Modification of an evidence-based protocol for advanced appendicitis in children.

INTRODUCTION: We previously developed an evidence-based clinical pathway for children with advanced appendicitis. The pathway standardized the choice and duration of antibiotic therapy and established discharge criteria. Initially, the pathway led to a 50% decrease in the rate of superficial and deep surgical site infections and a significant decrease in hospital length of stay. Four years after implementation, we noted an increase in the infectious complication rate and the emergence of resistant bacteria to commonly used antibiotics. In this study, we prospectively collected peritoneal fluid cultures at the time of appendectomy in an effort to optimize our antibiotic therapy and decrease complication rates. METHODS: Microbiology analysis of peritoneal fluid cultures obtained at the time of appendectomy was performed in patients with an intraoperative diagnosis of advanced appendicitis. Clinical information, including demographics, laboratory data, and postoperative outcomes were collected and compared to the historic cohort. X(2), Student's t-test, and Fisher exact test were used where appropriate. RESULTS: The historic and prospective cohorts were similar with respect to clinical and demographic data. The postoperative intra-abdominal abscess rate remained unchanged (28% from 24%, P = 0.603). Escherichia coli and Pseudomonas aeruginosa were the most commonly isolated aerobic bacteria from peritoneal fluid in the prospective cohort. Thirty-two percent of these patients had Pseudomonas spp., and 12% had Enterococcus spp. or Escherichia coli resistant to cefoxitin in their peritoneal fluid cultures. DISCUSSION: A significant proportion (40%) of children with advanced appendicitis had organisms either not susceptible or resistant to our first line antibiotic in their peritoneal fluid cultures. Our clinical pathway now recommends piperacillin-tazobactam as the most effective empiric therapy for advanced appendicitis in children. Microbiologic analysis of peritoneal fluid at appendectomy may be used to tailor antibiotic therapy in advanced appendicitis.

Repair of congenital diaphragmatic hernias on Extracorporeal Membrane Oxygenation (ECMO): does early repair improve patient survival?

INTRODUCTION: The optimal timing of repair for congenital diaphragmatic hernia (CDH) patients that require ECMO is controversial. Early repair on ECMO theoretically allows for restoration of normal thoracic anatomy but entails significant bleeding risks. The purpose of this study was to examine the institutional outcomes of early CDH repair on ECMO. METHODS: The records of infants with CDH placed on ECMO from 2001 to 2011 were reviewed. Since 2009, a protocol was instituted for early repair while on ECMO. For this study, three cohorts were analyzed: early repair (<72 h), late repair (>72 h), and post-decannulation. These groups were compared for outcomes regarding morbidity and survival. RESULTS: Forty-six CDH patients received ECMO support with an overall survival of 53%. Twenty-nine patients (11 early/18 late) were repaired on ECMO, while 17 patients had repair post-decannulation. Survival was 73%, 50%, and 64% for those repaired early, late, or post-decannulation, respectively. Despite significantly worse prenatal factors, patients repaired early on ECMO had a similar survival. When comparing patients repaired on ECMO, the early group patients were decannulated 6 days earlier (p-value=0.009) and had significantly lower circuit complications (p=0.03). CONCLUSION: In conclusion, early repair on ECMO was associated with decreased ECMO duration, decreased circuit complications, and a trend towards improved survival.

Increased complication rates associated with Port-a-Cath placement in pediatric patients: location matters.

INTRODUCTION: Port-a-Caths (PACs) are commonly placed below the clavicle or below the inframammary line for cosmesis. We hypothesized that inframammary placement is associated with increased catheter-related complications due to redundant catheter length. METHODS: A review of pediatric patients with PAC placement from 2007 to 2009 was performed. Port placement was identified as subclavicular (SC) or inframammary by x-ray (below the fifth-intercostal space). Inframammary ports were stratified by the midclavicular line: medial inframammary (MIM) and lateral inframammary (LIM). Early complications (<30 days) and late complications were analyzed. RESULTS: We identified 167 SC, 46 MIM, and 166 LIM patients. LIM placement was independently associated with increased total complication rate (p<0.001), migration rate (p<0.001), and operative exchange (p=0.017) compared to the SC group. The catheter survival time was decreased in the LIM vs. SC group (1021 ± 55 vs. 1396 ± 48 days, p=0.005). Additionally, LIM placement was independently associated with increased odds of catheter removal (p=0.006). MIM patients demonstrated fewer complications compared to the LIM group (17.4% vs. 44.6%, p=0.001) and were similar to the SC group (17.4% vs. 20.4%, p=0.835). CONCLUSIONS: Lateral inframammary chest wall placement of PACs is independently associated with increased total complication rates, migration rates, and need for operative exchange. We recommend subclavicular or medial inframammary PAC placement in children.

The importance of surgeon involvement in the evaluation of non-accidental trauma patients.

INTRODUCTION: Non-Accidental Trauma (NAT) is a significant cause of childhood morbidity and mortality, causing 50% of trauma-related deaths at our institution. Our purpose was to evaluate the necessity of primary surgical evaluation and admission to the trauma service for children presenting with NAT. METHODS: We reviewed all NAT patients from 2007-2011. Injury types, demographic data, and hospitalization information were collected. Comparisons to accidental trauma (AT) patients were made using Wilcoxon rank sum and Student's t tests. RESULTS: We identified 267 NAT patients presenting with 473 acute injuries. Injuries in NAT patients were more severe than in AT patients, and Injury Severity Scores, ICU admission rates, and mortality were all significantly (p<0.001) higher. The majority suffered from polytrauma. Multiple areas of injury were seen in patients with closed head injuries (72%), extremity fractures (51%), rib fractures (82%), and abdominal/thoracic trauma (80%). Despite these complex injury patterns, only 56% received surgical consults, resulting in potential delays in diagnosis, as 24% of abdominal CT scans were obtained >12 hours after hospitalization. CONCLUSION: Given the high incidence of polytrauma in NAT patients, prompt surgical evaluation is necessary to determine the scope of injury. Admission to the trauma service and a thorough tertiary survey should be considered for all patients.

Initial experience with single-vessel cannulation for venovenous extracorporeal membrane oxygenation in pediatric respiratory failure.

OBJECTIVES: Venovenous extracorporeal membrane oxygenation has been used to provide cardiopulmonary support in critically ill infants and children. Recently, dual-lumen venovenous extracorporeal membrane oxygenation has gained popularity in the pediatric population. Herein, we report our institutional experience using a bicaval dual-lumen catheter for pediatric venovenous extracorporeal membrane oxygenation support, which has been our unified approach for venovenous extracorporeal membrane oxygenation since 2009. DESIGN: This study is a retrospective review. SETTING: The setting is a tertiary children's hospital in a major metropolitan area. PATIENTS: Between 2009 and 2011, 11 patients were cannulated using a dual-lumen bicaval venous catheter. Patient demographics, cannulation details, circuit complications, complications of catheter use, and patient outcomes were collected from a retrospective chart review. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eleven of the patients were cannulated for venovenous extracorporeal membrane oxygenation using the dual-lumen bicaval cannula. The median age at the time of venovenous cannulation was 1.9 years (range, 0.14-17.1), and the median weight was 10.2 kg (range, 3-84). Three patients (27%) required conversion to venoarterial extracorporeal membrane oxygenation. The median duration of extracorporeal membrane oxygenation support was 10 days (2-38 days). Fifty-five percent of patients suffered from a bleeding complication (disseminated intravascular coagulation, pulmonary hemorrhage, or intraventricular hemorrhage), and 45% had a circuit complication. Adequate flow rates were achieved in all patients. The overall hospital mortality in the series was 55%. There were no cannula-related complications. CONCLUSIONS: This review presents the first single-institution experience with the dual-lumen Avalon cannula in pediatric patients. Preliminary results indicate that the catheter can be safely placed and has an acceptable complication profile; however, continued study within larger trials is necessary to fully ascertain the clinical profile of this catheter.

The surgical management of Rapunzel syndrome: a case series and literature review.

BACKGROUND/PURPOSE: The surgical removal of a trichobezoar is the rare end complication of the psychiatric disorders trichotillomania and trichophagia. The more severe form of the disease is termed Rapunzel syndrome, where the bezoar extends from the gastric body beyond the pylorus into the duodenum. Traditional therapy has included endoscopy, often with subsequent laparotomy, and associated psychiatric intervention. We present the largest and most recent series of patients with trichobezoars managed in a single institution. METHODS: A retrospective review of all cases of trichobezoar at our institution from 2003 to 2011 was performed. Demographic data, presenting complaints, imaging, surgical treatment, and subsequent management were collected. RESULTS: All 7 patients were female, ages 5 to 23 years (mean, 11.5 years). Although multiple imaging modalities were necessary for preoperative diagnosis, most patients were accurately diagnosed without endoscopic evaluation (85%). All patients required an exploratory laparotomy for definitive treatment. At laparotomy, 5 patients were found to have postpyloric extension of the trichobezoar (71%). One of 7 patients had a wound infection postoperatively. There were no other surgical complications or recurrences requiring further exploration. CONCLUSIONS: Our series of trichobezoar patients appear to have a high rate of Rapunzel syndrome, and perhaps postpyloric extension should be considered the rule rather than the exception. Our series demonstrates that diagnosis can be established with a thorough history combined with radiography, and treatment should be a combination of laparoscopy and/or laparotomy with psychiatric consultation.

Water-absorbing balls: a "growing" problem.

Foreign body ingestion is a potentially serious clinical problem in children. We report a case of an 8-month-old infant who developed complete bowel obstruction requiring laparotomy due to ingestion of a superabsorbent polymer ball with advertised growth up to 400 times its original size. Most ingested foreign bodies that pass through the pylorus will make it safely through the gastrointestinal tract. This is not true for water-absorbing balls that progressively increase in size and cause intestinal obstruction. Other household products and toys on the market use a similar polymer-based water-absorbing technology, thus increasing the risk for accidental ingestion by young children. These rapidly expanding objects can cause significant morbidity, and timely diagnosis and treatment are prudent to improve patient outcomes.

Needle core vs open biopsy for diagnosis of intermediate- and high-risk neuroblastoma in children.

BACKGROUND: Open biopsy has been the mainstay for definitive diagnosis of neuroblastoma in pediatric patients. However, needle core biopsy may represent a faster, less invasive, and safer alternative to open biopsy in children. The purpose of this study was to compare safety and efficacy between needle core and open biopsy in the diagnosis of patients with intermediate- and high-risk neuroblastoma at our institution. METHODS: We retrospectively reviewed the medical records of children with intermediate- and high-risk neuroblastoma who underwent open or needle core biopsies from 2002 to 2010. Data collected included patient demographics, tumor size, sample adequacy for diagnosis and risk stratification (histology and cytogenetics), length of hospital stay, time to initiate chemotherapy after biopsy, need for repeat biopsy, and both intraoperative and postoperative complications. Mann-Whitney U and Fisher's exact tests were used for statistical analysis. RESULTS: During the study period, 7 patients underwent needle core primary biopsies (5 intermediate-risk primary tumors and 2 high-risk primary tumors), and 4 patients underwent needle core biopsy for metastatic tumors, whereas 21 patients had open biopsies (10, intermediate risk; 11, high risk). Median age at biopsy and median tumor size were similar in both groups. There was no significant difference in adequacy of biopsy, need for repeat biopsy, time to initiate chemotherapy, length of stay, or minor complications. The rate of major complications differed significantly between the 2 groups with 0% after needle core biopsy vs 48% after open biopsy (P = .027). CONCLUSIONS: In children, needle core biopsy is comparable in efficacy with open biopsy in the diagnosis of intermediate- and high-risk neuroblastoma with significantly lower rates of major postoperative complications. These findings warrant a larger scale evaluation of diagnostic needle core biopsies in pediatric patients with solid tumor.