Association Between Nil Per Os Status and Intubated Patients Undergoing Surgery.

INTRODUCTION: Patient outcomes heavily rely on nutritional support. However, holding enteric feeds prior to surgical operations in critically ill patients is still a common practice in intensive critical units. Our objective is to describe the relationship between duration of nil per os (NPO) and respiratory outcomes in intubated, critically ill patients requiring operative intervention. METHODS: We conducted a retrospective analysis on intubated, critically ill patients who underwent operative intervention between January 1, 2016, and December 31, 2018, to investigate how the duration of NPO status may affect respiratory outcomes. We compared adverse respiratory events among patients who maintain NPO ≥6 h (NPO group) versus those who were NPO <6 h (non-NPO group) prior to surgery. RESULTS: Two hundred patients met inclusion criteria: 104 for NPO and 96 for non-NPO. Aspiration event was found in 5.8% of NPO patients and 7.3% in non-NPO patients, P = 0.66. Desaturation event was found in 16.3% for NPO and 14.6% in non-NPO, P = 0.73. Pneumonia was found in 18.3% of NPO patients and 19.8% in non-NPO patients, P = 0.78. Reintubated rates were 13.5% for NPO and 16.7% for non-NPO, P = 0.57. Median (range) hours of NPO for non-NPO was 1.0 h (0-3.0) and 13.0 h (6.0-20.0) for NPO, P < 0.05. CONCLUSIONS: For intubated, critically ill patients requiring operative intervention, there was no difference observed in adverse respiratory events between those kept NPO for 6 h or greater compared to those kept NPO for less than 6 h. Patients were commonly without enteric nutrition for periods of time much greater than the American Society of Anesthesia's recommended 6-h period.

Factors Associated With Successful Video-Assisted Thoracoscopic Surgery for Traumatic Hemothorax in Children: A Cross-Sectional Study.

INTRODUCTION: Due to the rarity of traumatic hemothorax in children, no studies have evaluated factors associated with successful video-assisted thoracoscopic surgery (VATS) as definitive management. METHODS: We conducted an exploratory cross-sectional analysis of pediatric patients in the Trauma Quality Programs database from 2008 to 2017 with traumatic hemothorax managed with primary VATS. Those with early resuscitative thoracotomy for cardiac arrest were excluded. We stratified patients by blunt or penetrating mechanism and estimated absolute differences (ADs) and 95% confidence intervals (CIs) to identify factors associated with successful VATS without conversion to thoracotomy or reoperation. RESULTS: A total of 293 patients were eligible. Among 184 penetrating injuries, 150 (82%) underwent successful VATS, 6 (3%) required reoperation, and 28 (15%) converted to thoracotomy. Diaphragmatic injuries (AD = -28, 95% CI = -46 to -10) and rib fractures (AD = 12, 95% CI = 1 to 23) had the strongest negative and positive associations (respectively) with successful VATS. There were 109 blunt injuries: 86 (79%) underwent successful VATS, 6 (6%) required reoperation, and 17 (16%) converted to thoracotomy. Moderate or severe head injury (AD = -15, 95% CI = -32 to 2), injury severity score >15 (AD = -19, 95% CI = -33 to -5), and the presence of diaphragmatic injury (AD = -38, 95% CI = -71 to -4) had the strongest negative associations with successful VATS. CONCLUSIONS: Some children with traumatic hemothorax can be successfully managed with VATS. For penetrating mechanism, diaphragmatic injuries were associated with less success, while rib fractures were associated with more success. For blunt mechanism, diaphragmatic injuries, injury severity score >15, or moderate or severe head injury were associated with less success.

Association Between the SARS-Cov2 Pandemic and Pediatric Surgical Consultations.

INTRODUCTION: The purpose of this study was to evaluate changes to acute pediatric surgical needs during the early phase of the SARS-Cov2 (COVID-19) pandemic. METHODS: We performed a retrospective cohort study of all in-hospital pediatric surgery consultations placed through the consult paging system at a single institution. We compared both median and absolute differences for emergency department (ED), operative, and hospital outcomes between March, April, and May of 2019 versus 2020. RESULTS: There were 225 in-hospital pediatric surgery consults in 2019 and 123 in 2020. Overall, mean age was 8.4-y (standard deviation = 6.4) and 60% were male. Initial vitals were similar between years and a similar proportion of patients underwent laboratory and imaging tests. In 2020, children spent a median of 1.1-h fewer in the ED (95% confidence interval = -2.2, -0.1) and 0.9-h fewer in the ED before surgical consultation (95% confidence interval = -1.5, -0.3) compared to 2019. Patients required significantly more procedures in the ED in 2020 (n = 16, 14.3%) than 2019 (n = 13, 6.2%) (P = 0.02), most commonly laceration repairs. In 2019, 46 children (20.4% of all consults in 2019) presented with appendicitis and 27 children (22.0% of all consults in 2020) in 2020. Complicated appendicitis was more common in 2020 (n = 12, 44.4%) than 2019 (n = 9, 19.6%) (P = 0.02). Two children (7.4%) were managed nonoperatively with a drain in 2020 compared to none in 2019 (P = 0.13). Median time from surgical consultation to surgery, median operative time, and median time to discharge was similar for children with appendicitis in both years. CONCLUSIONS: The early phase of the pandemic was associated with more efficient triaging in the ED, but more ED procedures and more complex surgical pathology.

Subcutaneous Endoscopic-Assisted Ligation of the Internal Ring for Inguinal Hernia Repair in Neonates Under Spinal Anesthesia.

Introduction: While laparoscopy is now widely accepted for inguinal hernia repair in infants, it traditionally has required general anesthesia. We sought to evaluate the safety of laparoscopic inguinal hernia repair in infants under spinal anesthesia. Materials and Methods: We performed a retrospective cohort study of all inguinal hernia repairs at a single institution between December 2011 and June 2019 in patients younger than 6 months of age. Four groups were compared: laparoscopic under general anesthesia, laparoscopic with spinal anesthesia, open with spinal anesthesia, and open under general anesthesia. Main outcome measures include operative time, cost, and postoperative outcomes. These were assessed using Kruskal-Wallis median comparison. Results: Of the 226 patients meeting inclusion criteria, 54% (122/226) of patients underwent general anesthesia, while 46% (104/226) had spinal. When compared to general anesthesia, spinal anesthesia was associated with significantly shorter procedure times (P < .01) and lower cost (P < .01) for both open and laparoscopic approaches. Complications were few and underpowered to calculate significance across each group. Conclusions: Laparoscopic inguinal hernia repair can be safely performed in infants under spinal anesthesia without significant compromise of early perioperative outcomes. Advantages may include shorter procedure time and lower cost.

Factors Associated with Successful Video-Assisted Thoracoscopic Surgery and Thoracotomy in the Management of Traumatic Hemothorax.

BACKGROUND: Few studies have identified factors associated with successful VATS or thoracotomy as the initial operative strategy among patients with traumatic hemothorax. MATERIAL AND METHODS: We performed an exploratory analysis using the 2008 to 2017 TQP database. We identified all patients aged 18 to 89 years with traumatic hemothorax who were treated with tube thoracostomy alone in the first 24-hours of admission, followed by VATS or thoracotomy. Logistic regression was used to identify factors associated with successful VATS (no conversion or reoperation) or thoracotomy (no reoperation) as the initial operative strategy. RESULTS: Among 2052 patients managed with initial VATS after chest tube drainage, 1710 (83%) were successful, while 263 (13%) were converted to thoracotomy and 79 (4%) required reoperation. On multivariable analysis, poor GCS (OR = 0.96 [95% CI = 0.94-0.99]), major injury (OR = 0.69 [95% CI = 0.53-0.90]), and diaphragmatic injury (OR = 0.42 [95% CI = 0.30-0.60]) were associated with lower odds of successful VATS, while rib fractures (OR=1.29 [95% CI=1.01-1.66]) were associated with higher odds of success of the initial operative plan. Among 3486 patients initially managed with thoracotomy after drainage with tube thoracostomy, 3118 (89.4%) were successful, while 11% (n = 368) required reoperation. Multivariable analysis revealed that major injury (OR = 0.68 [95% CI = 0.50-0.92]), blunt mechanism (OR = 0.63 [95% CI = 0.50-0.78]), and diaphragmatic injury (OR = 0.67, 95% CI = 0.53-0.84]) were associated with lower odds of successful thoracotomy as the initial operative plan. CONCLUSIONS: More severe injuries and diaphragmatic injuries have lower odds of successful of VATS or thoracotomy as the initial operative management strategy among patients with traumatic hemothorax. Rib fractures may be associated with higher odds of success of VATS as the initial management strategy.

Return of the Banana Knife: An Alternative Instrument for Laparoscopic Pyloromyotomy.

Background: When the disposable arthroscopic banana knife (Linvatec, Largo, FL) became unavailable, many pediatric surgeons adapted the use of spatula tip cautery for laparoscopic pyloromyotomy; however, reusable arthroscopic knives remain readily available and are well suited to the procedure. Methods: We compared laparoscopic pyloromyotomy with a reusable arthroscopic banana knife (Sklar, West Chester, PA; catalog no. 45-6050) to those using spatula tip cautery at a single institution between September 1, 2012, and December 31, 2019. Mann-Whitney U test was used to compare operative time, room time, and time to discharge between groups. Results: Overall, 109 patients underwent pyloromyotomy for hypertrophic pyloric stenosis during the study time period. Of these, 12 were open and one was undertaken with the Storz pyloromyotomy knife, so these were excluded. A total of 74 (77.1%) laparoscopic cases with spatula tip cautery and 22 (22.9%) with the banana knife were included. Mean age at the time of surgery was ∼37 days. The majority of patients in each group were white, male, and full term. The most common comorbid conditions were reactive airway disease and neonatal abstinence syndrome. There were no significant differences in operative time (P = .61), room time (P = .41), or time from surgery to discharge (P = .26) between procedures using the banana knife and those using the cautery spatula tip. There were no perforations or recurrences. Conclusion: Our findings suggest that the reusable banana knife is a safe and effective alternative to spatula tip cautery for laparoscopic pyloromyotomy, with no difference in operative time, time from surgery to discharge, or complications.

Metabolic and bariatric surgery is likely safe, but underutilized in adolescents aged 13-17 years.

BACKGROUND: Bariatric surgery is now accepted for adolescents; however, we may need to improve access to surgery for this vulnerable age group. OBJECTIVES: To compare the demographic characteristics and short-term safety outcomes of adolescents, college-aged individuals, and young adults who have had metabolic and bariatric surgery. SETTING: Bariatric surgery centers. METHODS: Patients aged 13-25 years in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from 2015-2018 with a Current Procedural Terminology (CPT) code for sleeve gastrectomy (SG) or gastric bypass (GB) were included. Patients were stratified by operation and analyzed by age: adolescents (13-17 yr), college-aged (18-21 yr), and young adults (22-25 yr). RESULTS: Of the 760,076 patients in the database, 1047 adolescents (.1%), 10,429 college-aged individuals (1.4%), and 24,841 young adults (3.8%) underwent SG or GB. The majority of patients in each group were female and white. Diabetes was most common among adolescents, hypertension among college-aged individuals. The most prevalent co-morbidity among young adults was diabetes. Preoperative BMI was 47 across all age strata. SG was performed in 27,292 patients: 879 (3.2%) adolescents, 7955 (29.2%) college-aged, and 18,447 (67.6%) young adults. Postoperative complications occurred in approximately 1% of individuals and were similar between age groups (P = .23). A total of 8292 patients underwent GB: 146 (1.8%) adolescents, 2207 (26.6%) college-aged, and 5939 (71.6%) young adults. There was no difference in 30-day complication rates between age groups (P = .32). CONCLUSIONS: There may be a disparity in access to metabolic and bariatric surgery among adolescents, particularly for racial and ethnic minorities; however, these procedures are likely safe in adolescents as young as 13.

Evaluation of Rhodiola crenulata on growth and metabolism of NB-1691, an MYCN-amplified neuroblastoma cell line.

Outcomes of children with high grade neuroblastoma remain poor despite multi-agent chemotherapy regimens. Rhodiola crenulata extracts display anti-neoplastic properties against several cancers including breast cancer, melanoma, and glioblastoma. In this study, we evaluated the anti-neoplastic potential of Rhodiola crenulata extracts on human neuroblastoma cells. Through this work, cell viability and proliferation were evaluated following treatments with ethanol (vehicle control) or Rhodiola crenulata extract in neuroblastoma, NB-1691 or SK-N-AS cells, in vitro. HIF-1 transcriptional activity was evaluated using a dual luciferase assay. Quantitative real-time polymerase chain reaction was utilized to assess the expression of HIF-1 targets. Selected metabolic intermediates were evaluated for their ability to rescue cells from Rhodiola crenulata extract-induced death. Lactate dehydrogenase, pyruvate kinase, and pyruvate dehydrogenase activities and NAD+/NADH levels were assayed in vehicle and Rhodiola crenulata extract-treated cells. The effects of Rhodiola crenulata extracts on metabolism were assessed by respirometry and metabolic phenotyping/fingerprinting. Our results revealed striking cytotoxic effects upon Rhodiola crenulata extract treatment, especially prominent in NB-1691 cells. As a greater response was observed in NB-1691 cells therefore it was used for remaining experiments. Upon Rhodiola crenulata extract treatment, HIF-1 transcriptional activity was increased. This increase in activity correlated with changes in HIF-1 targets involved in cellular metabolism. Serendipitously, we observed that addition of pyruvate protected against the cytotoxic effects of Rhodiola crenulata extracts. Therefore, we focused on the metabolic effects of Rhodiola crenulata extracts on NB-1691 cells. We observed that while the activities of pyruvate kinase and pyruvate dehydrogenase activities were increased, the activity of lactate dehydrogenase activity was decreased upon Rhodiola crenulata extract treatment. We also noted a decline in the total NAD pool following Rhodiola crenulata extract treatment. This correlated with decreased cellular respiration and suppressed utilization of carbon substrates. Through this work, we observed significant cytotoxic effects of Rhodiola crenulata extract treatment upon treatment on NB-1691 cells, a human neuroblastoma cell line with MYCN amplification. Our studies suggest that these cytotoxic effects could be secondary to metabolic effect induced by treatment with Rhodiola crenulata extract.

A Novel Macroscale Acoustic Device for Blood Filtration.

Retransfusion of a patient's own shed blood during cardiac surgery is attractive since it reduces the need for allogeneic transfusion, minimizes cost, and decreases transfusion related morbidity. Evidence suggests that lipid micro-emboli associated with the retransfusion of the shed blood are the predominant causes of the neurocognitive disorders. We have developed a novel acoustophoretic filtration system that can remove lipids from blood at clinically relevant flow rates. Unlike other acoustophoretic separation systems, this ultrasound technology works at the macroscale, and is therefore able to process larger flow rates than typical micro-electromechanical system (MEMS) scale acoustophoretic separation devices. In this work, we have first demonstrated the systematic design of the acoustic device and its optimization, followed by examining the feasibility of the device to filter lipids from the system. Then, we demonstrate the effects of the acoustic waves on the shed blood; examining hemolysis using both haptoglobin formation and lactate dehydrogenase release, as well as the potential of platelet aggregation or inflammatory cascade activation. Finally, in a porcine surgical model, we determined the potential viability of acoustic trapping as a blood filtration technology, as the animal responded to redelivered blood by increasing both systemic and mean arterial blood pressure.

Single incision laparoscopic proficiency correlates with residency training level.

BACKGROUND: With experience, certain psychomotor skills should translate from standard laparoscopy to single-incision laparoscopy (SIL). We proposed to compare all surgical postgraduate year (PGY) levels and determine if experience translated to improved SIL skills. METHODS: Surgical residents of all PGY levels (1-5) at our institution were included. Baseline surveys were obtained to determine resident level of exposure to both SIL and standard laparoscopic cases. Participants performed the following tasks: running of the bowel, endoloop placement, extracorporeal suture tying, and intracorporeal suture tying. Tasks were performed on a commercially provided simulated inanimate organ model. Participants were given 5 min to complete each task. Data were collected and analyzed by an impartial-certified Fundamentals of Laparoscopic Surgery proctor. RESULTS: A total of 31 residents participated in the study. Overall, there was minimal SIL exposure among all residents. As expected, PGY level correlated with increased ability to complete assigned tasks within the allotted time. There was a statistically significant difference in the number of individuals able to complete a task based on PGY level for all given tasks (P = 0.005). With increased difficulty, the percentage of higher level residents able to complete the task decreased (100% PGY5 completed running of bowel versus 0% intracorporeal knot tying). CONCLUSIONS: Certain psychomotor skills did appear to translate to SIL skills. However, further dedicated SIL training may help to better develop certain laparoscopic skills devoted to SIL.

Laparoscopic Pediatric Inguinal Hernia Repair: A Pilot Study in a Novel Guinea Pig Animal Model.

BACKGROUND: The purpose of this study was to compare different techniques for pediatric laparoscopic inguinal hernia repair. We hypothesize that the amount of dissection performed at the internal ring, with or without division of the peritoneum, will impact healing and thus long-term success of the repair. METHODS: Following the Institution's Animal Care and Use Committee approval (708024-4), 20 Hartley guinea pigs underwent laparoscopic repair of their natural open internal rings. The guinea pigs were divided equally into four surgical groups: intracorporeal suture repair (IS), hernia dissection and division with intracorporeal suture (DDIS) repair, subcutaneous endoscopically assisted ligation (SEAL), and Yueng (HOOK) repair. After a 6-week survival period, a necropsy was performed. Repairs were evaluated and tested under pressures up to 30 mmHg. The suture was then removed to assess primary healing. Experimental data were analyzed using chi-square test. RESULTS: There were no perioperative or postoperative complications. On initial evaluation, before suture removal, repair integrity was as follows: 5/10 IS, 10/10 DDIS, 7/10 SEAL, and 7/10 HOOK (P = .09). After suture removal, repair integrity was as follows: 3/10 IS, 10/10 DDIS, 5/10 SEAL, and 6/10 HOOK (P = .01). CONCLUSION: Overall, dissecting and dividing the sac with intracorporeal suture (DDIS) closure had the best outcome. This method appears to best replicate standard open high ligation.

Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma: Evaluation of the National Trauma Data Bank.

BACKGROUND: Traumatic pancreatic injury is associated with significant morbidity and mortality. We evaluated the differences in outcomes among children with blunt pancreatic injuries managed operatively and nonoperatively. STUDY DESIGN: The National Trauma Data Bank was evaluated from 2002 to 2011. Patients less than18 years of age with blunt pancreatic injuries and Abbreviated Injury Scale (AIS) scores ≥ 3 were identified. Patients were divided into nonoperative (NO), operative (O), and delayed operative (DO; operation performed 48 hours or more after admission) groups. Outcomes evaluated were total length of stay (LOS), ICU use/LOS, complications, and death. Univariate comparisons were performed using Fisher's exact and Kruskal-Wallis rank tests. Multivariable analyses were performed using robust regression and logistic regression. RESULTS: There were 424 cases analyzed. Mean (± SD) age was 10.6 ± 5.3 years, and mean Injury Severity Score (ISS) was 23.4 ± 13.4. Operative groups differed by age (p = 0.002), AIS severity (p = 0.04), and concomitant head injury (p = 0.01), but were similar with regard to sex, race, and ISS. Length of stay was significantly higher in the DO group compared with the NO or O groups; the NO group had the lowest LOS (covariate-adjusted: 18.7 days vs 11.8 days, p < 0.001 and 12.6 days, p < 0.001, respectively) and infection rates (10.2% vs 1.6% and 6.2%, respectively, p = 0.04). The ICU LOS was greatest in the DO group (vs NO, p = 0.03; O, p = 0.29), as was the likelihood of ICU use (vs NO, p = 0.02; O, p = 0.75). Groups did not differ with respect to outcomes including death (p = 0.94) and overall complication rate (p = 0.63). CONCLUSIONS: Overall, children managed nonoperatively have equivalent or better outcomes when compared with operative and delayed operative management in regard to death, overall complications, LOS, ICU LOS, and ICU use.

Rhodiola crenulata inhibits Wnt/ß-catenin signaling in glioblastoma.

BACKGROUND: Rhodiola crenulata is a perennial plant that grows in the high altitudes of Eastern Europe and Asia. R crenulata has been used for many years in Eastern traditional medicine for a variety of medicinal purposes and it has been shown to elicit antineoplastic effects. The purpose of this study is to determine if R crenulata extract exhibits antitumor properties on glioblastoma multiforme (GBM), the most common and aggressive primary brain tumor. MATERIALS AND METHODS: Human U87 GBM cells were treated with 200 µg/mL of R crenulata or vehicle control. Cell proliferation was measured via MTS assay and clonogenic assay. The expressions of glial fibrillary acidic protein, a protein marker of differentiation, E-cadherin, and non-phospho active ß-catenin were measured with immunocytochemistry. Neurosphere assay was performed in low attachment plates. Activity of the Wnt/ß-catenin transcriptional activation was assessed via a dual-luciferase assay. RESULTS: MTS and clonogenicity assays revealed a decrease in proliferation with R crenulata therapy with an increased sensitivity to radiation. Immunocytochemistry revealed that R crenulata induced glial fibrillary acidic protein and E-cadherin expression suggestive of a more differentiated state. In agreement with the change in differentiation neurosphere formation was decreased upon treatment with R crenulata. ß-Catenin dual reporter assay revealed a decrease in Wnt promoter activity after treatment with R crenulata; this was supported by a decrease in nuclear localization of ß-catenin. CONCLUSIONS: Treatment with R crenulata extract effectively suppresses proliferation, stimulates differentiation, and eliminates tumorsphere formation of GBM cells in vitro. The observed effects are associated with inhibition of Wnt/ß-catenin signaling pathway.

Evaluation of the treatment of pectus carinatum with compressive orthotic bracing using three dimensional body scans.

PURPOSE: The purpose of this study is to measure the effectiveness of compressive orthotic brace therapy for the treatment of pectus carinatum using an adjusted Haller Index (HI) measurement calculated from 3D body scan (BS) images. METHODS: Pediatric patients with pectus carinatum were treated with either compressive orthotic bracing or observation. An adjusted BS Haller index (HI) was calculated from serial 3D BS images obtained on all patients. Medical records were evaluated to determine treatment with bracing and brace compliance more than 12hours daily. Compliant patient measurements were compared to non-compliant and non-brace groups. RESULTS: Forty patients underwent compressive orthotic bracing, while ten were observed. Twenty-three patients were compliant with bracing, and seventeen patients were non-compliant. Compliant patients exhibited an 8.2% increase, non-compliant patients had a 1.5% increase, and non-brace patients exhibited a 2.5% increase in BS HI. The change in BS HI of compliant patients was significantly different compared to non-brace patients (p=0.004) and non-compliant patients (p<0.001). CONCLUSIONS: Three dimensional BS is an effective, radiation free, and objective means to evaluate patients treated with compressive orthotic bracing.

Improving tactile sensation in minimally invasive pediatric surgery.

PURPOSE: The aim of this study was to investigate factors that impact tactile sensation during minimally invasive pediatric surgery. METHODS: Three different 3-mm Maryland laparoscopic instruments were tested with and without the resistance of a trocar (Ethicon 3-mm): Jarit (24-cm shaft, 113 g), Storz (30-cm shaft, 62 g), and an ultra-light prototype (24-cm shaft, 5 g). Experiments were conducted in a custom-designed laparoscopic simulator that directs instruments at fixed angles toward a central target. Surgeons were instructed to insert the instruments into the simulator and make contact with the target with as little force as possible. Instantaneous pressure measurements on the target were measured and recorded every 0.0001 seconds. The differences between impact pressures were compared with a paired, two-tailed, Student's t test. RESULTS: Twenty-seven (27) surgeons participated in the study. The ultra-light prototype had significantly lower impact pressures than the Storz instrument at all angles both with a trocar (P < 0.05) and without a trocar (P < 0.001). The ultra-light prototype had significantly lower impact pressures than the Jarit instrument at all angles in the absence of a trocar (P < 0.001), but with a trocar in place the only significant difference was at 5 degrees (P < 0.001). The presence of the trocar on the ultra-light prototype had a negative impact on tactile sensation that was statistically significant (P < 0.01). CONCLUSIONS: The presence of a trocar negatively impacted the surgeon's tactile sensation. Decreasing instrument mass by 10- to 20 fold did make a statistically significant improvement in tactile sensation.

The deflux procedure reduces the incidence of urinary tract infections in patients with vesicoureteral reflux.

PURPOSE: The aim of this study was to review the experience of a single institution with the Deflux (Q-Med Scandinavia; Uppsala, Sweden) procedure and assess its effectiveness in reducing the incidence of urinary tract infections (UTIs) in children with vesicoureteric reflux (VUR). MATERIALS AND METHODS: After institutional review board approval, the charts of 100 patients with VUR, who presented between June 2003 and June 2005, were prospectively reviewed. Data collected included: demographics, the number of preoperative and postoperative UTIs, a radiologic grade of VUR on a voiding cystourethrogram (VCUG) and the presence of VUR on a radionuclide VCUG 3 months after the procedure. Patients were continued on oral antibiotics until urine culture at 3 months was negative and no reflux was demonstrated on VCUG. The student's t test was used for data analysis. RESULTS: The mean age was 3.8 +/- 0.3 years, and 76% were girls. From 155 ureters treated, 10 had Grade I reflux, 42 Grade II, 76 Grade III, 25 Grade IV, and 2 Grade V. A second injection was required in 22 ureters (14.2%). The overall success rate of the procedure (Grade 0 reflux at 3 months) was 77.4% after the first injection and 83.9% after a second injection. The success rate per grade was: 100% for Grade I, 88.1% for Grade II, 86.8% for Grade III, 64% for Grade IV, and 50% for Grade V. The mean follow-up was 446 +/- 20 days. The mean volume injected/ureter was 0.6 +/- 0.03 mL. Thirteen (13) patients had UTIs after the procedure, compared to 75 before. There was a 5-fold reduction in the incidence of UTIs/year, from a mean of 0.68 +/- 0.09 pre- to 0.12 +/- 0.04 postinjection (P = 0.001). The majority of UTIs were caused by Escherichia coli (74% pre- and 82% postinjection). CONCLUSIONS: We conclude that the Deflux procedure is effective not only in eliminating VUR on radiologic studies, but also in reducing the incidence of UTIs and antibiotic use in children with VUR.

Giant polypoid gastric heterotopia of the jejunum presenting with intermittent intussusception.

We report the case of a 17-year-old female with symptoms of intermittent small bowel obstruction. Computed tomography scan of the abdomen revealed an intussusception. The patient underwent a laparoscopic-assisted resection of the mass, which proved to be gastric heterotopia of the jejunum. We report on the case, discuss the surgical approach, and review the pertinent literature.

Geographic information system localization of community-acquired MRSA soft tissue abscesses.

BACKGROUND: Soft tissue infections with methicillin-resistant Staphylococcus aureus (MRSA) pose an ever-increasing risk to children in the community. Although historically these infections were limited to children with prolonged hospitalization, the authors have seen an increase in community-acquired infections in children without identifiable risk factors. The goal of this study is to determine the incidence of truly community-acquired MRSA soft tissue infections in our community and geographically map regions of increased risk. METHODS: After obtaining the institutional review board's approval, a retrospective chart review was conducted on 195 patients records who underwent an incision and drainage of soft tissue infections from January 1, 2000, to December 31, 2003. Thirteen patients were excluded from the study because no cultures were taken at the time of incision and drainage. RESULTS: The most common organism isolated from wound culture was S aureus , 40% (73/182), of which 45% (33/73) were MRSA. Eighty-one percent (27/33) of MRSA infections were in Springfield, 1 of 18 towns represented in the patient population. Geographic information system analysis identified a significant MRSA cluster 1.96 km in diameter within the city of Springfield. CONCLUSIONS: Geography proved to be a significant risk factor for presenting with MRSA infection. Geographic maps of antibiotic resistance can be used to guide physician antibiotic selection before culture results are available. This has significant implications for the health care provider in proper antibiotic selection within the community.

Feasibility of thoracoscopic U-clip esophageal anastomosis: an alternative for esophageal atresia reconstruction.

BACKGROUND: The authors propose that U-Clips can significantly decrease the technical difficulty of performing thoracoscopic esophageal reconstruction, thus, reducing operating time, the incidence of postoperative leak, and stricture rate. METHODS: After obtaining Institutional Animal Care and Use Committee approval, 3 4-kg female piglets underwent complete thoracoscopic esophageal transections. The esophagus was reconstructed thoracoscopically using S50 and S60 U-Clips over an 8F transanastomotic tube. Esophagrams were performed on postoperative day (POD) 7, 21, 44, and 77. RESULTS: Mean operating time was 57 minutes (45 to 75 min). Two of 3 piglets had no evidence of leak on POD 7 esophagrams. One animal had a small leak that resolved spontaneously on antibiotics. All 3 piglets tolerated a formula diet orally by POD 8. Over a 77-day survival period all 3 piglets had steady weight gain on an oral diet. CONCLUSIONS: U-Clips are a feasible alternative to sutures for esophageal reconstruction in thoracoscopic surgery. Further study is warranted to investigate the full potential of U-Clips in minimally invasive pediatric surgery.