Minimally invasive esophagectomy and gastric pull-up in children.

PURPOSE: Minimally invasive esophagectomy and gastric pull-up is a widely accepted method in adults. However, the experience in the pediatric population is limited. Minimally invasive esophagectomy represents a new alternative technique to the conventional open approach. We wish to report our small case series of minimally invasive esophagectomy and gastric pull-up in pediatric patients. The aim of the study is to evaluate the feasibility, safety, and outcomes of the procedure. METHODS: Three patients (2 girls and 1 boy) with average age 46 months (34-57 months) and average weight 12.6 kg (11-15 kg) underwent the procedure. The indications for esophagectomy were esophageal stricture from caustic ingestion (2 patients) and failed repair of esophageal atresia (1 patient). RESULTS: Average operative time was 7 h (0519-0752 hours). There were no intraoperative complications with the average blood loss of 50 cc (5-125 cc). No anastomotic leaks were noted on the initial esophagrams that were obtained on postoperative day five or six. One patient developed a cervical wound infection on postoperative day seven due to a retained piece of Penrose, which required a neck exploration, removal of foreign body and repair of a small leak. One patient developed an anastomotic stricture at the 7-month follow-up. She was successfully treated with two balloon dilatations. One patient developed a delayed esophagogastric anastomotic leak at 3 months. The leak spontaneously closed after surgical drainage. At average of 22-month follow-up (15-36 months), all patients were eating regular food with excellent weight gain. CONCLUSION: Minimally invasive esophagectomy and gastric pull-up is technically challenging but feasible and safe with acceptable outcomes. However, further study is needed to further validate the approach.

Combined laparoscopic and thoracoscopic esophagectomy and gastric pull-up in a child.

Severe caustic burns to the esophagus may necessitate esophagectomy with replacement, if stictures form which are not amenable to dilation. Traditionally, the operation is performed via open transabdominal and/or thoracic approaches. Here we describe our minimally invasive approach, combining laparoscopy and thoracoscopy for esophagectomy, stomach tubularization and a cervical esophagogastrotomy. We successfully performed the procedure in a 4-year-old boy. There were no intraoperative complications, and his initial esophagram showed good patency with no leaks. However, one week postoperatively he was noted to have a retained foreign body and a minor anastomotic leak, which was most likely caused by the foreign body. He underwent a neck re-exploration,removal of the foreign body, and repair of the anastomotic leak. His subsequent hospital course was uneventful. He tolerated feedings and was discharged home on an unrestricted diet. The minimally invasive approach to esophagectomy and esophageal replacement is feasible and is an excellent option in select patients.

What are the true advantages of a pediatric appendicitis clinical pathway?

Multiple protocols have been described for pediatric appendicitis, but few have been compared with off-protocol treatment. We performed such a comparison. Children treated for appendicitis by three pediatric surgeons over a 28-month period were studied. A protocol of primary wound closure without drains, standardized use of antibiotics, and patient discharge according to pre-determined clinical criteria was compared with individualized drain use, antibiotic selection, and discharge timing. Three hundred ninety-seven children were treated, 43 per cent on pathway (Group I) and 57 per cent off pathway (Group II). The two groups showed similar incidence of acute (45% vs 46%), complicated (50% vs 49%), and normal (5%) appendix. Among patients with simple appendicitis, Group I had less postoperative antibiotic use (16% vs 80% P < 0.001), shorter hospital stays (1.44 vs 1.89 days, P = 0.001), and decreased hospital charges (dollars 9,289 vs dollars 10,751, P = 0.001). Among patients with complicated appendicitis, Group I had less drain placement (4% vs 27%, P < 0.001), less use of discharge antibiotics (13% vs 39%, P < 0.001), and no readmission (0% vs 5%, P = 0.05). Infectious complications were similar between the two groups. A clinical pathway decreases the use of unnecessary antibiotics, hospital stay, and charges for simple appendicitis. It decreases the use of unnecessary drains, and eliminates readmissions after complicated appendicitis.

Emergent vs urgent appendectomy in children: a study of outcomes.

BACKGROUND: Emergent appendectomy (EA) in children is still considered surgical dogma and continues to be recommended as a standard of care. This study examined whether emergent operation has any outcome advantages over urgent operation. METHODS: The charts of children treated for appendicitis during a recent 28-month period at 2 children's hospitals, where appendectomies are not performed between midnight and 7 am, were reviewed. Outcomes were compared between patients who underwent EA (within 8 hours of presentation) vs those who underwent urgent appendectomy (UA, after 8 hours). RESULTS: Three hundred sixty-five children met the criteria for the study. One hundred sixty-one (44%) were in the EA group (5.3 +/- 2.1 hours), and 204 (56%) were in the UA group (16.8 +/- 9.7 hours). The incidence of gangrenous or perforated appendicitis was significantly higher in the EA group (47% vs 36%, P = .04). There were no significant differences between EA and UA in postoperative outcomes, including readmissions (3.7% vs 1.0%, P = .08), wound infections (0.6% vs 2.4%, P = .17), or postoperative abscesses (1.9% vs 1.5%, P = .77). There were no significant differences in average hospital stay or average hospital charges between EA and UA (3.2 days for both, 14,775 dollars vs 14,850 dollars), respectively. CONCLUSIONS: Emergent appendectomy in children has no advantages over UA with respect to gangrene and perforation rates, readmissions, postoperative complications, hospital stay, or hospital charges. Performance of a UA at a time convenient to the surgeon should be considered within the standard of care.

Staphylococcal rib osteomyelitis in a pediatric patient.

Osteomyelitis in children commonly occurs in the long bones such as the femur, tibia, and humerus. It is rarely found in the ribs, occurring in less than 1% of children with osteomyelitis. Thirteen cases of rib osteomyelitis were reported in the literature, of which, 11 were caused by Staphylococcus aureus. Pediatric osteomyelitis often masquerades as skeletal neoplasia, as illustrated in the following case presentation. Here, the authors describe a case of pediatric staphylococcal rib osteomyelitis, review the published literature on similar cases, and describe its medical and surgical treatment.