Esophageal foreign bodies in the pediatric population: our first 500 cases.

BACKGROUND: Children with esophageal foreign bodies are frequently seen by pediatric surgeons. Choking and dysphagia are common presentations; however, esophageal perforation has been reported. Historically, rigid esophagoscopy with extraction of the foreign body has been the recommended treatment. Alternatively, Foley balloon extraction is a safe and effective approach. METHODS: Over a 16-year period, 555 children presented with an esophageal foreign body. Retrospective analysis of the medical record was undertaken. Statistics were by univariate analysis. RESULTS: Two hundred ninety-eight boys and 257 girls presented with a mean age of 3.24 years. Dysphagia (37%) and drooling (31%) were the most common symptoms. Foreign bodies were lodged in the superior esophagus in 73%, and 88% of the objects were coins. Balloon extraction with fluoroscopy was performed in 468 children. Eighty percent of the objects were successfully removed with a mean fluoroscopy time of 2.2 min, and 8% were advanced into the stomach. The overall success rate was 88%, with failures necessitating rigid esophagoscopy under general anesthesia. Children younger than 1 year were the most likely to fail (25% failure rate). Airway aspiration never occurred. Significant savings in patient charges were observed with this approach. CONCLUSIONS: Balloon extraction of pediatric esophageal foreign bodies is a safe and cost-effective procedure. This technique is applicable for infants, children, and adolescents. Experienced practitioners should be able to achieve greater than 80% success rate.

Relative value units correlate with pediatric surgeons' operating time: when perceived myth becomes reality.

PURPOSE: In 1992, the Congress implemented a Medicare payment system based on relative value units (RVUs). Today, RVUs are increasingly used to determine surgeon reimbursement from Medicare, Medicaid, and private third-party payers. We questioned whether current RVU assignments accurately reflect the quantity of time that surgeons spend operating. METHODS: Over a 12-month period, 59 common pediatric operations were identified and classified as general surgery (n = 34), urology (n = 13), or minimally invasive (n = 10). Only operations performed as an outpatient or requiring less than one inpatient day of direct surgeon involvement were included. By regression analysis, correlation coefficients were generated comparing average operating time per procedure to the corresponding RVU generated. RESULTS: Of 59 specific operations, a total of 744 general surgery cases, 1155 urological cases, and 370 minimally invasive cases were performed. RVU efficiency was greatest in general surgery (1 RVU = 5.18 operating minutes), followed by minimally invasive operations (1 RVU = 6.80 minutes) and urological operations (1 RVU = 8.59 minutes). Regression analysis proved minimally invasive operations to correlate best with RVUs with R2 = 0.8376, followed by urology at R2 = 0.6753, and then general surgery at R2 = 0.649. CONCLUSIONS: The RVU has emerged as the most dominant factor influencing reimbursement of practicing pediatric surgeons. Despite common surgeon bias, RVUs do correlate with current operating times. These data prove important as surgeons analyze cost, negotiate contracts, and strategically plan for fiscal success.

Urachal anomalies in children: the vanishing relevance of the preoperative voiding cystourethrogram.

PURPOSE: Children with a wet, draining, or infected umbilicus are often referred to pediatric surgeons. Unfortunately, uniform guidelines regarding diagnostic imaging are lacking. Historically, the persistence of the urachus was attributed to intrauterine distal urinary obstruction. Today, many surgeons continue to advocate preoperative voiding cystourethrogram (VCUG). METHODS: Records of children with urachal abnormalities over the past 10 years were reviewed. Demographics, presentation, imaging, genitourinary anomalies, operations, length of stay, and complications were recorded. Statistical evaluation was by descriptive analysis. RESULTS: Fifty-six children were diagnosed with urachal anomalies. Age at operation was 2.5 years (1 day-13 years). Fifty percent of patients were less than 1 year. Ultrasound was used in 88% of cases. Voiding cystourethrogram (34%) and computed tomography (14%) were also used. Average hospitalization was 1.9 (0-13) days. Thirty-two percent underwent operations as outpatients. Seven percent developed wound infections. Eight children (14%) had genitourinary anomalies. However, no VCUG examination (n = 19) documented an obstructive process. CONCLUSIONS: The current study represents the largest reported series of symptomatic urachal anomalies in children. Disorders of the urachus are variable in presentation with the diagnosis reliably made by history and ultrasound alone. Further testing, including VCUG, is not warranted, adding additional cost, an invasive procedure, and inconvenience to the child.