Use of Ultrasound in the Evaluation of Cryptorchidism: A Single-Institution Analysis

INTRODUCTION

The American Urological Association guidelines recommend against the performance of ultrasound and other imaging modalities in the evaluation of patients with cryptorchidism before expert consultation. We aimed to examine our institutional experience with cryptorchidism and measure adherence to currently available guidelines.

METHODS

An institutional review board-approved retrospective review of ultrasound utilization in the evaluation of patients with cryptorchidism was performed from June 1, 2016, to June 30, 2019, at a single tertiary level pediatric hospital.

RESULTS

We identified 1796 patients evaluated in surgical clinics for cryptorchidism. Surgical intervention was performed in 75.2% (n = 1351) of the entire cohort. Ultrasound was performed in 42% (n = 754), most of which were ordered by referring physicians (91% n = 686). Of those who received an ultrasound, surgical intervention was performed in 78% (n = 588). Those 166 patients (22%) who did not undergo surgical intervention were referred with ultrasounds suggesting inguinal testes; however, all had normal physical examinations or mildly retractile testes at the time of consultation and were discharged from the outpatient clinic. There were 597 patients referred without an ultrasound, 81% (n = 483) were confirmed to have cryptorchidism at the time of specialist physical examination and underwent definitive surgical intervention, the remainder (19%, n = 114) were discharged from the outpatient clinics.

CONCLUSIONS

Ultrasound evaluation of cryptorchidism continues despite high-quality evidence-based guidelines that recommend otherwise, as they should have little to no bearing on the surgeon's decision to operate or the type of operation. Instead, physical examination findings should guide surgical planning.

Determining the Optimal Technique for Bar Fixation in the Repair of Pectus Excavatum

Introduction: Pectus bar stabilizers are routinely used for bar fixation in the repair of pectus excavatum. We aimed to determine the optimum technique for bar fixation by reviewing our institutional experience with the use of bilateral, unilateral, and no stabilizer placement. Methods: Retrospective single pediatric center review of patients who underwent minimally invasive bar placement for pectus excavatum and subsequent bar removal between December 2001 and July 2019 was performed. Demographic data, details about the surgery, the number of bars and stabilizers used, and follow-up information were collected. Stabilizer-related complications included pain requiring stabilizer removal, surgical site infections (SSIs), and bar displacement. Data are presented as medians with interquartile ranges (IQRs) and frequencies with percentages. Results: A total of 561 patients were included. The cohort was predominantly male (83.1%, n = 466) with a median age at the time of bar placement of 15 years (IQR 12.4, 16.3) and a median Haller index of 3.8 (IQR 3.4, 4.5). Pain attributed to the stabilizer site that required removal was observed only in the bilateral stabilizer group (2.5%, n = 13). SSI related to the stabilizer site occurred in 1.8% (n = 9) of the bilateral stabilizer cases and 2.1% (n = 1) of the unilateral stabilizer cases. Bar displacement was observed in 0.6% (n = 3) of the bilateral stabilizer cases and 2 of those patients also had an SSI. There were no complications in the no stabilizer group. Conclusion: As the trend moves toward unilateral and no stabilizer use, we observe fewer cases of pain requiring stabilizer removal with no increase in bar displacements.

Evaluation of Post-neonatal Intensive Care Unit Home Irrigations Prior to Pull-through: Implications for Hirschsprung Disease Management

BACKGROUND

Pull-through procedures for Hirschsprung disease (HD) can be performed during the Neonatal Intensive Care Unit (NICU) stay or delayed until discharge following home irrigations. This study assesses the safety of a delayed pull-through as an alternative to neonatal reconstruction in infants with successful abdomen decompression with home irrigations based on Hirschsprung-associated enterocolitis (HAEC) development.

METHODS

A single-institution retrospective review of neonates with HD who underwent delayed or neonatal pull-through from July 2018-July 2022. Endpoints included post-pull-through HAEC incidence, recurrence at an 18-month follow-up, time to the first HAEC episode, NICU length of stay (LOS), and HAEC-related LOS.

RESULTS

Twenty-four neonates were included. Eighteen were discharged from the NICU with home irrigations. Of these, 3 (28%) developed enterocolitis preoperatively, 12 (67%) underwent a delayed pull-through. NICU LOS in the delayed cohort was 3 times shorter than in the neonatal (6 vs. 18 days, p < 0.01). The incidence of enterocolitis (82% vs. 80%), time to the first episode (43 vs. 57 days), and HAEC-related LOS (median of 3 days) were similar.

CONCLUSIONS

Delayed HD pull-through is a viable neonatal reconstruction alternative that reduces NICU stay without increasing the risk of postoperative HAEC development.

TYPE OF STUDY

Original Research Article.

LEVEL OF EVIDENCE

III.

Exchange of Extracorporeal Membrane Oxygenation Cannulas for Hemodialysis Catheters in Children Requiring Renal Replacement Therapy

BACKGROUND

Pediatric patients requiring extracorporeal membrane oxygenation (ECMO) may require renal replacement therapy even after decannulation. However, data regarding transition from ECMO cannulation to a hemodialysis catheter in pediatric patients is not currently available.

METHODS

Patients <18 years old who had an ECMO cannula exchanged for a hemodialysis catheter during decannulation at a tertiary care children's center from January 2011 to September 2022 were identified. Data was collected from the electronic medical record.

RESULTS

A total of 10 patients were included. The cohort was predominantly male (80.0%, n = 8) with a median age of 1 day (IQR 1.0, 24.0). All ECMO cannulations were veno-arterial in the right common carotid artery and internal jugular vein. The median time on ECMO was 8.5 days (IQR 6.0, 15.0). One patient had the venous cannula exchanged for a tunneled hemodialysis catheter during decannulation, two were transitioned to peritoneal dialysis, and seven had the temporary hemodialysis catheter converted to a tunneled catheter by Interventional Radiology (when permanent access was required) at a median time of 10 days (IQR 8.0, 12.5). Of these 7 patients, 28.6% (n = 2) developed catheter-associated infection within 30 days of replacement, with one requiring catheter replacement. Transient bloodstream infection occurred in 10.0% (n = 1) within 30 days of ECMO cannula exchange.

CONCLUSION

Venous ECMO cannula exchange for a hemodialysis catheter in children requiring renal replacement therapy after decannulation is possible as a bridge to a permanent hemodialysis or peritoneal catheter if renal function does not recover, while supporting vein preservation.

Duodenal Atresia Repair: A Single-Center Comparative Study

BACKGROUND

The use of laparoscopy in the repair of duodenal atresia has been increasing. However, there is no consensus regarding which surgical approach has better outcomes. We aimed to compare the different surgical approaches and types of anastomoses for duodenal atresia repair.

METHODS

Patients who underwent duodenal atresia repair at a single pediatric center were identified between January 2006 and June 2022. Those with concomitant gastrointestinal anomalies or who required other simultaneous operations were excluded. The primary outcome was rate of complications, defined as rate of leak, stricture, and re-operation by surgical approach and technique of anastomosis.

RESULTS

A total of 78 patients were included. The majority were female (51.3%, n = 40), with a median age of 4 days (IQR 3.0,8.0) and a median weight of 2.7 kg (IQR 2.2,3.3) at repair. The re-operation rate was 7.7% (n = 6), of which two were anastomotic leaks, and four were anastomotic strictures. The leak rate was 5.6% (n = 1/18) for the open handsewn and 4.8% (n = 1/21) for the laparoscopic handsewn technique. The stricture rate was 12.5% (n = 1/8) for the laparoscopic-assisted handsewn, 9.1% (n = 2/22) for the laparoscopic U-clip, 4.8% (n = 1/21) for the laparoscopic handsewn, and none with laparoscopic stapled and laparoscopic converted to open handsewn techniques. No differences were found in complication rate when controlling for surgical approach.

CONCLUSION

The method of surgical approach did not affect the outcomes or complications in the repair of duodenal atresia.

Persistent Pediatric Breast Abscesses Following Initial Treatment at Tertiary and Community Centers

INTRODUCTION

Little data exist on the management of pediatric breast abscesses that fail initial treatment. Therefore, this study aimed to evaluate and report outcomes in these patients.

METHODS

All patients <18-year-old treated for a breast abscess between January 2008 and December 2018 were included. Patients were divided into two groups: initial treatment at our institution (Group 1) and initial treatment at referring centers (Group 2). The primary outcome was disease persistence following treatment at our institution. Secondary outcomes included treatment modalities and patient characteristics.

RESULTS

In total, 145 patients were identified: 111 in Group 1 and 34 in Group 2. Antibiotics alone were the initial treatment in 52.3% (n = 58) of Group 1 patients and 64.7% (n = 22) of Group 2 patients. Invasive treatment was more common in Group 1 (45.9% vs 5.8%; P < 0.00001). Patients with persistent disease in Group 1 were treated with aspiration (n = 7, 50%), incision and drainage (n = 5, 35.7%), antibiotics (n = 1, 7.14%), and manual expression (n = 1, 7.14%.), while Group 2 patients were treated with antibiotics (50%, n = 17), aspiration (26.47%, n = 9), incision and drainage (17.65%, n = 6), and manual expression (5.88%, n = 2). Group 2 patients with persistent disease were more likely to be treated with antibiotics or a change in antibiotics (50% vs 7.14%; P = 0.005). Following treatment at our institution, the rate of persistent disease was similar between groups (12.6% vs 11.8%).

CONCLUSIONS

Persistent breast abscesses may be treated with antibiotics in appropriate cases. Damage to the developing breast bud should be minimized. Disease persistence is similar once treated at tertiary care centers.

Hypertrophic Pyloric Stenosis Protocol: A Single Center Study

BACKGROUND

Initial treatment of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Our aim was to describe the protocol and subsequent outcomes.

METHODS

We conducted a single-center retrospective review of patients diagnosed with HPS from 2016 to 2023. All patients were given ad libitum feeds postoperatively and discharged home after tolerating three consecutive feeds. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the number of preoperative labs drawn, time from arrival to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate.

RESULTS

The study included 333 patients. A total of 142 patients (42.6%) had electrolytic disturbances that required fluid boluses in addition to 1.5x maintenance fluids. The median number of lab draws was 1 (IQR 1,2), with a median time from arrival to surgery of 19.5 hours (IQR 15.3,24.9). The median time from surgery to first and full feed was 1.9 hours (IQR 1.2,2.7) and 11.2 hours (IQR 6.4,18.3), respectively. Patients had a median postoperative LOS of 21.8 hours (IQR 9.7,28.9). Re-admission rate within the first 30 postoperative days was 3.6% (n = 12) with 2.7% of re-admissions occurring within 72 hours of discharge. One patient required re-operation due to an incomplete pyloromyotomy.

DISCUSSION

This protocol is a valuable tool for perioperative and postoperative management of patients with HPS while minimizing uncomfortable intervention.

Infliximab Rescue Therapy in Pediatric Severe Colitis

INTRODUCTION

Clinical remission has been achieved with infliximab in patients with refractory ulcerative colitis (UC). However, there is conflicting data regarding its effectiveness as rescue therapy in adult acute severe colitis. Furthermore, pediatric inflammatory bowel disease (IBD) is associated with more severe disease that may be less amenable to attempted rescue. We reviewed our experience and outcomes with pediatric severe colitis after attempted inpatient rescue with infliximab.

METHODS

A single-institution, retrospective review was conducted of pediatric patients with UC or indeterminate colitis who received inpatient rescue infliximab therapy from 1/2000 to 1/2019. Rescue infliximab therapy was considered if a child failed non-biologic therapy or progressed to fulminant or toxic colitis. Primary outcome was failed therapy resulting in colectomy. A p-value of <0.05 determined significance.

RESULTS

Thirty patients met inclusion criteria. The median age at administration of rescue infliximab treatment was 14 years [IQR 13,17]. Rescue therapy with infliximab was successful in 33% (n = 10), while 67% (n = 20) underwent colectomy. Children on maintenance steroids were less likely to be successfully rescued with infliximab and require colectomy (p = 0.03). Children requiring colectomy had a longer hospital stay (p = 0.03), more abdominal radiographs (p = 0.01), and were on a longer duration of antibiotics (p = <0.01) compared to children who were successfully rescued with infliximab. There was no difference in baseline vital signs or laboratory abnormalities between the two groups.

CONCLUSION

In severe acute ulcerative or indeterminate colitis cases where infliximab has not been previously used, rescue infliximab can be used to avoid colectomy but has a high failure rate.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Retrospective study.

Institutional outcomes of blunt liver and splenic injury in the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium era

BACKGROUND

The Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium practice management guideline was created to standardize management of blunt liver or spleen injury across pediatric trauma centers. We describe our outcomes since guideline adoption at our institution and hypothesize that blunt liver or spleen injury may be managed more expeditiously than currently reported without compromising safety.

METHODS

A retrospective cohort study was conducted on patients younger than 18 years presenting with blunt liver and/or splenic injuries from March 2016 to March 2021 at one participating center.

RESULTS

A total of 199 patients were included. There were no clinically relevant differences for age, body mass index, or sex among the cohort. Isolated splenic injuries (n = 91 [46%]) and motor vehicle collisions (n = 82 [41%]) were the most common injury and mechanism, respectively. The overall median length of stay (LOS) was 1.2 days (interquartile range, 0.45-3.3 days). Intensive care unit utilization was 23% (n = 46). There was no statistically significant difference in median LOS among patients with isolated solid organ injuries, regardless of injury grade. There were no readmissions associated with non-operative management.

CONCLUSION

The Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium guideline fosters high rates of nonoperative management with low intensive care unit utilization and LOS while demonstrating safety in implementation, irrespective of injury grade.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Long-Term Recurrence Rates and Patient Satisfaction after Repair of Pectus Excavatum

BACKGROUND

 Pectus excavatum deformities are usually repaired with a minimally invasive approach in which a metal bar is used to correct the chest wall abnormality. We aimed to evaluate long-term outcomes and patient satisfaction after surgical correction.

METHODS

 Patients who underwent pectus excavatum repair and subsequent bar removal at a single tertiary care center from January 2000 to December 2020 were identified. A retrospective chart review was performed, and a telephone survey was conducted to evaluate perceived inward chest movement, need for surgeon reevaluation, surgical reintervention, and overall satisfaction. Data are presented as medians with interquartile ranges (IQRs) and frequencies with percentages.

RESULTS

 A total of 583 patients were included. The survey response rate was 26.2% (n = 153). The respondents were predominantly male (80.4%, n = 123) with a median age at surgical correction of 14.9 years (IQR 12.9, 16.1) and a median Haller index (HI) of 3.8 (IQR 3.4, 4.5). Median time to bar removal was 2.9 years (IQR 2.5, 3.0) with a median age at removal of 17.7 years (IQR 15.5, 19.0). Median time from surgery to survey follow-up was 9.6 years (IRQ 5.0, 11.4) with respondents having a median age at follow-up of 25 years (IQR 22.0, 28.4). The satisfaction rate was 96.7% (n = 148) with a reintervention rate of 2.0% (n = 3). The perceived inward chest movement was 30.7% (n = 47) with 12.8% (n = 6) of those requesting surgical reevaluation.

CONCLUSION

 There is a high level of satisfaction many years after correction of pectus excavatum and bar removal. With the advent of cryoablative therapy since 2017, patient satisfaction improved by experience of less postoperative pain. Reintervention rate is low despite some patients reporting a perceived chest wall inward movement.

Satisfaction With Same-Day Discharge After Laparoscopic Appendectomy for Nonperforated Appendicitis

INTRODUCTION

Same-day discharge (SDD) after laparoscopic appendectomy for acute nonperforated appendicitis is safe, without an increased rate of postoperative complications, emergency department visits, or readmissions. We aimed to evaluate caregiver satisfaction with this protocol.

METHODS

Patients discharged on the day of laparoscopic appendectomy for nonperforated acute appendicitis were identified between January 2022 and August 2022. Surveys to evaluate satisfaction with the protocol were distributed to the caregivers via email or text message 96 h after discharge. Telephone surveys were conducted if there were no responses to the initial online survey. The surveys assessed comfort with SDD, postoperative pain control adequacy, postoperative provider contact, and overall satisfaction. The protocol focused on avoidance of narcotics in the postoperative period and immediate return to a regular diet.

RESULTS

A total of 255 cases of nonperforated acute appendicitis underwent SDD. The survey response rate was 50.6% (n = 129). Most respondents were Caucasian (69.0%, n = 89) and male (51.9%, n = 67) with a median age of 12.0 y (IQR 8.9,14.7). The median postoperative length of hospital stay was 3.8 h (interquartile range [IQR] 3.2,4.8). The overall satisfaction rate was 91.5%, with 118 caregivers feeling satisfied with SDD. Most caregivers felt comfortable with the SDD protocol (89.9%, n = 116), with 22.5% (n = 29) calling a medical provider postoperatively. Approximately nine out of 10 caregivers reported that pain was adequately controlled (91.5%, n = 118). In contrast, those that were dissatisfied reported issues with pain control and anxiety with SDD after a surgical procedure.

CONCLUSIONS

Caregiver satisfaction and comfort with same-day discharge following laparoscopic appendectomy is high with appropriate anticipatory guidance and preoperative education.

Laparoscopic Repair of an Incarcerated Left Ovary, Hemi-Uterus, and Salpinx Within A Left Inguinal Hernia

Inguinal hernia repair is one of the most common operations performed by pediatric surgeons. These hernias typically present as asymptomatic or symptomatic swellings in the groin, extending into the labia in girls or the scrotum in boys. Surgical repair is indicated as these hernias do not spontaneously close and carry a risk of incarceration. We report a case of an extremely rare finding at the time of laparoscopic inguinal hernia repair in a preteen girl, highlighting the variable clinical presentation of this common condition and the laparoscopic approach to repair.

Management of primary spontaneous pneumothorax in children: A single institution protocol analysis

BACKGROUND

The Midwest Pediatric Surgery Consortium (MWPSC) suggested a simple aspiration of primary spontaneous pneumothorax (PSP) protocol, failing which, Video-Assisted Thoracoscopic Surgery (VATS) should be considered. We describe our outcomes using this suggested protocol.

METHODS

A single institution retrospective analysis was conducted on patients between 12 and 18 years who were diagnosed with PSP from 2016 to 2021. Initial management involved aspiration alone with a ≤12 F percutaneous thoracostomy tube followed by clamping of the tube and chest radiograph at 6 h. Success was defined as ≤2 cm distance between chest wall and lung at the apex and no air leak when the clamp was released. VATS followed if aspiration failed.

RESULTS

Fifty-nine patients were included. Median age was 16.8 years (IQR 15.9, 17.3). Aspiration was successful in 33% (20), while 66% (39) required VATS. The median LOS with successful aspiration was 20.4 h (IQR 16.8, 34.8), while median LOS after VATS was 3.1 days (IQR 2.6, 4). In comparison, in the MWPSC study, the mean LOS for those managed with a chest tube after failed aspiration was 6.0 days (±5.5). Recurrence after successful aspiration was 45% (n = 9), while recurrence after VATS was 25% (n = 10). Median time to recurrence after successful aspiration was sooner than that of the VATS group [16.6 days (IQR 5.4, 19.2) vs. 389.5 days (IQR 94.1, 907.0) p = 0.01].

CONCLUSION

Simple aspiration is safe and effective initial management for children with PSP, although most will require VATS. However, early VATS reduces length of stay and morbidity.

LEVEL OF EVIDENCE

IV. Retrospective study.

Evaluating caretaker satisfaction with same-day discharge after gastrostomy tube placement

BACKGROUND

Same-day discharge (SDD) after laparoscopic gastrostomy tube (G-tube) placement, using written and video-based preoperative education, has been our standard institutional practice since 2017. We aim to evaluate caretaker satisfaction with this protocol.

METHODS

All patients planned for SDD after G-tube placement from February 2021-February 2022 were identified. Chart review was performed to identify demographic information, successful same-day discharge or reason for postoperative admission, time to first postoperative feed, length of stay (LOS), and complications requiring emergency department evaluation, readmission, or reoperation. Telephone follow-up at two weeks postoperatively was conducted to evaluate satisfaction with the SDD protocol.

RESULTS

Forty-nine patients were eligible for SDD with a median age of 1.1 years [0.7, 4.4]. Forty-two (86%) patients were successfully discharged the same day with a median LOS of 7.5 h [6.7, 8.1], and 7 (14%) were admitted postoperatively for further education or emesis with a median LOS of 30.4 h [26.9, 31.2]. Median time to initiation of feeds was 2.3 h [1.7, 2.9]. 8 (16%) patients were evaluated in the emergency department within 30 days postoperatively, resulting in two re-admissions: one for peri‑stomal erythema and fever requiring oral antibiotics at 21 days and one for G-tube dislodgement requiring reoperation and replacement at 28 days. On two-week telephone follow-up, 42 caretakers (100%) felt that their education was adequate for same-day discharge and felt comfortable with the same-day discharge protocol. Six (14%) caretakers stated their child's pain was not well controlled at some point between discharge and survey follow-up, and three caretakers (7%) called a provider within the first 24 h for issues with pain. Forty-one caretakers (98%) expressed satisfaction going home the day of surgery.

CONCLUSION

Caretaker satisfaction and comfort with same-day discharge following laparoscopic G-tube placement are high, ascribed to comprehensive preoperative education and anticipatory guidance.

TYPE OF STUDY

Prognostic.

LEVEL OF EVIDENCE

Level 1.

Pre-hospital CPR after traumatic arrest: Outcomes at a level 1 pediatric trauma center

BACKGROUND

The survival of traumatic cardiopulmonary arrest (TCA) requiring pre-hospital cardiopulmonary resuscitation (P-CPR) is abysmal across age groups. We aim to describe the mechanisms of injury and outcomes of children suffering from TCA leading to P-CPR at our institution.

METHODS

A retrospective review was conducted to identify children ages 0-17 years who suffered TCA leading to P-CPR at our institution between 5/2009 and 3/2020. For analysis, patients were stratified into those still undergoing CPR at arrival and those who attained pre-hospital return of spontaneous circulation (ROSC). Primary outcome was discharge alive from the hospital.

RESULTS

P-CPR was initiated for 48 patients who had TCA; 23 had pre-hospital ROSC. Of the 25 children undergoing CPR at presentation, none survived to discharge. The median duration of CPR, from initiation to time of death declaration was 34 min [29,50]. Seventeen patients died after resuscitation attempts in the ED, while 8 died after admission to the PICU. Of the 23 patients who attained pre-hospital ROSC, 6 survived to discharge. All survivors required intensive rehabilitation services at discharge and at most recent follow-up, 5 had residual deficits requiring medical attention.

CONCLUSION

There are poor outcomes in children with pre-hospital traumatic cardiopulmonary arrest, particularly in those without pre-hospital ROSC. These data further support the need for standardized guidelines for resuscitation in children with traumatic cardiopulmonary arrest.

Diversity and demographics of APSA members: Understanding our identity

INTRODUCTION

There are existing healthcare disparities in pediatric surgery today. Identity and racial incongruity between patients and providers contribute to systemic healthcare inequities and negatively impacts health outcomes of minoritized populations. Understanding the current demographics of the American Pediatric Surgical Association and therefore the cognitive diversity represented will help inform how best to strategically build the organization to optimize disparity solutions and improve patient care.

METHODS

1558 APSA members were sent an anonymous electronic survey. Comparative data was collected from the US Census Bureau and the Association of American Medical Colleges. Results were analyzed using standard statistical tests.

RESULTS

Of 423 respondents (response rate 27%), the race and ethnicity composition were 68% non Hispanic White, 12% Asian American and Pacific Islander, 6% Hispanic, 5% multiracial, and 4% Black/African American. Respondents were 35% women, 63% men, and 1% transgender, androgyne, or uncertain. Distribution of sexual identity was 97% heterosexual and 3% LGBTQIA. Religious identity was 50% Christian, 22% Agnostic/Atheist, 11% Jewish, 3% Hindu, and 2% Muslim. 32% of respondents were first-generation Americans. Twenty-four different primary languages were spoken, and 46% of respondents were conversational in a second language. These findings differ in meaningful ways from the overall American population and from the population of matriculants in American medical schools.

CONCLUSION

There are substantial differences in the racial, gender, and sexual identity composition of APSA members compared with the overall population in the United States. To achieve excellence in patient care and innovate solutions to existing disparities, representation, particularly in leadership is essential.

TYPE OF STUDY

Survey; original research.

LEVEL OF EVIDENCE

Level IV.

Testicular torsion disparities in the pediatric population

BACKGROUND

There are disparate findings in the literature on the impact of race and insurance status on gonadal loss in testicular torsion. We sought to determine if race or levels of social vulnerability influence the rate of torsion or gonadal loss.

METHODS

Retrospective cross-sectional review between December 2017 and September 2019. Social vulnerability index was dichotomized using the 75th percentile. Primary outcome was the diagnosis of testicular torsion.

RESULTS

515 patients were included. There was no difference in median age, torsion diagnosis, and orchiectomy rate between the two institutions. Black/African American patients were >3 times more likely than Caucasian patients to be diagnosed with TT when controlled for dichotomized SVI, insurance, and age (OR 3.39, 95% CI 1.74 - 6.61, p < 0.01).

CONCLUSION

Black/African American children have an increased risk of testicular torsion. Despite these patients having higher levels of social vulnerability, it was not associated.

Umbilical access in laparoscopic surgery in infants less than 3 months: A single institution retrospective review

INTRODUCTION

Umbilical access in laparoscopic surgery has been cited as a factor for increased complications in low-birth-weight infants and those less than three months old. In a previous series, 10.6% of pediatric surgeons reported complications in this population associated with umbilical access, citing carbon dioxide (CO₂) embolism as the most common complication. To further examine the safety of this technique, we report our outcomes with blunt transumbilical laparoscopic access at our institution over four years.

METHODS

A retrospective review was performed of patients less than three months of age who underwent laparoscopic pyloromyotomy or inguinal hernia repair from 2016 to 2019. Operative reports, anesthesia records, and postoperative documentation were reviewed for complications related to umbilical access. Complications included bowel injury, vascular injury, umbilical vein cannulation, CO₂ embolism, umbilical surgical site infection (SSI), umbilical hernia requiring repair, and death.

RESULTS

Of 365 patients, 246 underwent laparoscopic pyloromyotomy, and 119 underwent laparoscopic inguinal hernia repairs. Median age at operation was 5.9 weeks [4.3,8.8], and median weight was 3.9 kg [3.4,4.6]. Nine complications (2.5%) occurred: 5 umbilical SSIs (1.4%), 1 bowel injury upon entry requiring laparoscopic repair (0.2%), 1 incisional hernia repair 22 days postoperatively (0.2%), and 2 cases of hypotension and bradycardia upon insufflation that resolved with desufflation (0.5%). There were no intraoperative mortalities or signs/symptoms of CO₂ embolism.

CONCLUSION

In this series, umbilical access for laparoscopic surgery in neonates less than three months of age was safe, with minimal complications. Although concern for umbilical vessel injury, cannulation, and CO₂ embolism exists, these complications are not exclusively associated with umbilical access technique.

Evaluation of a fluid resuscitation protocol for patients with hypertrophic pyloric stenosis

INTRODUCTION

We previously developed an institutional, evidence-based fluid resuscitation protocol for neonates with infantile hypertrophic pyloric stenosis (HPS) based on the severity of electrolyte derangement on presentation. We aim to evaluate this protocol to determine its efficacy in reducing the number of preoperative lab draws, time to electrolyte correction, and overall length of stay.

METHODS

A single center, retrospective review of 319 infants with HPS presenting with electrolyte derangement from 2008 to 2020 was performed; 202 patients managed pre-protocol (2008-2014) and 117 patients managed per our institutional fluid resuscitation algorithm (2016-2020). The number of preoperative lab draws, time to electrolyte correction, and length of stay before and after protocol implementation was recorded.

RESULTS

Use of a fluid resuscitation algorithm decreased the number of infants who required four or more preoperative lab draws (20% vs. 6%) (p < .01), decreased median time to electrolyte correction between the pre and post protocol cohorts (15.1 h [10.6, 22.3] vs. 11.9 h [8.5, 17.9]) (p < .01), and decreased total length of hospital stay (49.0 h [40.3, 70.7] vs. 45.7 h [34.3, 65.9]) (p < .05).

CONCLUSION

Implementation of a fluid resuscitation algorithm for patients presenting with hypertrophic pyloric stenosis decreases the frequency of preoperative lab draws, time to electrolyte correction, and total length of hospital stay. Use of a fluid resuscitation protocol may decrease discomfort through fewer preoperative lab draws and shorter length of stay while setting clear expectations and planned intervention for parents.

LEVEL OF EVIDENCE

III - Retrospective comparative study.

Laparoscopic Gastrostomy in Infants During an Open Abdominal Procedure: A Novel Approach

Introduction: Infants with intra-abdominal pathology necessitating open abdominal surgery may also require placement of a gastrostomy tube (GT). Use of laparoscopy provides better visualization for gastrostomy placement and lowers the risk of complications compared with an open approach. We describe a series of patients who underwent laparoscopic GT placement at the time of an open abdominal procedure. Methods: All patients who underwent an open abdominal procedure with concurrent laparoscopic gastrostomy from January 2010 to June 2020 were reviewed. Descriptive statistics were performed with categorical variables reported as proportions and continuous variables reported as medians with interquartile range [IQR]. Results: Twelve patients were included; 8 (67.5%) were male. The median age at time of surgery was 10 weeks [IQR 6, 14], with a median weight of 4.1 kg [IQR 3.4, 4.8]. Ten patients had the laparoscope placed through the open incision, whereas 2 had the laparoscope placed through a separate incision. Median operative time was 106 minutes [IQR 80, 125]. There were no intraoperative complications. Postoperative complications included surgical site infection in 5 (41.7%), leaking around the GT in 3 (25%), and malfunction of the tube in 1 (8.3%). One patient required reoperation 28 days postoperatively due to malfunction. Conclusion: Laparoscopic GT can be safely performed at the time of an open abdominal procedure, and frequently through the same incision, harnessing the benefits of a laparoscopic approach even when an open incision is needed.

Management of Hirschsprung associated enterocolitis-How different are practice strategies? An international pediatric endosurgery group (IPEG) survey

INTRODUCTION

Hirschsprung's-associated enterocolitis (HAEC) is a common post-operative problem for patients with Hirschsprung disease (HSCR). However, treatment strategies remain variable among providers, institutions, and even nations. The purpose of this study was to identify differences in treatment patterns for HAEC.

METHODS

A questionnaire was distributed to members of the International Pediatric Endoscopic Group (IPEG) community that focused on HSCR and HAEC management strategies. Questionnaire responses were collected via the Research Electronic Data Capture (RedCap).

RESULTS

178 responses were obtained: 30% from North America, 20% South America, 20% Europe, 26% Asia, and 4% from Australia. 37% had a dedicated pediatric colorectal center. After diagnosis, 53% send patients home with irrigations, while 29% perform a primary PT before discharge; the type of PT varied between Soave (50%), Swenson (25%) and Duhamel (13%). Only 29 respondents (17%) stated their institution had guidelines for HAEC management; however, inpatient treatments were fairly consistent: 95% performed rectal irrigations, 93% obtained an abdominal radiograph, and 72% held feeds; 55% taught families irrigations before discharge. Utilization of Botulinum (BT) injections was mixed: 36% never utilized BT injections, 33% only used BT if irrigations were not tolerated, and 16% only injected BT for recurrent episodes. Preventative HAEC measures were also varied and included anal dilations (44%), prophylactic antibiotics (34%), probiotics (29%), and routine home irrigations (22%).

CONCLUSION

There is wide variation of care in managing enterocolitis episodes in patients with Hirschsprung disease. Further research leading to consensus guidelines and standardization practices can help improve the care for these patients.

LEVEL OF EVIDENCE

V TYPE OF STUDY: Treatment study/ survey.

Short and long term outcomes of using cryoablation for postoperative pain control in patients after pectus excavatum repair

INTRODUCTION

We report the findings of a three-year prospective observational study elucidating long-term symptoms and complications of patients who underwent minimally invasive pectus excavatum repair with intercostal nerve cryoablation with specific attention to postoperative pain control associated with the cryoablation technique.

METHODS

Surveys were administered to patients who underwent bar placement for pectus excavatum with intercostal nerve cryoablation from 2017 to 2021 regarding pain scores, pain medication usage, and limitations to activity beginning on the day of surgery, on the day of discharge, and at two-week and three-month follow-up.

RESULTS

Of 110 patients, forty-eight (44%) completed the discharge survey; sharp pain and pressure on the first postoperative night were the most described pain characteristics, most frequently in the middle of the chest. On follow-up, 55% of patients reported tolerable residual pain at two weeks and 41% at three months, with 25% requiring intermittent pain medication at three months. There were three readmissions for inadequate pain control and 110 calls to the surgery clinic by three-month follow-up, most commonly for persistent pain and frequent popping sensation with movement.

DISCUSSION

Although cryoablation is an excellent pain control modality, these data suggest that patients underreport functional symptoms and experience more frequent discomfort and alteration of daily living activities.

Behind the mask: extended use of surgical masks is not associated with increased risk of surgical site infection

PURPOSE

COVID-19 has prompted significant policy change, with critical attention to the conservation of personal protective equipment (PPE). An extended surgical mask use policy was implemented at our institution, allowing use of one disposable mask per each individual, per day, for all the cases. We investigate the clinical impact of this policy change and its effect on the rate of 30-day surgical site infection (SSI).

METHODS

A single-institution retrospective review was performed for all the elective pediatric general surgery cases performed pre-COVID from August 2019 to October 2019 and under the extended mask use policy from August 2020 to October 2020. Procedure type, SSI within 30 days, and postoperative interventions were recorded.

RESULTS

Four hundred and eighty-eight cases were reviewed: 240 in the pre-COVID-19 cohort and 248 in the extended surgical mask use cohort. Three SSIs were identified in the 2019 cohort, and two in the 2020 cohort. All postoperative infections were superficial and resolved within 1 month of diagnosis with oral antibiotics. There were no deep space infections, readmissions, or infections requiring re-operation.

CONCLUSION

Extended surgical mask use was not associated with increased SSI in this series of pediatric general surgery cases and may be considered an effective and safe strategy for resource conservation with minimal clinical impact.

Evaluation of a Symptom-Based Algorithm for Managing Battery Ingestions in Children

OBJECTIVES

 While complications from battery ingestion can be severe, especially with the emergence of stronger battery elements, not all ingestions require prompt removal. We aim to evaluate a symptom-focused algorithm for battery ingestion that emphasizes observation over intervention to investigate its safety.

MATERIALS AND METHODS

 Patients were identified through a query of foreign-body ingestion radiographs obtained between 2017 and 2020. A retrospective chart review was then performed of all patients who presented with button battery ingestions to identify compliance with our algorithm, overall outcomes, and complications.

RESULTS

 In total, 2% of all radiographs (44/2,237) demonstrated button battery ingestions. The median age of patients was 3.8 years (interquartile range, 2.6-5.3). Most batteries were found in the stomach (64%, n = 28), but were also identified in the esophagus (14%, n = 6), small bowel (14%, n = 6), and colon (9%, n = 4). All esophageal batteries were managed with immediate endoscopic retrieval. Ten gastric batteries were not managed per protocol, with seven admitted for observation despite being asymptomatic and repeat abdominal X-rays demonstrating persistent gastric location of the battery. Four patients underwent esophagogastroduodenoscopy; however, in two patients the battery had migrated past the stomach prior to intervention. All small bowel batteries and three of four asymptomatic colon batteries were managed per protocol; one patient had additional imaging that demonstrated battery passage.

CONCLUSION

 Adherence to a symptom-focused protocol for conservative management of button battery ingestions beyond the gastroesophageal junction is safe and frequently does not require admission, serial imaging, or intervention.

Review of Perioperative Prophylactic Antibiotic Use during Laparoscopic Cholecystectomy and Subsequent Surgical Site Infection Development at a Single Children's Hospital

OBJECTIVES

 With the rise of antibiotic resistance, the use of prophylactic preoperative antibiotics (PPA) has been questioned in cases with low rates of surgical site infection (SSI). We report PPA usage and SSI rates after elective laparoscopic cholecystectomy at our institution.

MATERIALS AND METHODS

 A retrospective review of children younger than 18 years who underwent elective outpatient laparoscopic cholecystectomy between July 2010 and August 2020 was performed. Demographic, preoperative work-up, antibiotic use, intraoperative characteristics, and SSI data were collected via chart review. SSI was defined as clinical signs of infection that required antibiotics within 30 days of surgery.

RESULTS

 A total of 502 patients met the inclusion criteria; 50% were preoperatively diagnosed with symptomatic cholelithiasis, 47% with biliary dyskinesia, 2% with hyperkinetic gallbladder, and 1% with gallbladder polyp(s). The majority were female (78%) and Caucasian (80%). In total, 60% (n = 301) of patients received PPA, while 40% (n = 201) did not; 1.3% (n = 4) of those who received PPA developed SSI, compared with 5.5% (n = 11) of those who did not receive PPA (p = 0.01). Though PPA use was associated with a 77% reduction in the risk of SSI in multivariate analysis (p = 0.01), all SSIs were superficial. One child required readmission for intravenous antibiotics, while the remainder were treated with outpatient antibiotics. Gender, age, body mass index, ethnicity, and preoperative diagnosis did not influence the likelihood of receiving PPA.

CONCLUSION

 Given the relatively low morbidity of the superficial SSI, conservative use of PPA is advised to avoid contributing to antibiotic resistance.

30 Years of Flipping the Coin-Heads or Tails?

INTRODUCTION

 Swallowed coins are a frequent cause of pediatric emergency department visits. Removal typically involves endoscopic retrieval under anesthesia. We describe our 30-year experience retrieving coins using a Foley catheter under fluoroscopy ("coin flip").

MATERIALS AND METHODS

 Patients younger than 18 years who underwent the coin flip procedure from 1988 to 2018 were identified. Failure of fluoroscopic retrieval was followed by rigid endoscopic retrieval in the operating room. Detailed subanalysis of patients between 2011 and 2018 was also performed.

RESULTS

 A total of 809 patients underwent the coin flip procedure between 1988 and 2018. Median age was 3.3 years; 51% were male. The mean duration from ingestion to presentation was 19.8 hours. Overall success of removal from the esophagus was 85.5%, with 76.5% of coins retrieved and 9% pushed into the stomach. All remaining coins were retrieved by endoscopy. Complication rate was 1.2% with nine minor and one major complications, a tracheal tear that required repair. In our recent cohort, successful fluoroscopic removal led to shorter hospital lengths of stay (3.2 vs. 18.1 hours, p < 0.001).

CONCLUSION

 Patients who present with a coin in the esophagus can be successfully managed with a coin flip, which can be performed without hospital admission, with rare complications.

The impact of botulinum injection for hospitalized children with Hirschsprung-associated enterocolitis

INTRODUCTION

Stasis from obstruction at the level of the internal anal sphincter (IAS) can lead to Hirschsprung-associated enterocolitis (HAEC) and may be improved by botulinum toxin (BT) injections. Our aim was to determine if BT injection during HAEC episodes decreased the number of recurrent HAEC episodes and/or increased the interval between readmissions.

METHODS

A retrospective review was performed of patients admitted for HAEC from January 2010 to December 2019. Demographics and outcomes of patients who received BT were compared to patients who did not receive BT during their hospital stay.

RESULTS

A total of 120 episodes of HAEC occurred in 40 patients; 30 patients (75%) were male, 7 (18%) had Trisomy 21 and 10 (25%) had long-segment disease. On multivariate analysis, patients who received BT during their inpatient HAEC episode had a longer median time between readmissions (p = 0.04) and trending toward an association with fewer readmissions prior to a follow-up clinic visit (p = 0.08).

CONCLUSION

The use of BT in HD patients hospitalized for HAEC is associated with an increased time between recurrent HAEC episodes and trended toward fewer recurrent episodes. The use of BT should be considered in the management of patients admitted with HAEC.

Outpatient Botulinum Injections for Early Obstructive Symptoms in Patients with Hirschsprung Disease

INTRODUCTION

Botulinum toxin (BT) injections may play a role in preventing Hirschsprung associated enterocolitis (HAEC) episodes related to internal anal sphincter (IAS dysfunction). Our aim was to determine the association of outpatient BT injections for early obstructive symptoms on the development of HAEC.

METHODS

A retrospective review of children who underwent definitive surgery for Hirschsprung disease (HSCR) from July 2010 - July 2020 was performed. The timing from pull-through to first HAEC episode and to first BT injection was recorded. Primary analysis focused on the rate of HAEC episodes and timing between episodes in patients who did and did not receive BT injections.

RESULTS

Eighty patients were included. Sixty patients (75%) were male, 15 (19%) were diagnosed with trisomy 21, and 58 (72.5%) had short-segment disease. The median time to pull-through was 150 days (IQR 16, 132). Eight patients (10%) had neither an episode of HAEC or BT injections and were not included in further analysis. Forty-six patients (64%) experienced at least one episode of HAEC, while 64 patients (89%) had at least one outpatient BT injection. Compared to patients who never received BT injections (n = 9) and those who developed HAEC prior to BT injections (n = 35), significantly fewer patients who received BT injections first (n = 28) developed enterocolitis (P < 0.001), with no patient developing more than one HAEC episode.

CONCLUSION

Outpatient BT is associated with decreased episodes of HAEC and increased interval between HAEC episodes requiring inpatient treatment. Scheduling outpatient BT injections to manage obstructive symptoms may be beneficial after pull-through for HSCR.

Same-day discharge for pediatric laparoscopic gastrostomy

BACKGROUND

Laparoscopic gastrostomy is a common procedure in children. We developed a same-day discharge (SDD) protocol for laparoscopic button gastrostomy.

METHODS

We performed a prospective observational study of children undergoing laparoscopic button gastrostomy and were eligible for SDD from August 2017-September 2019. Patients were eligible if: 1) the family was comfortable with eliminating overnight admission and were suitable candidates for outpatient surgery (absence of major co-morbidities), 2) they were not undergoing additional procedures requiring admission, and 3) they received pre-operative education.

RESULTS

Sixty-two patients who underwent laparoscopic button gastrostomy were eligible for SDD. The median age was 2.1 years [IQR 0.9-4.1], and the median weight was 10.5 kg [IQR 7.6-15.5]. Forty-one (66%) were previously nasogastric fed. The median operative time was 22 min [IQR 16-29]. The median time to initiation of feeds was 4.4 h [IQR 3.4-5.5]. Fifty-one (82%) were discharged the same day with a median length of stay of 9 h [IQR 7-10]. Eleven were admitted, most commonly for further teaching. Eleven SDD patients were seen in the emergency room <30 days at a median 5 days [IQR 3-12] post-operatively, primarily for mechanical complications.

CONCLUSION

Same-day discharge following laparoscopic gastrostomy is safe and feasible for select pediatric patients who undergo pre-operative education. The SDD pathway results in a low admission rate and relatively low ER visits.

TYPE OF STUDY

Prospective Observational Study.

LEVEL OF EVIDENCE

Level II.

Declining frequency of thoracoscopic decortication for empyema - redefining failure after fibrinolysis

BACKGROUND

Primary fibrinolysis for pediatric empyema has become standard of care at our institution. Early study of our protocol revealed a 16% thoracoscopic decortication rate after primary fibrinolysis. We now report the frequency with which children progress to operation with maturation of the protocol.

METHODS

A database of patients diagnosed with empyema between September 2014 and March 2019 was examined. Patients who underwent tissue plasminogen activator (tPA) therapy with or without subsequent video-assisted thoracoscopic (VATS) decortication were included. Patients with additional indications for tube thoracostomy or VATS were excluded.

RESULTS

Forty-eight patients were included. Median age was 4.5 years [IQR 2-9.3]. Median length of stay (LOS) was 8 days [IQR 6-11]. No patients underwent primary VATS. Median days with a chest tube was 5 [IQR 5-6] and median number of doses of tPA was 3 [IQR 3-3]. Seven patients (14.6%) had a chest tube replaced without undergoing VATS. The VATS rate was 4.2% in the first half of this study but 0% in the last 33 months.

CONCLUSION

Thoracoscopic decortication is rarely necessary in children with empyema. Raising the threshold for surgical intervention and utilizing further nonoperative measures can avoid an operation in most children without increasing in-hospital length of stay.

LEVEL OF EVIDENCE

IV.

Characterization of Pediatric Breast Abscesses and Optimal Treatment: A Retrospective Analysis

BACKGROUND

Literature on pediatric breast abscesses is sparse; therefore, treatment is based on adult literature which has shifted from incision and drainage (I&D) to needle aspiration. However, children may require different treatment due to different risk factors and the presence of a developing breast bud. We sought to characterize pediatric breast abscesses and compare outcomes.

MATERIALS AND METHODS

A retrospective review of patients presenting with a primary breast abscess from January 2008 to December 2018 was conducted. Primary outcome was persistent disease. Antibiotic utilization, treatment required, and risk factors for abscess and recurrence were also assessed. A follow-up survey regarding scarring, deformity, and further procedures was administered. Fisher's exact and Kruskal-Wallis tests for group comparisons and multivariable regression to determine associations with recurrence were performed.

RESULTS

Ninety-six patients were included. The median age was 12.8 y [IQR 4.9, 14.3], 81% were women, and 51% were African-American. Most commonly, patients were treated with antibiotics alone (47%), followed by I&D (27%), and aspiration (26%). Twelve patients (13%) had persistent disease. There was no difference in demographic or clinical characteristics between those with persistent disease and those who responded to initial treatment. The success rates of primary treatment were 80% with antibiotics alone, 90% with aspiration, and 96% with I&D (P = 0.35). The median time to follow-up survey was 6.5 y [IQR 4.4, 8.5]. Four patients who underwent I&D initially reported significant scarring.

CONCLUSIONS

Treatment modality was not associated with persistent disease. A trial of antibiotics alone may be considered to minimize the risk of breast bud damage and adverse cosmetic outcomes with invasive intervention.

Ethics of randomized trials in pediatric surgery

To provide the best evidence-based treatment for children, and timely evaluation of innovations, the role of the pediatric surgeon's participation in randomized controlled trials (RCTs) and prospective comparative studies is required. The ethical considerations of pediatric surgical RCTs pose unique practical difficulties in the design and performance of clinical trials in children. There are several ethical issues unique to pediatric surgical RCTs: diseases with low volume, an inability to conduct Phase 1 and 2 trials, parental emotional involvement, difficulty with recruitment in surgical trials, volume, and modified study design, issues with permission vs. assent and investigator bias. This article reviews the ethical aspects unique to pediatric surgical RCTs and prospective comparative studies.Level of evidence: Level 3.

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

BACKGROUND

Pain following bar placement for pectus excavatum is the dominant factor post-operatively and determines length of stay (LOS). We recently adopted intercostal cryoablation as our preferred method of pain control following minimally invasive pectus excavatum repair. We compared the outcomes of cryoablation to results of a recently concluded trial of epidural (EPI) and patient-controlled analgesia (PCA) protocols.

METHODS

We conducted a prospective observational study of patients undergoing bar placement for pectus excavatum using intercostal cryoablation. Results are reported and compared with those of a randomized trial comparing EPI with PCA. Comparisons of medians were performed using Kruskal-Wallis H tests with alpha 0.05.

RESULTS

Thirty-five patients were treated with cryoablation compared to 32 epidural and 33 PCA patients from the trial. Cryoablation was associated with longer operating time (101 min, versus 58 and 57 min for epidural and PCA groups, p < 0.01), resulted in less time to pain control with oral medication (21 h, versus 72 and 67 h, p < 0.01), and decreased LOS (1 day, versus 4.3 and 4.2 days, p < 0.01).

CONCLUSION

Intercostal cryoablation during minimally invasive pectus excavatum repair reduces LOS and perioperative opioid consumption compared with both EPI and PCA.

LEVEL OF EVIDENCE

II.

Epidemiology of 577 Pediatric Firearm Fatalities: A 2-year Review of the National Trauma Data Bank

The purpose of this study was to delineate the epidemiology of pediatric firearm injuries, including ethno-demographic patterns with impact on years of potential life lost (YPLL). A 2-year review of the National Trauma Data Bank (2007 to 2008) was conducted. Firearm fatalities in records of patients younger than 18 years were identified. Data were analyzed by demographic and injury characteristics and YPLL was calculated by ethnicity. A total of 577 deaths were identified in the pediatric group. Blacks accounted for 49.7 per cent of the fatalities; Hispanics, 19.2 per cent; whites, 17.7 per cent, and other ethnicity, 13.4 per cent. Median Injury Severity Score was 25 with a median Glasgow Coma Scale score of 3. Traumatic brain injury was present in 84.2 per cent of the records. Assault accounted for 72.8 per cent, self-inflicted injury 12.7 per cent, and unintentional injuries were 8.2 per cent. Most firearm fatalities occurred at home (33.6%). By emergency department (ED) disposition, 29.3 per cent died in the ED, 32.9 per cent were admitted to the intensive care unit, and 30.0 per cent taken to the operating room. Blacks had a total of 17,446 YPLL, Hispanics 6,776 YPLL, and whites 6,718 YPLL. Pediatric firearm fatalities still remain an important public health concern. Inclusive gun control policies focused on primary prevention of accidental injuries may be more effective in mitigating its impact.

Associated Injuries in Traumatic Sternal Fractures: A Review of the National Trauma Data Bank

Sternal fractures occur infrequently with blunt force trauma. The demographics and epidemiology of associated injuries have not been well characterized from a national trauma database. The National Trauma Data Bank was queried for patients with closed sternal fractures. The demographics were analyzed by age, gender, mechanism and indicators of anatomic and physiologic injuries. Types of commonly associated injuries were also determined. A total of 23,985 records were analyzed. Males accounted for 68.3 per cent and whites 70.9 per cent. Motor vehicle crash was the leading mechanism. More than 56 per cent had severe injuries based on Injury Severity Score (greater than 15) and 17 per cent with Glasgow Coma Score 8 or less. Crude mortality was 7.9 per cent. The majority (57.8%) and approximately one-third (33.7%) of the patients had rib fractures and lung contusions, respectively, 22.0 per cent with closed pneumothorax, 21.6 per cent had a closed thoracic vertebra fracture, 16.9 per cent with lumbar spine fracture, 3.9 per cent with concussion, and blunt cardiac injury in 3.6 per cent. Sternal fractures are usually associated with severe blunt trauma. Lung contusion remains the leading associated injury followed by vertebral spine fractures. Cardiac injuries are less frequent and vascular injuries less so. Mechanism of injury and presence of sternal fractures should alert providers to these potential associated injuries.

Intra-abdominal Abscess After Appendectomy-Are Drains Necessary in All Patients?

BACKGROUND

Research has shown that patients who develop a postoperative intra-abdominal abscess (PIAA) after appendectomy have a greater number of health care visits with drain placement. Our institution developed an algorithm to limit drain placement for only abscesses with a size >20 cm². We sought to determine the adherence to and effectiveness of this algorithm.

METHODS

This prospective observational study included patients aged 2-18 y old who developed a PIAA from September 2017 to June 2019. Outcomes were compared between patients with a small or large abscess. Analysis was performed in STATA; P < 0.05 was significant.

RESULTS

Thirty patients were included. The median age was 10.6 y (7, 11.7); 60% were men, and 60% were Caucasian. The median duration of symptoms before diagnosis of appendicitis was 3 d (2, 6). Thirteen patients (43%) were diagnosed with a PIAA while still inpatient, and 17 (57%) were readmitted at a later date. After algorithm implementation, 95% (n = 19) of patients with a large abscess had aspiration ± drain placement, whereas 30% (n = 3) with a small abscess underwent drainage. Length of stay after abscess diagnosis, total duration of antibiotics, and number of health care visits were the same between groups. One patient with a small abscess required reoperation for an obstruction, whereas one patient with a large abscess that was drained was readmitted for a recurrent abscess.

CONCLUSIONS

Small PIAA can be successfully managed without intervention. Our proposed algorithm can assist in determining which patients can be treated with antibiotics alone.

Ligament of Treitz Release With Duodenal Lowering for Pediatric Superior Mesenteric Artery Syndrome

BACKGROUND

Operative approaches for superior mesenteric artery syndrome (SMAS) vary from Roux-en-Y duodenojejunostomy to the more conservative division of the ligament of Treitz with inferior duodenal derotation known as the Strong procedure. We sought to examine outcomes following a modified version of Strong procedure where the duodenum is lowered as opposed to derotated for the management of SMAS.

MATERIALS AND METHODS

We conducted a retrospective chart review of children who underwent surgical management of SMAS between January 2008 and December 2017. An online survey regarding symptom resolution, feeding practices, and the need for additional procedures was distributed. Data are reported as medians with interquartile range (IQR) and proportions as percentages.

RESULTS

Seven patients with a median age of 15 y (IQR 8, 16) and median body mass index of 16.9 (IQR, 12.6, 22.1) were included. Presenting symptoms included pain (71%), nausea (57%), and vomiting (43%). Six patients initially underwent duodenal lowering, whereas one patient underwent duodenoduodenostomy. One patient underwent adhesiolysis for bowel obstruction in the early postoperative period. All patients had symptom resolution at a postoperative follow-up of 22 d (IQR, 15, 45). Two patients had symptom recurrence, and one patient required reoperation. Six patients completed the survey at a median of 2.3 y (IQR, 1.7, 3.2) postoperatively, of which four underwent duodenal lowering. Of these, 75% (n = 3) were asymptomatic. One patient with recurrence reported occasional nausea and emesis but has not required additional surgery.

CONCLUSIONS

Release of the ligament of Treitz with duodenal lowering results in resolution of symptoms in 75% of patients. This operative approach may be considered before performing more complex operations for SMAS.

Same-Day Discharge and Quality of Life for Primary Laparoscopic Rectopexy for Rectal Prolapse in Children: A 10-Year Experience

Introduction: Rectal prolapse (RP) in pediatric patients may require surgical intervention. Varying surgical approaches and heterogenous patient populations have resulted in difficulty defining surgical outcomes and superiority of technique. We sought to review our surgical and self-reported outcomes of patients who underwent laparoscopic rectopexy for idiopathic RP. Methods: Records of children <18 years who underwent primary laparoscopic rectopexy between March 2009 and March 2019 were retrospectively reviewed. Patients with redo rectopexy were excluded. Demographics, pre- and postoperative treatment, and outcome data were collected and reported using descriptive statistics. Qualitative analysis of a quality of life (QoL) questionnaire administered to patients and parents 2-10 years postoperatively was performed. Results: Fifteen patients were included. Median age at surgery was 5 years (interquartile range [IQR] 3, 12.5); 60% were male and median weight was 22 kg (IQR 16.4, 39.2). Median length of stay was 6 hours (IQR 4, 22) with 9 (60%) discharged the same day. Perioperatively, 73% were on laxative for constipation, whereas only 33% were on laxative therapy at 6 months postrectopexy. Median follow-up was 19 months (IQR 8, 39). Three patients (20%) suffered recurrent RP (2 required redo rectopexy), and 2 patients self-limited urinary retention. Respondents to the QoL questionnaire indicated improvement in symptoms after surgery. No patient reported fecal incontinence, smearing, or leakage of stool. Conclusion: Laparoscopic rectopexy is a safe minimally invasive approach for children with idiopathic RP that offers high patient satisfaction with same-day discharge, early recovery, and low recurrence.

Non-operative management of solid organ injuries in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee systematic review

PURPOSE

The American Pediatric Surgical Association (APSA) guidelines for the treatment of isolated solid organ injury (SOI) in children were published in 2000 and have been widely adopted. The aim of this systematic review by the APSA Outcomes and Evidence Based Practice Committee was to evaluate the published evidence regarding treatment of solid organ injuries in children.

METHODS

A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Four principal questions were examined based upon the previously published consensus APSA guidelines regarding length of stay (LOS), activity level, interventional radiologic procedures, and follow-up imaging. A literature search was performed including multiple databases from 1996 to 2016.

RESULTS

LOS for children with isolated solid organ injuries should be based upon clinical findings and may not be related to grade of injury. Total LOS may be less than recommended by the previously published APSA guidelines. Restricting activity to grade of injury plus two weeks is safe but shorter periods of activity restriction have not been adequately studied. Prophylactic embolization of SOI in stable patients with image-confirmed arterial extravasation is not indicated and should be reserved for patients with evidence of ongoing bleeding. Routine follow-up imaging for asymptomatic, uncomplicated, low-grade injured children with abdominal blunt trauma is not warranted. Limited data are available to support the need for follow-up imaging for high grade injuries.

CONCLUSION

Based upon review of the recent literature, we recommend an update to the current APSA guidelines that includes: hospital length of stay based on physiology, shorter activity restrictions may be safe, minimizing post-injury imaging for lower injury grades and embolization only in patients with evidence of ongoing hemorrhage.

TYPE OF STUDY

Systematic Review.

LEVELS OF EVIDENCE

Levels 2-4.

Emergency department discharge following successful radiologic reduction of ileocolic intussusception in children: A protocol based prospective observational study

PURPOSE

Pediatric intussusception's first line treatment consists of fluoroscopic guided air enema reduction. Postprocedure, these patients are usually admitted overnight for observation. The purpose of our study was to document the results of emergency department (ED) observation and discharge protocol after successful reduction of ileocolic intussusception.

METHODS

A prospective observational study was conducted after implementation of an ED protocol for ileocolic intussusception from 10/2014 to 7/2017 and compared these patients to a historical cohort immediately prior to protocol initiation (10/2011-9/2014). Data collected included demographics, total time in the ED and hospital, enema reduction, recurrence, and requirement for operative intervention. Results reported as means with standard deviation and medians reported with interquartile ranges (IQR).

RESULTS

115 patients were treated with the prospective protocol and were compared to a 90 patient historical cohort. Reduction was successful in 84%-89% of cases. Median hospital time after enema was shorter in the protocol group [4.8 h (4.25, 14.97) versus 19.7 h (13.9, 33.45), p < 0.01]. Only 33% of patients were admitted following the protocol; the most common admission reason was persistent abdominal discomfort.

CONCLUSION

ED observation and discharge after successful air enema reduction in children with ileocolic intussusception are safe, facilitate early discharge, and reduce hospital resource utilization.

LEVEL OF EVIDENCE

III.

Outcomes Following Dynamic Compression Bracing for Pectus Carinatum

Introduction: Children with pectus carinatum (PC) are particularly vulnerable to psychosocial effects of poor body image, even though they may not experience physical symptoms. Nonoperative treatment with orthotic bracing is effective in PC correction. We describe our experience with dynamic compression bracing (DCB) for PC patients and their satisfaction with bracing. Materials and Methods: Prospective institutional data of patients undergoing DCB from July 2011 to June 2018 were reviewed and analyzed for those who entered the retainer mode after correction, defined by a correction pressure of <1 psi. A telephone survey was conducted regarding their bracing experience and satisfaction with the outcome on a scale of 1-10. Results: Of 460 PC patients, 144 reached the retainer mode. Median time to retainer mode was 5.5 months. There was no statistically significant relationship between initial correction pressure or carinatum height and time to retainer mode (P = .08 and P = .10, respectively). Fifty-seven percent were compliant with brace use, and median time to retainer mode in this subset was significantly shorter than noncompliant patients (3.5 months versus 10 months, P < .001). Fifty-three percent responded to the survey 13 months [interquartile ratios 3, 33] after the last clinic visit. The main barrier to compliance with wearing the brace was discomfort (37%), while the main motivation for compliance was appearance (58%). All endorsed bracing as worthwhile, with 94% reporting a satisfaction rating of 8 or greater for the correction outcome. Conclusion: DCB is effective in achieving correction of PC in compliant patients. Regardless of time to retainer mode, patients reported high satisfaction with bracing.