial burden of a health care system. The purpose of this study was to characterize these charges at a level-1 pediatric trauma center.

METHODS

Financial data for children (<14 years) admitted for traumatic injury from 1/2009 to 12/2014 were analyzed. The charges of the index admission and first two years following discharge were evaluated.

RESULTS

5853 trauma patients were included with average annual charges of $11,128,730. The most common mechanisms of injury were fall (44%), sports (12%), and bike (9%). The median ISS was 6 (IQR 4-10) with a mortality rate of 1.8% and Z-score of 13.04 (p<0.001). The overall total charges per patient during the index admission were $9513. Spinal cord and major abdominal injuries had the greatest charges per patient ($55,560 and $23,618 respectively) primarily owing to hospital LOS. During the first year after discharge, the total charges per patient were $1733, of which spinal cord injury resulted in highest overall ($19,426), owing to inpatient rehabilitation. For all other injury patterns, mean total charges per patient were $2376 (range $791-$3573).

CONCLUSIONS

The value proposition in health care requires us to define outcomes relative to costs. Injury severity, major injury location, and hospital length of stay are the highest contributors for the financial burden of pediatric traumatic injury, while inpatient readmissions and inpatient rehabilitation drove higher charges in the years following discharge.

TYPE OF STUDY

Clinical Research Paper.

LEVEL OF EVIDENCE

II - Cohort Study.

Clearance of tunneled central venous catheter associated blood stream infections in children

BACKGROUND

The optimal time to reinsert central venous catheters (tCVC) after a documented central line associated blood stream infection (CLABSI) is unclear. The goal of this study is to identify risk factors for children who develop persistent bacteremia after tCVC removal due to CLABSI.

METHODS

We performed a retrospective cohort study from a tertiary children's hospital. Children who underwent removal of a tCVC due to CLABSI were included in our analysis. Our primary outcome was persistent bacteremia after tCVC removal defined by a persistently positive blood culture. Salient patient demographic and clinical factors were extracted from the medical record.

RESULTS

A total of 140 patients met inclusion criteria and 27 (19%) had a persistent CLABSI after removal of the tCVC. There were no significant differences between the patients who cleared their bacteremia and those who develop persistent bacteremia. The median (IQR) time to positive blood culture after tCVC removal was 2.7 days (1.7- 4.0).

CONCLUSIONS

We did not identify any patient risk factors distinguishing between a child who will clear a CLABSI versus develop a persistent CLABSI after tCVC removal. Blood stream infection clearance was rapid after tCVC removal, supporting a brief line holiday prior to tCVC reinsertion.

LEVEL OF EVIDENCE

Level III Retrospective Case-Control Study.

Paravertebral regional blocks decrease length of stay following surgery for pectus excavatum in children

PURPOSE

Management of postoperative pain following repair of pectus excavatum has traditionally included thoracic epidural analgesia, narcotics, and benzodiazepines. We hypothesized that the use of intercostal or paravertebral regional blocks could result in decreased inpatient length of stay (LOS).

METHODS

We conducted a retrospective cohort study of 137 patients (118 Nuss and 19 Ravitch - Nuss and Ravitch patients were analyzed separately) who underwent surgical repair of pectus excavatum with pain management via epidural, intercostal, or paravertebral analgesia from January 2009-December 2012. Measured outcomes included LOS, pain scores, benzodiazepine/narcotic requirements, emesis, professional fees, hospital cost, and total cost.

RESULTS

In the Nuss patients, LOS was significantly reduced in the paravertebral group (p<0.005) and the intercostal group (p<0.005) compared to the epidural group, but was paradoxically countered by a nonsignificant increase in total cost (p=0.09). While benzodiazepine doses/day was not increased in the paravertebral group (p=0.08), an increase was seen in narcotic use (p<0.005). Despite increased narcotic use, no differences were seen in emesis between epidural and paravertebral use. Compared to epidural, pain scores were higher for both intercostal and paravertebral on day one (p<0.005), but equivalent for paravertebral on day three (p=0.62). The Ravitch group was too small for detailed independent statistical analysis but followed the same overall trend seen in the Nuss patients.

CONCLUSION

Our use of paravertebral continuous infusion pain catheters for pectus excavatum repair was an effective alternative to epidural analgesia resulting in shorter LOS but not a decrease in overall cost.

Effectiveness of an organized bowel management program in the management of severe chronic constipation in children

BACKGROUND

Chronic constipation is a common problem in children. The cause of constipation is often idiopathic, when no anatomic or physiologic etiology can be identified. In severe cases, low dose laxatives, stool softeners and small volume enemas are ineffective. The purpose of this study was to assess the effectiveness of a structured bowel management program in these children.

METHODS

We retrospectively reviewed children with chronic constipation without a history of anorectal malformation, Hirschsprung's disease or other anatomical lesions seen in our pediatric colorectal center. Our bowel management program consists of an intensive week where treatment is assessed and tailored based on clinical response and daily radiographs. Once a successful treatment plan is established, children are followed longitudinally. The number of patients requiring hospital admission during the year prior to and year after initiation of bowel management was compared using Fisher's exact test.

RESULTS

Forty-four children with refractory constipation have been followed in our colorectal center for greater than a year. Fifty percent had at least one hospitalization the year prior to treatment for obstructive symptoms. Children were treated with either high-dose laxatives starting at 2mg/kg of senna or enemas starting at 20ml/kg of normal saline. Treatment regimens were adjusted based on response to therapy. The admission rate one-year after enrollment was 9% including both adherent and nonadherent patients. This represents an 82% reduction in hospital admissions (p<0.001).

CONCLUSIONS

Implementation of a structured bowel management program similar to that used for children with anorectal malformations, is effective and reduces hospital admissions in children with severe chronic constipation.

Impact of newly adopted guidelines for management of children with isolated skull fracture

PURPOSE

In an effort to standardize practices and reduce unnecessary hospital resource utilization, we implemented guidelines for management of patients with isolated skull fractures (ISF). We sought to examine the impact of these guidelines.

METHODS

Patients with nondisplaced/depressed fracture of the skull vault without intracranial hemorrhage were prospectively enrolled from February 2010 to February 2014.

RESULTS

Eighty-eight patients (median age=10months) were enrolled. Fall was the most common mechanism of injury (87%). The overall admission rate was 57%, representing an 18% decrease from that reported prior to guideline implementation (2003-2008; p=0.001). Guideline criteria for admission included vomiting, abnormal neurologic exam, concern for abuse, and others. Forty-two percent of patients were admitted outside of the guideline, primarily because of young age (20%). Patients transferred from another hospital (36%) were more likely to be admitted, though the majority (63%) did not meet admission criteria. No ED-discharged patient returned for neurologic symptoms, and none reported significant ongoing symptoms on follow-up phone call.

CONCLUSIONS

Implementation of a new guideline for management of ISF resulted in a reduction of admissions without compromising patient safety. Young age remains a common concern for practitioners despite not being a criterion for admission. Interhospital transfer may be unnecessary in many cases.

Magnamosis: a novel technique for the management of rectal atresia

We report a case of rectal atresia treated using magnets to create a rectal anastomosis. This minimally invasive technique is straightforward and effective for the treatment of rectal atresia in children.

Sclerotherapy for intra-abdominal lymphatic malformations in children

PURPOSE

Sclerotherapy is well described as a treatment for lymphatic malformations (LMs) in the head, neck, and other soft tissue areas. This study aims to evaluate the effectiveness of intralesional sclerotherapy as primary treatment for intra-abdominal LMs in children.

METHODS

We conducted a retrospective review from 2008 to 2012 of all children with intra-abdominal LMs treated with sclerotherapy at our tertiary children's hospital.

RESULTS

In this study, five patients underwent sclerotherapy as a primary intervention for intra-abdominal LMs. The ages of these patients ranged from 12 to 52 months at the time of initial treatment. Doxycycline was used as the primary sclerotherapy agent. The patients required between three and five (median 3) sclerosing treatments over a period that ranged from 5 to 366 days (median 28). No child has required an operation and all LMs have decreased in size. The median decease in maximum diameter is 62% (21-67). Complete resolution has not been attained but all have experienced symptomatic relief with a median follow-up of 3 (1-24) months.

CONCLUSIONS

Sclerotherapy is an effective first-line therapy for intra-abdominal LMs in the pediatric population and should be considered when treating these difficult lesions.

Musculoskeletal deformities following repair of large congenital diaphragmatic hernias

PURPOSE

Large congenital diaphragmatic hernias (CDH) can be repaired with either a muscle flap or prosthetic patch. The purpose of this study was to assess the frequency and severity of scoliosis, chest wall, and abdominal wall deformities following these repairs.

METHODS

Neonates who underwent CDH repair (1989-2012) were retrospectively reviewed. We then validated our retrospective review by comparing results of a focused radiologic evaluation and clinical examination of patients with large defects seen in prospective follow-up clinic. Tests for association were made using Fisher's exact test.

RESULTS

236 patients survived at least 1year. Of these patients, 30 had a muscle flap, and 13 had a patch repair. Retrospectively, we identified pectus in 9% of primary repairs, 47% of flap repairs, and 54% of patch repairs. We identified scoliosis in 7% of primary repairs, 13% of flap repairs, and 15% of patch repairs. Prospectively, 75% of flap patients and 67% of patch patients had pectus and 13% of flap patients and 33% of patch patients had scoliosis. There was no significant difference between flap and patch patients.

CONCLUSIONS

Scoliosis and pectus deformity were common in children with large CDH. The operative technique did not appear to affect the incidence of subsequent skeletal deformity.

Treatment and outcome of traumatic biliary injuries in children

BACKGROUND/PURPOSE

Traumatic biliary tract injuries in children are rare but may result in significant morbidity. The objective of this study was to review the occurrence of traumatic biliary tract injuries in children, management strategies, and outcome.

METHODS

We conducted a retrospective review of patients with biliary tract injury using the trauma registry at our level 1 pediatric trauma center from 2002-2012.

RESULTS

Twelve out of 13,582 trauma patients were identified, representing 0.09% of all trauma patients. All were secondary to blunt trauma. Mean age was 9.7 years [range 4-15], and mean Injury Severity Score was 31 ± 14, with overall survival of 92%. Biliary injuries included major ductal injury (6), minor ductal injury with biloma (4), gallbladder injury (2), and intrahepatic ductal injury (1). Major ductal injuries were managed by endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent (5) and Roux-en-Y hepaticojejunostomy (1). Associated gallbladder injury was managed by cholecystectomy. In addition, the associated biloma was managed with percutaneous drainage (7), laparoscopic drainage (2), or during laparotomy (3). Two patients with ductal injuries developed late strictures after initial management with ERCP and stent placement. One of the two patients ultimately required a left hepatectomy, and the other has been managed conservatively without evidence of cholangitis. Two patients required placement of additional drains and prolonged antibiotics for superinfection following biloma drainage.

CONCLUSION

Biliary tract injuries are rare in children, and many are amenable to adjunctive therapy, including ERCP and biliary stent placement with or without placement of a peritoneal drain. Patients with a discrete ductal injury are at higher risk for stricture and require close follow up. Hepaticojejunostomy remains the definitive repair for large extrahepatic biliary tract injuries or transections.

Complete VACTERL evaluation is needed in newborns with rectoperineal fistula

PURPOSE

Given that a rectoperineal fistula is developmentally the most mature lesion in the spectrum of anorectal malformations, it is not clear whether it merits a complete VACTERL evaluation. We sought to determine if the same evaluation is required to rule out associated anomalies in newborns with rectoperineal fistula as those with more complex anorectal malformations.

METHODS

We performed a retrospective review of the pediatric colorectal center database at our tertiary care children's hospital from 2000 to 2012. Patients with anorectal malformations were categorized as rectoperineal fistula or "other" using the Krickenbeck classification. Records were reviewed to identify associated anomalies.

RESULTS

308 patients (156 males) were treated at our institution during the time period (rectoperineal fistula=102). Thirty-five (34%) patients with a perineal fistula had at least one associated anomaly. The most common anomalies were cardiac lesions (29% excluding PFO and PDA), genitourinary (20.6%), and malformations of the spine (15.7%). The overall occurrence of anomalies was lower than the "other" group.

CONCLUSION

Our review demonstrates that newborns with a rectoperineal fistula frequently have associated anomalies and should undergo an evaluation similar to more complex lesions. These findings illustrate the importance of a structured approach to the evaluation of even the most straightforward lesions.

Decompressive laparotomy for abdominal compartment syndrome in children on ECMO: effect on support and survival

PURPOSE

Abdominal compartment syndrome (ACS) may complicate ECMO due to significant fluid shifts resulting in tense ascites and interstitial edema. This compromises venous cannula flow leading to inadequate patient support. It is debatable whether decompressive laparotomy should be performed in these patients due to the risk of bleeding and poor prognosis. We sought to evaluate the effect of decompressive laparotomy on ECMO support and patient survival.

METHODS

We reviewed our tertiary care children's hospital ECMO registry (2000-2011) identifying those who underwent decompressive laparotomy. All had ACS as characterized by abdominal hypertension with abdominal distention, hemodynamic instability, oliguria, rising central venous pressures, and inadequate venous return to the ECMO circuit. Physiologic parameters immediately before and 60 min after laparotomy were compared using a signed rank test.

RESULTS

Seven patients were identified. ACS developed within 8 h of initiating ECMO in 6 patients. Decompressive laparotomy resulted in significant improvement of patient physiologic parameters and ECMO venous return. One patient had significant bleeding following laparotomy. There were no survivors but three were organ donation candidates after stabilization via decompressive laparotomy.

CONCLUSION

Decompressive laparotomy for ACS in patients on ECMO markedly improves support and tissue perfusion. While in our series ECMO complicated by ACS carries a poor prognosis, we cannot confidently define this as futile therapy due to the limited sample size.

Split abdominal wall muscle flap repair vs patch repair of large congenital diaphragmatic hernias

PURPOSE

Large congenital diaphragmatic hernias are commonly repaired with a prosthetic patch. We hypothesized that a split abdominal wall muscle flap would reduce the risk of recurrence.

METHODS

A retrospective review of neonates with congenital diaphragmatic hernia in whom primary repair was not possible was performed. Kaplan-Meier analyses and Cox proportional hazards modeling were performed.

RESULTS

Of 153 patients, 46 could not have repair with primary closure of the diaphragm. Thirty-three survived to discharge and were subjected to analysis for recurrence. Ten underwent repair with a patch, whereas 23 had a muscle flap (internal oblique and transversalis) patch. The groups were similar with regard to demographics, need for extracorporeal membrane oxygenation, repair on extracorporeal membrane oxygenation, and size of the defect. Fifty percent of patch repairs recurred with a median time of 0.5 years. Only one (4.3%) of the patients who had muscle flap patch developed a recurrence. This was significant on Kaplan-Meier analysis (P = .0009) and had a hazard ratio of 14.3 on Cox regression (P = .018). Median follow-up exceeded 4 years. No children required surgery for an abdominal wall hernia.

CONCLUSIONS

The split abdominal wall muscle flap allows for closure of large congenital diaphragmatic hernia defects with autologous tissue. This approach is associated with significantly fewer recurrences than patch repairs.

Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation

PURPOSE

The management of children presenting with an isolated skull fracture (ISF) posttrauma is highly variable. We sought to estimate the risk of neurologic deterioration in children with a Glasgow coma score (GCS) 15 and ISF to reduce unnecessary hospital admissions.

METHODS

A retrospective review at a level I pediatric trauma referral center was conducted for patients with ISF on head computed tomography from 2003 to 2008. Patients were excluded for injury greater than 24 hours prior, GCS less than 15, intracranial pathology, significant fracture depression, or complex fractures involving facial bones or skull base.

RESULTS

A total of 235 patients were identified with an ISF. The median age was 11 months, with falls accounting for 87% of the injuries. One hundred seventy-seven patients were admitted, and 58 patients were discharged from the emergency department after a period of observation (median, 3.3 hours). Median length of stay for those admitted to the hospital was 18.2 hours. One patient developed vomiting following overnight observation and a repeat computed tomography scan demonstrated a small extra-axial hematoma that required no intervention. The mean total costs for patients discharged from the emergency department were $291 vs $1447 for those admitted for observation (P < .001).

CONCLUSION

Patients with a presenting GCS of 15 and an ISF can be safely discharged from the emergency department after a short period of observation if they are asymptomatic and have a reliable social environment. This could result in significant savings by eliminating inpatient costs.

Prophylactic appendectomy: unnecessary in children with incidental appendicoliths detected by computed tomographic scan

PURPOSE

Controversy exists regarding the clinical significance of an isolated appendicolith on computed tomographic (CT) scan. We sought to determine the risk of developing appendicitis in children with an incidentally noted appendicolith.

METHODS

We retrospectively reviewed all pelvic CT scans in patients 18 years or younger at a tertiary care children's hospital from October 2005 to September 2008. Patients with an appendicolith and no radiographic evidence of acute appendicitis were selected for further review. Written questionnaire and telephone follow-up were attempted in all patients.

RESULTS

Two thousand nine hundred thirteen pelvic CT scans were performed during the study period. The incidence of an isolated appendicolith during the study period was 2.6% (n = 75). Seven patients underwent appendectomy at initial presentation. Nine children underwent appendectomy subsequently: 3 electively and 6 at the time of return with abdominal pain. Only 6 of these 16 appendectomy specimens had histologic evidence of appendicitis, whereas only 3 demonstrated an appendicolith. Subsequent appendicitis developed in 5.8% (n = 4) of patients with an isolated appendicolith. Follow-up was achieved in 50% of patients who did not have an appendectomy (median, 2.8 years).

CONCLUSION

Children with an incidental appendicolith are at low risk for developing appendicitis. The appendicoliths were often a transient finding not confirmed on surgical pathologic condition or subsequent imaging.

Managing radiation risk in the evaluation of the pediatric trauma patient

Pediatric trauma is usually a nonoperative experience for the pediatric general surgeon. The pediatric trauma surgeon resuscitates the child and then evaluates and triages the identified injuries. A common diagnostic tool is the computed tomography (CT) scan. Most children who require evaluation for significant trauma will get a CT scan, but there are no national guidelines directing the assessment. Injuries to the head, cervical spine, chest, and abdomen can all be imaged with a CT scan; the question is whether the liberal approach to imaging children is appropriate. Over the past decade, concern has arisen about the radiation dose delivered by CT. This concern has generated a national campaign to "image gently." This article reviews the data involving the risk of medical radiation exposure and discusses strategies for managing the risk.

Decompressive laparotomy for abdominal compartment syndrome in children: before it is too late

PURPOSE

Abdominal compartment syndrome (ACS) in children is an infrequently reported, rapidly progressive, and often lethal condition underappreciated in the pediatric population. This underrecognition can result in a critical delay in diagnosis causing increased morbidity and mortality. This study examines the clinical course of patients treated for ACS at our institution.

METHODS

A review of children requiring an emergency laparotomy (n = 264) identified 26 patients with a diagnosis of ACS. ACS was defined as sustained intraabdominal hypertension (bladder pressure >12 mm Hg) that was associated with new onset organ dysfunction or failure.

RESULTS

Patients ranged in age from 3 months to 17 years old and were cared for in the pediatric intensive care unit (PICU). Twenty-seven percent (n = 7) were transferred from referring hospitals, 50% (n = 13) were admitted directly from the emergency department, and 23% (n = 6) were inpatients before being transferred to PICU. Admission diagnoses included infectious enterocolitis (n = 12), postsurgical procedure (n = 10), and others (n = 4). Patients progressed to ACS rapidly, with most requiring decompressive laparotomy within 8 hours of PICU admission (range, <1-96 hours). Preoperatively, all patients had maximum ventilatory support and oliguria, 85% (n = 22) required vasopressors/inotropes, and 31% (n = 8) required hemodialysis. Mean bladder pressure was 25 mm Hg (range, 12-44 mm Hg). In 42% (n = 11), cardiac arrest preceeded decompressive laparotomy. All patients showed evidence of tissue ischemia before decompressive laparotomy with an average preoperative lactate of 8 (range, 1.2-20). Decompressive laparotomy was done at the bedside in the PICU in 13 patients and in the operating room in 14 patients. Abdominal wounds were managed with open vacuum pack or silastic silo dressings. Physiologic data including fluid resuscitation, oxygen index, mean airway pressure, vasopressor score, and urine output were recorded at 6-hour intervals beginning 12 hours before decompressive laparotomy and extending 12 hours after operation. The data demonstrate improvement of all physiologic parameters after decompressive laparotomy except for urine output, which continued to be minimal 12 hours post intervention. Mortality was 58% (n = 15) overall. The only significant factor related to increased mortality was bladder pressure (P = .046; odds ratio, 1.258). Cardiac arrest before decompressive laparotomy, need for hemodialysis, and transfer from referring hospital also trended toward increased mortality but did not reach significance.

CONCLUSION

Abdominal compartment syndrome in children carries a high mortality and may be a consequence of common childhood diseases such as enterocolitis. The diagnosis of ACS and the potential need for emergent decompressive laparotomy may be infrequently discussed in the pediatric literature. Increased awareness of ACS may promote earlier diagnosis, treatment, and possibly improve outcomes.

Elimination of soybean lipid emulsion in parenteral nutrition and supplementation with enteral fish oil improve cholestasis in infants with short bowel syndrome

BACKGROUND

Parenteral nutrition-associated liver disease (PNALD) is a potentially fatal complication for children with intestinal failure. Fish oil-based lipid emulsions have shown promise for the treatment of PNALD but are not readily available. Six cases are presented in which cholestasis resolved after soybean lipid emulsion (SLE) was removed from parenteral nutrition (PN) and enteral fish oil was given.

METHODS

A retrospective review at a tertiary children's hospital (July 2003 to August 2008) identified 6 infants with intestinal failure requiring PN for >6 months who developed severe hepatic dysfunction that was managed by eliminating SLE and providing enteral fish oil.

RESULTS

Twenty-three infants with short bowel syndrome requiring prolonged PN developed cholestasis. SLE was removed in 6 of these patients, and 4 of the 6 received enteral fish oil. Standard PN included 2-3 g/kg/d SLE with total PN calories ranging from 57 to 81 kcal/kg/d at the time of SLE removal. Hyperbilirubinemia resolved after elimination of SLE within 1.8-5.4 months. Total PN calories required to maintain growth generally did not change.

CONCLUSIONS

Temporary elimination of SLE and supplementation with enteral fish oil improved cholestasis in PN-dependent infants. Further trials are needed to evaluate this management strategy.

Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age

OBJECT

Cervical spine clearance after trauma in children 0-3 years of age is deceptively difficult. Young children may not be able to communicate effectively, and severe injuries may require intubation and sedation. Currently, no published guidelines are available to aid in decision-making in these complex situations. The purpose of this study was to determine whether a safe and effective protocol-driven system could be developed for clearance of the cervical spine in noncommunicative children between 0 and 3 years of age.

METHODS

Children 0-3 years of age, including intubated patients, who were admitted after trauma activation at Primary Children's Medical Center in Salt Lake City or the Children's Hospital of New York from 2002 to 2006 were managed according to a cervical spine clearance protocol. Data were collected in a prospective fashion. Radiographic and clinical methods of clearing the cervical spine, as well as the type and management of injuries, were recorded.

RESULTS

A total of 2828 pediatric trauma activations required cervical spine clearance during the study period. Of these, 575 (20%) were children <or= 3 years of age who were admitted to the hospital. To facilitate clearing the cervical spine in these children, plain radiographs (100%), CT studies (14%), and MR images (10%) were obtained. Nineteen ligamentous injuries (3.3%) and 9 fractures/dislocations (1.5%) were detected, with 4 patients requiring operative stabilization (0.7%). No late injuries have been detected.

CONCLUSIONS

The protocol used has been effective in detecting cervical spine injuries in noncommunicative children after trauma. The combination of clinical information and radiographic studies is essential for safely clearing the cervical spine in these complex situations. Clearance of the cervical spine without CT or MR imaging studies is possible in the majority of cases, even in very young patients.

Use of focused abdominal sonography for trauma at pediatric and adult trauma centers: a survey

PURPOSE

Focused abdominal sonography for trauma (FAST) has been popularized for the initial evaluation of trauma patients. We sought to understand the scope of practice on a national level with specific attention to its use in the pediatric age group.

METHODS

An electronic survey was sent to all American College of Surgeons level I trauma centers and the National Association of Children's Hospitals and Related Institutions that were freestanding children's hospitals.

RESULTS

The survey was emailed to 124 centers, and 98 (79%) completed the survey. Of the surveyed centers, 23% cared for adults only, 28% were freestanding children's hospitals, and 49% managed both. At adults-only institutions, 96% use FAST and at children's hospitals, only 15%; it is used at 85% of centers that care for both. For the centers that use FAST on children, 88% have no age limit. Of all the institutions that typically use FAST, the individual performing the examination could be a surgeon (73%), an emergency department doctor (48%), or a radiologist (3%). Of the centers that perform FAST, 51% bill for the FAST examination.

CONCLUSIONS

Adult hospitals are much more likely to perform FAST examinations in the trauma patient, and many adult centers routinely use FAST to examine pediatric patients.

Division of the fistula in laparoscopic-assisted repair of anorectal malformations-are clips or ties necessary?

BACKGROUND

Laparoscopic-assisted anorectoplasty (LAARP) was introduced in 2000 by Georgeson (J Pediatr Surg. 2000;35:927-930) and has gained interest because of improved visualization of the rectal fistula and the ability to place the pull-through segment within the levator muscle complex with minimal dissection. Currently, there is no consensus on how the fistula should be managed during LAARP. We postulated that the fistula could be managed with simple division and temporary diversion of urine through a Foley catheter without surgical ligation of the fistula similar to the management of a traumatic urethral injury.

METHODS

A retrospective chart review was performed of patients with imperforate anus who underwent LAARP between January 2005 and September 2007.

RESULTS

Eight patients were managed with a LAARP. Five male patients had the fistula simply divided. In these 5 patients, the location of the fistula was rectoprostatic (2) and rectobulbar (3). The Foley catheter was left in position until a retrograde urethrogram demonstrated no evidence of a leak (range, 6-40 days). There were no postoperative urethral strictures and one diverticulum. Follow-up has ranged from 10 to 19 months.

CONCLUSION

Male patients with a rectourethral fistula at or just below the prostate can be safely and successfully managed with simple division of the fistula.

Closed gastroschisis: total parenteral nutrition-free survival with aggressive attempts at bowel preservation and intestinal adaptation

BACKGROUND

In infants with gastroschisis antenatal closure of the umbilical defect results in a proximal atresia with ischemia and/or volvulus of the extracorporeal midgut. It has been described as "closed gastroschisis" or "vanishing midgut."

METHODS

A 10-year review of 219 gastroschisis patients identified 10 infants with this rare complication.

RESULTS

In these 10 infants, the extracorporeal midgut was invariably matted and fibrosed. In 3 cases, the midgut had completely "vanished." In the remaining 7 cases, the remnant midgut was surgically reduced into the abdominal cavity with care not to compromise the diminutive vascular pedicle. Abdominal exploration was performed several weeks later to reestablish bowel continuity; 4 required an ostomy and 2 underwent a serial transverse enteroplasty. Mean residual length of salvaged small bowel was 79 cm with retention of the distal half of the colon. Eight infants survived the initial hospitalization, with a mean length of stay of 121 days and mean hospital charge of $287,094. Six of the 7 long-term survivors have been completely weaned off total parenteral nutrition.

CONCLUSION

A nihilistic attitude toward infants with closed gastroschisis may not be uniformly supported because in the majority of these infants' long-term independence from total parenteral nutrition was achieved.

The split abdominal wall muscle flap repair for large congenital diaphragmatic hernias on extracorporeal membrane oxygenation

BACKGROUND

Numerous techniques exist for repairing large congenital diaphragmatic hernias (CDHs) including prosthetic patches, tissue-engineered grafts, and various muscle flaps. A split abdominal wall muscle flap is a simple, durable way to repair a large diaphragmatic hernia. This technique has not gained widespread use, and some have suggested that it would be inappropriate in the setting of extracorporeal membrane oxygenation (ECMO) because of bleeding risk. We present our series of diaphragmatic hernias with a focus on those repaired with the split abdominal wall technique while on ECMO.

METHODS

A retrospective, single-institution chart review was performed on all patients who underwent surgical repair for CDH over 6 years beginning in August 2000.

RESULTS

Seventy-five patients underwent repair. Sixteen were performed with patients on ECMO. Of these, 4 were closed primarily, 7 used a prosthetic patch, and 5 used a split abdominal wall muscle flap. Two patients in the prosthetic group developed a recurrent hernia, and 2 required reoperation for bleeding while on ECMO. No reoperations for bleeding were required in the abdominal muscle flap group.

CONCLUSIONS

The split abdominal wall muscle flap can be safely performed on anticoagulated patients. We believe it is a practical option for repairing large CDHs.

Temporary abdominal vacuum-packing closure in the neonatal intensive care unit

BACKGROUND

Temporary abdominal vacuum-packing (vac-pac) closure is well known in adult literature, yet has not been reported in infants.

METHODS

A review of children in the neonatal intensive care unit who underwent vac-pac closure from 2000 to 2006 was performed.

RESULTS

During this time, 7 infants underwent vac-pac closure after abdominal surgery. Median age was 39 days, with a median weight of 3.2 kg. Reasons for vac-pac included abdominal compartment syndrome (3), ongoing intraabdominal sepsis (1), anticipated second-look procedures (2), and abdominal observation after repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation (1). PaCO2 revealed a drop from a median preoperative level of 50.3 to 44.0 mm Hg postoperatively. Median preoperative urine output was 3.9 and 3.1 mL/(kg h) postoperatively. One patient died with an open abdomen from overwhelming Escherichia coli sepsis, and all surviving patients (85.7%) proceeded to definitive abdominal closure with the median time of vac-pac use being 4 days.

CONCLUSION

Vac-pac closure in infants is a safe and effective method of temporary abdominal closure. The detrimental effects of intraabdominal hypertension as well as risk of hemorrhage after repair of congenital diaphragmatic hernia while on extracorporeal membrane oxygenation also make this an important technique for abdominal observation.

Cervical spine clearance after trauma in children

OBJECT

Currently, no diagnostic or procedural standards exist for clearing the cervical spine in children after trauma. The establishment of protocols has been shown to reduce the time required to accomplish clearance and reduce the number of missed injuries. The purpose of this study was to determine if reeducation and initiation of a new protocol based on the National Emergency X-Radiography Utilization Study criteria could safely increase the number of pediatric cervical spines cleared by nonneurosurgical personnel.

METHODS

The authors collected and reviewed data regarding cervical spine clearance in children (age range 0-18 years) who presented to the emergency department at Primary Children's Medical Center in Salt Lake City, Utah, between 2001 and 2006 after sustaining significant trauma. Radiographic and clinical methods of clearing the cervical spine, as well as the type and management of injuries, were determined for two periods: Period I (January 2001-December 2003) and Period II (January 2004-February 2006). Between 2001 and 2003, 95% of 936 cervical spines were cleared by the neurosurgical service. Twenty-one ligamentous injuries (2.2%) and 12 fracture/dislocations (1.3%) were detected, and five patients (0.5%) required operative stabilization. Since January 2004, 585 (62.4%) of 937 cervical spines have been cleared by nonneurosurgical personnel. Twelve ligamentous injuries (1.3%) and 14 fracture/dislocations (1.5%) were identified, and four patients (0.4%) required operative stabilization. No late injuries were detected in either time period.

CONCLUSIONS

The protocol outlined in the paper has been effective in detecting cervical spine injuries in children after trauma and has increased the number of cervical spines cleared by nonneurosurgical personnel by nearly 60%. Reeducation with the establishment of protocols can safely facilitate clearance of the cervical spine after trauma by nonneurosurgical personnel.

The Failure of Nonoperative Management in Pediatric Solid Organ Injury: A Multi-institutional Experience

BACKGROUND

Nonoperative management (NOM) is the accepted treatment of most pediatric solid organ injuries (SOI) and, is typically successful. We sought to elucidate predictors of, and the time course to, failure in the subset of children suffering SOI who required operative intervention.

METHODS

A retrospective analysis was performed from January 1997 through December 2002 of all pediatric patients (age 0-20 years) with a SOI (liver, spleen, kidney, pancreas) from the trauma registries of seven designated, level I pediatric trauma centers. Failure of NOM was defined as the need for intra-abdominal operative intervention. Data reviewed included demographics, injury mechanism, injury severity (ISS, AIS, SOI grade, and GCS), and outcome. For the failures of NOM, time to operation and relevant clinical variables were also abstracted. A summary AIS (sAIS) was calculated for each patient by summing the AIS values for each SOI, to account for multiple SOI in the same patient. Univariate and multivariate analyses were employed, and significance was set at p < 0.05.

RESULTS

A total of 1,880 children were identified. Of these, 62 sustained nonsurvivable head injuries that precluded assessment of NOM outcome and were thus excluded. The remaining 1,818 patients comprised the overall study population. There were 1,729 successful NOM patients (controls -- C) and 89 failures (F), for an overall NOM failure rate of 5%. For isolated organ injuries, the failure rates were: kidney 3%, liver 3%, spleen 4%, and pancreas 18%. There were 14 deaths in the failure group from nonsalvageable injuries (mean ISS = 54 +/- 15). The two groups did not differ with respect to mean age or gender. An MVC was the most common injury mechanism in both groups. Only bicycle crashes were associated with a significantly increased risk of failing NOM (RR = 1.76, 95% CI = 1.02-3.04, p < 0.05). Injury severity and organ specific injuries were associated with NOM failure. When controlling for ISS and GCS, multivariate regression analysis confirmed that a sAIS > or = 4, isolated pancreatic injury, and >1 organ injured were significantly associated with NOM failure (p < 0.01). The median time to failure was 3 hours (range, 0.5-144 hours) with 38% having failed by 2 hours, 59% by 4 hours, and 76% by 12 hours.

CONCLUSIONS

Failure of NOM is un common (5%) and typically occurs within the first 12 hours after injury. Failure is associated with injury severity and multiplicity, as well as isolated pancreatic injuries.

The prevalence of driveway back-over injuries in the era of sports utility vehicles

BACKGROUND

Small children are vulnerable to serious accidents when a motor vehicle is placed in motion in a driveway. We describe a series of such accidents, consider the predisposing factors, and analyze the outcomes.

METHODS

We conducted a retrospective review of the trauma database of a large, level I, freestanding children's hospital with specific attention to driveway auto-pedestrian accidents.

RESULTS

During an 8-year period, 495 children were treated for injuries sustained in auto-pedestrian accidents, with 128 occurring in the driveway. The children's median age was 2.9 years, with 54% of the injuries sustained by boys. These often serious accidents carried an overall mortality rate of 6%. The most common injuries were abrasions, blunt head injury, and fractures. Chest trauma was associated with the highest mortality (11%), and both chest and abdominal trauma had the highest median Injury Severity Score of 13. Orthopedic injuries were the most common reason for operative intervention. Thirty-one percent of the children required intensive care unit monitoring, with their average unit stay being 3.9 days. Cars, trucks, and sports utility vehicles comprised 55%, 25%, and 12% of the accidents, respectively. Truck accidents carried the highest mortality rate (19%). Accidents were more likely to occur between 3:00 and 8:00 pm, between Thursday and Saturday, and between May and October. An increasing number of accidents occurred during the last 4 years of the study.

CONCLUSIONS

Driveway injuries are an underrecognized often severe form of auto-pedestrian accidents. To prevent these family tragedies, drivers of large vehicles with children younger than 12 years old should be extremely attentive and account for children outside the vehicle before moving.

CT scan and the pediatric trauma patient--are we overdoing it?

BACKGROUND

Recent literature expresses concern for an increased risk of cancer in children exposed to low-dose radiation during computed tomography (CT). In response, children's hospitals have implemented the ALARA (as low as reasonably achievable) concept, but this is not true at most adult referring institutions. The purpose of this study was to assess the diagnostic necessity of CT in the evaluation of pediatric trauma patients.

METHODS

A retrospective review was conducted of the trauma database at a large, level I, freestanding children's hospital with specific attention to the pattern of CT evaluations.

RESULTS

From January 1999 to October 2003, 1,653 children with traumatic injuries were evaluated by the trauma team, with 1,422 patients undergoing 2,361 CT scans. Overall, 54% of obtained scans were interpreted as normal. Fifty percent of treated patients were transferred from referring hospitals. Approximately half arrived with previous CT scans with 9% of these requiring further imaging. Of the 897 patients that underwent abdominal CT imaging, only 2% were taken to the operating room for an exploratory laparotomy. In addition, of those patients who had abnormal findings on an abdominal CT scan, only 5% underwent surgical exploration.

CONCLUSIONS

CT scans are used with regularity in the initial evaluation of the pediatric trauma patient, and perhaps abdominal CT imaging is being used too frequently. A substantial number of these scans come from referral institutions that may not comply with ALARA. The purported risk of CT radiation questions whether a more selective approach to CT evaluation of the trauma patient should be considered.

Management of duodenal injuries in children

BACKGROUND/PURPOSE

The natural history and management of pediatric duodenal injuries are incompletely described. This study sought to review injury mechanism, surgical management, and outcomes from a collected series of pediatric duodenal injuries.

METHODS

A retrospective chart review was conducted for a 10-year period of all children less than 18 years old treated for duodenal injuries at 2 pediatric trauma centers.

RESULTS

Forty-two children were treated for duodenal injuries. There were 33 blunt and 9 penetrating injuries. Injuries were classified using the Organ Injury Scale for the Duodenum. Twenty-four patients underwent operative management by primary repair (18), duodenal resection and gastrojejunostomy (4), or pyloric exclusion (2). Duodenal hematomas were treated nonoperatively in 94% of cases. The average ISS for operative versus nonoperative cases was 23 and 10, respectively. Delay in diagnosis or operative intervention (>24 hours) was associated with increased complication rate (43% v 29%) and hospitalization (32 v 20 days). Nine children requiring surgery experienced delays and were most highly associated with foreign body, child abuse, and bicycle injuries. There were no deaths caused by duodenal injuries.

CONCLUSIONS

Duodenal injuries in children were predominantly blunt and had a low mortality rate. When surgery was required, primary repair was usually feasible.

The split abdominal wall muscle flap--a simple, mesh-free approach to repair large diaphragmatic hernia

PURPOSE

The authors present a technique to repair large diaphragmatic hernias that is simple, can be done primarily, and offers a durable closure with living tissue.

METHODS

A review of congenital diaphragmatic hernias was performed for the period between January 1991 and August 2000. Repair types included primary repair, synthetic patch, or a split abdominal wall muscle flap. The split abdominal wall muscle flap is performed by downward rotation of the internal oblique and transversalis abdominal wall muscles. This repair requires that the initial subcostal incision be positioned at least 4 to 5 cm below the costal margin, low enough to insure an adequate length of muscle will be available to fill the defect.

RESULTS

Eight of 158 children with congenital diaphragmatic hernia underwent repair by abdominal wall muscle flap. Five of 8 had complete agenesis. Five survived the newborn period. Of the survivors, 4 of 5 required an additional surgical procedure, but none have had a recurrent hernia.

CONCLUSIONS

The split abdominal wall muscle flap is an effective technique to close large diaphragmatic hernias. The repair was carried out successfully in 8 patients with massive defects. In the surviving patients, the repair has proven to be a durable restoration of the diaphragm.

Hyperglycemia and Outcomes from Pediatric Traumatic Brain Injury

BACKGROUND

The clinical significance of hyperglycemia after pediatric traumatic brain injury is controversial. This study addresses the relationship between hyperglycemia and outcomes after traumatic brain injury in pediatric patients.

METHODS

We identified trauma patients admitted during a single year to our regional pediatric referral center with head regional Abbreviated Injury Scale scores > or = 3. We studied identified patients for admission characteristics potentially influencing their outcomes. The primary outcome measure was Glasgow Outcome Scale score.

RESULTS

Patients who died had significantly higher admission serum glucose values than those patients who survived (267 mg/dL vs. 135 mg/dL; p = 0.000). Admission serum glucose > or = 300 mg/dL was uniformly associated with death. Admission Glasgow Coma Scale score (odds ratio, 0.560; 95% confidence interval, 0.358-0.877) and serum glucose (odds ratio, 1.013; 95% confidence interval, 1.003-1.023) are independent predictors of mortality in children with traumatic head injuries. CONCLUSION Hyperglycemia and poor neurologic outcome in head-injured children are associated. The pathophysiology of hyperglycemia in neurologic injury after head trauma remains unclear.

Benign liver and biliary tract masses in infants and toddlers

There is a remarkable diversity of conditions encompassed by benign liver masses in infants and toddlers. The most common benign hepatic tumor in this age group is infantile hepatic hemangioendothelioma. Other commonly seen benign tumors are mesenchymal hamartoma and focal nodular hyperplasia. Hepatic adenoma is almost exclusively a disease of older children; primary hepatic teratoma is exceedingly rare. There are several distinguishing characteristics of these benign tumors on radiographic evaluation; however, imaging techniques such as ultrasound scan, computed tomography, and angiography are not always reliable in differentiating benign from malignant tumors. The differential diagnosis of benign hepatic tumors includes nonneoplastic cystic masses including biliary and simple hepatic cysts, hematoma, parasitic cysts, and pyogenic and amebic liver abscess. Choledochal cyst presents with a classic triad of abdominal pain, cholestatic jaundice, and a palpable abdominal mass. They are classified anatomically into 5 subtypes with the most popular types being type I and type IV. Treatment is with complete cyst excision with hepaticojejunostomy reconstruction.